Case Report: Middle lobe syndrome: a rare presentation in eosinophilic granulomatosis with polyangiitis.

Background: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of disorders characterized by necrotizing inflammation of small- and medium-sized blood vessels and the presence of circulating ANCA. Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic ANCA-associated vasculitis, characterized by peripheral eosinophilia, neuropathy, palpable purpuras or petechiae, renal and cardiac involvement, sinusitis, asthma, and transient pulmonary infiltrates. Middle lobe syndrome (MLS) is defined as recurrent or chronic atelectasis of the right middle lobe of the lung, and it is a potential complication of asthma. Case presentation: Herein, we describe a case of MLS in a 51-year-old woman, never-smoker, affected by EGPA, presenting exclusively with leukocytosis and elevated concentrations of acute-phase proteins, without any respiratory symptom, cough, or hemoptysis. Chest computed tomography (CT) imaging documented complete atelectasis of the middle lobe, together with complete obstruction of lobar bronchial branch origin. Fiberoptic bronchoscopy (FOB) revealed complete stenosis of the middle lobar bronchus origin, thus confirming the diagnosis of MLS, along with distal left main bronchus stenosis. Bronchoalveolar lavage (BAL) did not detect any infection. Bronchial biopsies included plasma cells, neutrophil infiltrates, only isolated eosinophils, and no granulomas, providing the hypothesis of vasculitic acute involvement less likely. First-line agents directed towards optimizing pulmonary function (mucolytics, bronchodilators, and antibiotic course) were therefore employed. However, the patient did not respond to conservative treatment; hence, endoscopic management of airway obstruction was performed, with chest CT documenting resolution of middle lobe atelectasis. Conclusion: To the best of our knowledge, this is the first detailed description of MLS in EGPA completely resolved through FOB. Identification of MLS in EGPA appears essential as prognosis, longitudinal management, and treatment options may differ from other pulmonary involvement in AAV patients.

The Additional Value of Lower Respiratory Tract Sampling in the Diagnosis of COVID-19: A Real-Life Observational Study.

Background: Since December 2019, SARS-CoV-2 has been causing cases of severe pneumonia in China and has spread all over the world, putting great pressure on health systems. Nasopharyngeal swab (NPS) sensitivity is suboptimal. When the SARS-CoV-2 infection is suspected despite negative NPSs, other tests may help to rule out the infection. Objectives: To evaluate the yield of the lower respiratory tract (LRT) isolation of SARS-CoV-2. To evaluate the correlations between SARS-CoV-2 detection and clinical symptoms, and laboratory values and RSNA CT review scores in suspect patients after two negative NPSs. To assess the safety of bronchoscopy in this scenario. Method: A retrospective analysis of data from LRT sampling (blind nasotracheal aspiration or bronchial washing) for suspected COVID-19 after two negative NPS. Chest CT scans were reviewed by two radiologists using the RSNA imaging classification. Results: SARS-CoV-2 was detected in 14/99 patients (14.1%). A correlation was found between SARS-CoV2 detection on the LRT and the presence of a cough as well as with typical CT features. Typical CT resulted in 57.1% sensitivity, 80.8% accuracy and 92.3% NPV. Neither severe complications nor infections in the personnel were reported. Conclusions: In suspect cases after two negative swabs, CT scan revision can help to rule out COVID-19. In selected cases, with consistent CT features above all, LRT sampling can be of help in confirming COVID-19.

Midazolam in flexible bronchoscopy premedication: effects on patient-related and procedure-related outcomes.

BACKGROUND: The role of midazolam in flexible bronchoscopy premedication has been debated. The aim of the present study was to evaluate whether midazolam premedication increases the patient-reported tolerance and the physician-reported or nurse-reported feasibility of bronchoscopy. METHODS: Randomized, double-blinded, placebo-controlled, 3-arm study. The study population included patients undergoing bronchoscopy for appropriate clinical indications. Patients were randomly assigned to receive 0.035 mg/kg intravenous midazolam (low dose), 0.07 mg/kg (high dose), or placebo. Vital parameters were monitored in continuum during the procedure. At the end of the procedure, the operating physician and assisting nurse filled out a questionnaire to score the procedure-related outcomes (satisfaction, feasibility, completeness, and unexpected events). Patients were asked to fill out a specific questionnaire to assess the patient-reported tolerance and satisfaction 2 hours after the bronchoscopy. RESULTS: A total of 100 patients (mean age 58.6±1.0; 57% male) were included in the study (33 in the low-dose midazolam group, 34 in the high-dose midazolam group, and 33 in the placebo group). The patient-reported tolerance score was significantly higher in the high-dose midazolam group than in the placebo group (P<0.01). No differences were found in the 3 groups in terms of the physician-reported feasibility and completeness of the procedure. In the groups of patients premedicated with midazolam, significant oxygen desaturation was recorded (at 10 and 8 min after the introduction of the bronchoscope) compared with the baseline value (P<0.01). CONCLUSIONS: In our study, premedication with midazolam increased the patient-reported tolerance of the bronchoscopy. However, the absence of premedication did not affect the diagnostic yield of the procedure.