39-YEAR-OLD FEMALE WITH MILD RESPIRATORY DISTRESS AND HYPOXIA.

The diagnosis of cryptogenic organizing pneumonia is usually delayed for several weeks due to treatment for presumed infectious pneumonia. We present a case of cryptogenic organizing pneumonia in a 39-year-old female who presented with shortness of breath and cough. She had both rapid clinical and radiological response to treatment with corticosteroids.

Broken lung.

We report a case of severe acute respiratory distress syndrome (ARDS) complicated by a very large bronchopleural fistula (BPF) measuring 30 mm in length and evident on computed tomography (CT) chest scan. Such a large BPF is a very rare occurrence. Generally, a BPF of more than 6 mm in size is considered as large.(1) Small BPFs can be easily missed on CT scan chest, but a persistent air-leak through an adequately placed chest tube should raise suspicion for a BPF.

Unexpected pulmonary mechanics during positive pressure mechanical ventilation in fibrotic lung disease with concomitant flail chest.

Understanding of pulmonary mechanics is essential to understanding mechanical ventilation. Typically, clinicians are mindful of peak and plateau pressures displayed on the ventilator and lung compliance, which is decreased in lung disease such as idiopathic pulmonary fibrosis (IPF). Decreased lung compliance leads to elevated peak and plateau pressures. We present a patient with IPF undergoing mechanical ventilation after cardiac arrest. Despite low lung compliance, he had normal peak and plateau pressures due to the presence of flail chest and increased chest wall compliance. This case highlights the role chest wall compliance plays in total respiratory system compliance and pulmonary mechanics.

Association of abnormal pulmonary vasculature on CT scan for COVID-19 infection with decreased diffusion capacity in follow up: A retrospective cohort study.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) is a respiratory viral illness causing pneumonia and systemic disease. Abnormalities in pulmonary function tests (PFT) after COVID-19 infection have been described. The determinants of these abnormalities are unclear. We hypothesized that inflammatory biomarkers and CT scan parameters at the time of infection would be associated with abnormal gas transfer at short term follow-up. METHODS: We retrospectively studied subjects who were hospitalized for COVID-19 pneumonia and discharged. Serum inflammatory biomarkers, CT scan and clinical characteristics were assessed. CT images were evaluated by Functional Respiratory Imaging with automated tissue segmentation algorithms of the lungs and pulmonary vasculature. Volumes of the pulmonary vessels that were ≤5mm (BV5), 5-10mm (BV5_10), and ≥10mm (BV10) in cross sectional area were analyzed. Also the amount of opacification on CT (ground glass opacities). PFT were performed 2-3 months after discharge. The diffusion capacity of carbon monoxide (DLCO) was obtained. We divided subjects into those with a DLCO <80% predicted (Low DLCO) and those with a DLCO ≥80% predicted (Normal DLCO). RESULTS: 38 subjects were included in our cohort. 31 out of 38 (81.6%) subjects had a DLCO<80% predicted. The groups were similar in terms of demographics, body mass index, comorbidities, and smoking status. Hemoglobin, inflammatory biomarkers, spirometry and lung volumes were similar between groups. CT opacification and BV5 were not different between groups, but both Low and Normal DLCO groups had lower BV5 measures compared to healthy controls. BV5_10 and BV10 measures were higher in the Low DLCO group compared to the normal DLCO group. Both BV5_10 and BV10 in the Low DLCO group were greater compared to healthy controls. BV5_10 was independently associated with DLCO<80% in multivariable logistic regression (OR 1.29, 95% CI 1.01, 1.64). BV10 negatively correlated with DLCO% predicted (r = -0.343, p = 0.035). CONCLUSIONS: Abnormalities in pulmonary vascular volumes at the time of hospitalization are independently associated with a low DLCO at follow-up. There was no relationship between inflammatory biomarkers during hospitalization and DLCO. Pulmonary vascular abnormalities during hospitalization for COVID-19 may serve as a biomarker for abnormal gas transfer after COVID-19 pneumonia.

The role of head computer tomographic scans on the management of MICU patients with neurological dysfunction.

Neurological dysfunction is common in patients admitted to the medical intensive care unit (MICU). However, the indications for head imaging in those patients are unclear. The objective of this study was to assess whether clinical variables would be useful in selecting patients who are likely to have an abnormality on head computerized tomographic (CT) scanning and to determine the impact of such scans on management decisions. We reviewed the charts of 740 patients admitted to our MICU between October 2002 and July 2004. A total of 123 patients (16.6%) had a head CT scan performed, with a new finding being present in 26 (21.1%) patients. In the patients with a new CT finding, there was a change in diagnosis in 11 (42%) patients and a change in treatment in 6 (23%) patients. Logistic regression analysis failed to determine any clinical characteristic that could predict a new finding on the CT scan. This study suggests that clinicians should have a low threshold for ordering a CT scan in MICU patients with acute neurological dysfunction.

Mediastinal mass diagnosed by endobronchial ultrasound as recurrent hepatocellular carcinoma in a post-liver transplantation patient.

OBJECTIVE: We presented a rare case of recurrent hepatocellular carcinoma after liver transplant manifested as an isolated mediastinal mass. METHODS: A 62-year-old man was referred for evaluation of atypical chest pain and abnormal finding of a computed tomography of the chest. He had history of chronic hepatitis C liver cirrhosis and hepatocellular carcinoma underwent orthotopic liver transplant as a curative treatment three years earlier. RESULTS: The computed tomography of the chest demonstrated paratracheal mediastinal lymphadenopathy. He subsequently underwent endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA). The right paratracheal lymph node station 4R was sampled. Rapid on-site cytology evaluation demonstrated recurrent metastatic hepatocellular carcinoma. CONCLUSION: Pulmonologist should be cognizant of diagnostic utility of EBUS-TBNA in this clinical setting as more transplant patients on immunosuppressive medications with enlarged mediastinal lymphadenopathy of unknown origin will be referred for further evaluation.

Brain natriuretic peptide measurement in pulmonary medicine.

Serum levels of natriuretic peptides are well established as important biomarkers in patients with cardiac disease. Less attention has been placed on the role of natriuretic peptides in patients with pulmonary conditions. In several well-defined groups of patients with pulmonary disease natriuretic peptides provide the clinician with clinically valuable information. A limitation of the interpretation of natriuretic peptides in pulmonary disease is the confounding effect of concurrent conditions such as heart failure, hypoxia, sepsis and renal failure. The present paper reviews the role of natriuretic peptides for diagnosis, risk stratification and prognosis of several pulmonary disorders.

Osborn wave in hypothermia from Vibrio vunificus sepsis unrelated to exposure.

A 58 year old man with history of cirrhosis presented with Vibrio vunificus sepsis. The patient developed multiorgan failure despite appropriate antibiotic therapy and fluid resuscitation. The patient developed moderate hypothermia. Electrocardiography showed Osborn wave. Osborn wave is commonly seen in accidental hypothermia. Although sepsis is known to cause hypothermia, Osborn wave in sepsis is not widely appreciated.

Methicillin-resistant Staphylococcus aureus pneumonia after thoracic surgery: successful treatment with linezolid after failed vancomycin therapy.

We describe 3 patients with methicillin-resistant Staphylococcus aureus, hospital-acquired pneumonia who demonstrated a microbiological and clinical failure with vancomycin despite adequate trough levels. All 3 patients were cured with linezolid.