RESUMO
CASE PRESENTATION: A 55-year-old woman with COPD, heart failure with preserved ejection fraction (congestive heart failure), diabetes mellitus, and hypertension presented with baseline dyspnea at rest that had worsened over the last week. She reported associated runny nose, congestion, and cough productive of green sputum. She smoked six cigarettes per day and denied alcohol, drugs, or occupational exposure. She was admitted and initiated on treatment for acute exacerbation of COPD; however, her condition did not improve with steroid, ceftriaxone, and nebulized albuterol and budesonide treatments. She had been diagnosed with asthma and COPD without ever undergoing pulmonary function testing. She presented 11 times to the ED with six hospital admissions in the last 1.5 years for worsening dyspnea at rest, wheezing, and lower extremity edema deemed secondary to exacerbation of her COPD or congestive heart failure. She reported medication compliance, which included fluticasone-vilanterol, tiotropium bromide, and furosemide. She repeatedly demonstrated mild vascular congestion on imaging without hyperinflation, a normal to mildly elevated brain natriuretic peptide (<10 to 200 pg/mL), and dyspnea without hypoxia. She was treated normally for both COPD and congestive heart failure exacerbations simultaneously with methylprednisolone, albuterol, and furosemide with rapid improvement over the course of 1 to 2 days. No significant improvement was noted with steroid therapy, despite receiving them as an inpatient and outpatient. At the time of discharge, her symptoms would be at her baseline.
Assuntos
Neoplasias Brônquicas/complicações , Neoplasias Brônquicas/diagnóstico , Dispneia/etiologia , Tumor de Células Granulares/complicações , Tumor de Células Granulares/diagnóstico , Doença Pulmonar Obstrutiva Crônica/complicações , Neoplasias Brônquicas/terapia , Feminino , Tumor de Células Granulares/terapia , Humanos , Pessoa de Meia-IdadeRESUMO
A 72-year-old woman was referred with incidentally detected multiple lung nodules, one of which was identified as 18F-fluorodeoxyglucose (FDG)-avid on positron emission tomography. Extensive workup followed, including numerous radiographs, surveillance scans and a CT-guided biopsy which demonstrated chronic inflammation only. Following a wedge-resection, a diagnosis of pulmonary hyalinising granuloma (PHG) was made. PHG is a cause of FDG-avid single or multiple pulmonary nodules and can mimic lung cancer or metastatic disease radiologically. The diagnosis is often difficult to make with minimally invasive techniques such as needle-guided biopsies which do not tend to yield the diagnosis and requires surgical resection for definitive diagnosis and exclusion of malignancy.
Assuntos
Granuloma/diagnóstico por imagem , Granuloma/cirurgia , Nódulos Pulmonares Múltiplos/diagnóstico por imagem , Nódulos Pulmonares Múltiplos/cirurgia , Idoso , Diagnóstico Diferencial , Feminino , Fluordesoxiglucose F18 , Humanos , Tomografia por Emissão de Pósitrons combinada à Tomografia ComputadorizadaRESUMO
Aortic syphilis today is infrequently diagnosed clinically. Described herein are findings in 5 women who had resection of a fusiform aneurysm of the tubular portion of ascending aorta, and examination of the wall of the aneurysm disclosed classic features of aortic syphilis. The 5 patients were among 36 who had ascending aortic operations at Baylor University Medical Center in Dallas in 2018 and early 2019. Syphilitic aneurysm in each spared the sinus portion and involved diffusely the tubular portion of ascending aorta, beginning at the sinotubular junction. The aneurysmal wall was thicker than normal because of thickening of both intima and adventitia. The latter contained foci of lymphocytes and plasmacytes and thickened and narrowed vasa vasora. The media was disrupted by fibrous scars, which weakened the integrity of the aorta. Aortitis of the tubular portion of ascending aorta in syphilis is a diffuse process, but often is mistakenly called "atherosclerosis" which, when present in this portion of aorta, can be extensive but is focal. Aortic syphilis is important to diagnose so that patients can receive antibiotic therapy to delay, prevent, or treat neurosyphilis, a common accompaniment of aortic syphilis.
Assuntos
Aneurisma Infectado/microbiologia , Aorta/microbiologia , Aneurisma Aórtico/microbiologia , Aortite/microbiologia , Sífilis Cardiovascular/microbiologia , Idoso , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/patologia , Aneurisma Infectado/cirurgia , Antibacterianos/uso terapêutico , Aorta/diagnóstico por imagem , Aorta/patologia , Aorta/cirurgia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/patologia , Aneurisma Aórtico/cirurgia , Aortite/diagnóstico por imagem , Aortite/patologia , Aortite/cirurgia , Aortografia , Biópsia , Implante de Prótese Vascular , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Fatores de Risco , Sífilis Cardiovascular/diagnóstico por imagem , Sífilis Cardiovascular/patologia , Sífilis Cardiovascular/cirurgia , Texas , Resultado do TratamentoRESUMO
Described herein is a 69-year-old woman who developed a large saccular aortic aneurysm at a previous cannulation site for repair of a ventricular septal defect at age 25 years. The aneurysm was resected and proved histologically to be a false one. The long interval between operations (44 years) exceeds those reported previously.
Assuntos
Falso Aneurisma/diagnóstico por imagem , Aorta/patologia , Implante de Prótese Vascular/métodos , Cateterismo Cardíaco/efeitos adversos , Angiografia por Tomografia Computadorizada/métodos , Comunicação Interventricular/cirurgia , Idoso , Falso Aneurisma/cirurgia , Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Comunicação Interventricular/diagnóstico por imagem , Humanos , Imageamento Tridimensional , Reoperação/métodos , Medição de Risco , Esternotomia/métodos , Fatores de Tempo , Resultado do TratamentoRESUMO
Much has changed since the last review of interventional pulmonology (IP) published in this Clinics series. The rate of development of new techniques and their complexities require IP physicians to be constantly maintaining and updating their skill set. International agreed training pathways help ensure that the interventionalists of the present and future have the required knowledge of anatomy, manual dexterity, and clinical judgment to keep up with the continuing advances that are constantly expanding IP's diagnostic and therapeutic boundaries. IP remains one of the most desirable subspecialities in pulmonology, and the technologic advances make the future an exciting one.
Assuntos
Broncoscopia/métodos , Pneumologia , HumanosAssuntos
Broncopatias/etiologia , Osteocondrodisplasias/complicações , Osteocondrodisplasias/diagnóstico por imagem , Doenças da Traqueia/complicações , Doenças da Traqueia/diagnóstico por imagem , Idoso , Broncopatias/diagnóstico por imagem , Broncopatias/terapia , Broncoscopia , Feminino , Humanos , Osteocondrodisplasias/terapia , Tomografia Computadorizada por Raios X , Doenças da Traqueia/terapiaAssuntos
Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias Pulmonares/secundário , Linfoma Cutâneo de Células T/patologia , Linfoma de Células T Periférico/patologia , Neoplasias Cutâneas/patologia , Idoso , Antinematódeos/administração & dosagem , Biópsia/métodos , Feminino , Fluordesoxiglucose F18 , Humanos , Imuno-Histoquímica , Linfoma de Células T Periférico/tratamento farmacológico , Linfoma de Células T Periférico/fisiopatologia , Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos , Indução de Remissão , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Gas trapping in emphysema results in resting and dynamic hyperinflation. We tested the hypothesis that a direct connection between the lung parenchyma and the atmosphere could increase expiratory flow and thereby potentially improve dyspnea through the relief of gas trapping. METHODS: Ex vivo we studied 7 emphysematous lungs and 3 fibrotic lungs (as controls) and measured expiratory flow before and after airway bypass insertion during a forced maneuver in an artificial thorax. Pilot studies were conducted in vivo in 6 patients with advanced emphysema using a size 9 endotracheal tube as a bypass surgically placed through the chest wall into the upper lobe. RESULTS: In the ex vivo emphysematous lungs the volume expelled during a forced expiratory maneuver increased from 169 to 235 mL (p < 0.05). In the in vivo group 4 patients retained the bypass tube for 3 months or more; total lung capacity was reduced, and the forced expiratory volume in 1 second increased by 23% (mean percent predicted at baseline versus 3 months, 24.4% versus 29.5%). CONCLUSIONS: An extrapulmonary airway bypass increases expiratory flow in emphysema. This may be a useful approach in hyperinflated patients with homogeneous emphysema.
Assuntos
Tubos Torácicos , Próteses e Implantes , Enfisema Pulmonar/cirurgia , Idoso , Dispneia/etiologia , Dispneia/fisiopatologia , Feminino , Volume Expiratório Forçado , Humanos , Técnicas In Vitro , Masculino , Pessoa de Meia-Idade , Enfisema Pulmonar/fisiopatologia , Fibrose Pulmonar/fisiopatologia , Fibrose Pulmonar/cirurgia , Ventilação Pulmonar , Volume Residual , Capacidade Pulmonar Total , Capacidade VitalRESUMO
Malignant mesothelioma is a fatal asbestos-associated malignancy originating from the lining cells (mesothelium) of the pleural and peritoneal cavities, as well as the pericardium and the tunica vaginalis. The exact prevalence is unknown but it is estimated that mesotheliomas represent less than 1% of all cancers. Its incidence is increasing, with an expected peak in the next 10-20 years. Pleural malignant mesothelioma is the most common form of mesothelioma. Typical presenting features are those of chest pain and dyspnoea. Breathlessness due to a pleural effusion without chest pain is reported in about 30% of patients. A chest wall mass, weight loss, sweating, abdominal pain and ascites (due to peritoneal involvement) are less common presentations. Mesothelioma is directly attributable to occupational asbestos exposure with a history of exposure in over 90% of cases. There is also evidence that mesothelioma may result from both para-occupational exposure and non-occupational "environmental" exposure. Idiopathic or spontaneous mesothelioma can also occur in the absence of any exposure to asbestos, with a spontaneous rate in humans of around one per million. A combination of accurate exposure history, along with examination radiology and pathology are essential to make the diagnosis. Distinguishing malignant from benign pleural disease can be challenging. The most helpful CT findings suggesting malignant pleural disease are 1) a circumferential pleural rind, 2) nodular pleural thickening, 3) pleural thickening of > 1 cm and 4) mediastinal pleural involvement. Involvement of a multidisciplinary team is recommended to ensure prompt and appropriate management, using a framework of radiotherapy, chemotherapy, surgery and symptom palliation with end of life care. Compensation issues must also be considered. Life expectancy in malignant mesothelioma is poor, with a median survival of about one year following diagnosis.
Assuntos
Mesotelioma/diagnóstico , Mesotelioma/patologia , Neoplasias Pleurais/diagnóstico , Neoplasias Pleurais/patologia , Humanos , Mesotelioma/diagnóstico por imagem , Mesotelioma/etiologia , Neoplasias Pleurais/diagnóstico por imagem , Neoplasias Pleurais/etiologia , Tomografia Computadorizada por Raios XRESUMO
Structural adaptations that occur in the diaphragm muscle of patients with chronic obstructive pulmonary disease (COPD), namely an increase in type I fibers and a decrease in type II fibers, have been explored in terms of the active contractile properties of the diaphragm. The aim of this study was to test the passive properties of the diaphragm by measuring the force response of relaxed diaphragm muscle fibers to stretching to determine the effect of COPD on these properties. Costal diaphragm biopsies were taken from patients with COPD and from controls with normal pulmonary function. From these biopsies, titin expression was assessed in diaphragm homogenates by gel electrophoresis, and the restoring force was measured by incremental stretching of single fibers in the relaxed state and measuring the force response to stretching. A quadratic model was used to illustrate the relationship between restoring force and muscle fiber length, and it revealed that COPD fibers generate significantly lower restoring forces than control fibers as judged by the area under the force-length curve. Furthermore, this finding applies to both type I and type II fibers. Gel electrophoresis revealed different titin isoforms in COPD and controls, consistent with the conclusion that COPD results not only in a change in muscle fiber-type distribution but in a structural change in the titin molecule in all muscle fiber types within the diaphragm. This may assist the muscle with the energetic changes in the length of the diaphragm required during breathing in COPD.