Massive hemoptysis in pregnancy due to invasive pulmonary aspergillosis with pulmonary tuberculosis co-infection.

A 37-year-old woman, 25 weeks pregnant, experienced sudden massive hemoptysis. She had a background history of systemic lupus erythematosus (SLE) and past pulmonary tuberculosis (PTB). Emergency intubation was necessary, and bronchoscopy revealed blood pooling in both main bronchi, with active bleeding from the right upper lobe bronchus. Urgent computed tomography (CT) angiography of the bronchial artery identified a bleeding source and was successfully embolized. Antifungal and anti-tuberculous therapy was initiated based on bronchoalveolar lavage results. Despite initial improvement, hemoptysis recurred after the third week, leading to repeat embolization, followed by a caesarean section and right upper lobectomy. Both mother and baby survived, remaining well at a 6-week follow-up, emphasizing the complexities of managing recurrent hemoptysis during pregnancy and potential drug interactions.

The benefit of indwelling pleural catheter with ambulatory pneumothorax device and autologous blood patch pleurodesis in lymphangioleiomyomatosis with persistent air leak.

We report a 35-year-old woman who presented with dyspnoea and chest pain for 1 week. High-resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video-assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter (Rocket® IPC™; Rocket Medical plc; WASHINGTON) was inserted and the patient was discharged after 1 day with an atrium pneumostat (Pneumostat™; Atrium Medical Corporation, Hudson, NH, USA) chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL.

Successful treatment of a complex malignant pleural effusion with 1 mg alteplase instilled through a non-draining indwelling pleural catheter.

Indwelling pleural catheter (IPC) is the treatment of choice in managing symptomatic recurrent malignant pleural effusion (MPE). Loculated effusions following insertion may occur due to infection, catheter malfunction or the inflammatory nature of MPE. Loculations may lead to ineffective drainage and make the IPC non-functional. We report a 56-year-old man with symptomatic loculated malignant pleural effusion with an IPC, successfully drained with a single dose of 1 mg recombinant tissue plasminogen activator alteplase. This is the lowest dose currently applied in our centre for efficient drainage and improvement of dyspnoea.

Disease-modifying antirheumatic drugs and organising pneumonia.

Organising pneumonia (OP) in rheumatoid arthritis (RA) may be part of pulmonary manifestation (disease related) or disease-modifying antirheumatic drugs (DMARDs) related. We report a case series of RA patients with DMARDs related OP. A 65-year-old woman developed OP 3 weeks after initiation of methotrexate (MTX). High-resolution CT (HRCT) scan of the thorax revealed bilateral consolidations in the lung bases. She had complete radiological resolution 6 months after corticosteroid therapy with cessation of MTX. The second case was of a 60-year-old woman on MTX with recent addition of leflunomide due to flare of RA. She developed worsening cough 4 months later and HRCT scan revealed consolidation in the left upper lobe with biopsy proven OP. She responded within 6 months of corticosteroid therapy with clinical and radiological resolution. This case series highlights that OP may developed with low-dose MTX (as early as 3 weeks) and leflunomide and the diagnosis requires a high index of suspicion.

Cryodebulking of endobronchial hamartoma via fibreoptic bronchoscopy and literature review.

Endobronchial hamartoma is a rare tumour. We report a 65-year-old woman with a history of recurrent pneumonia. Bronchoscopy revealed a 1 cm endobronchial mass obstructing the left upper lobe bronchus. Histopathological examination was consistent with a pulmonary hamartoma. This lesion was successfully debulked endoscopically with the use of a flexible cryoprobe without any complications. This case highlights both the importance of investigating recurrent pneumonia and the usefulness of endoscopic recanalisation in an obstructed segmental bronchus.

What happens when we treat the "Typhoid Mary" of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was declared a pandemic on 11 March 2020. We have since seen its fast spread worldwide. A likely contributing factor was the lack of symptoms of some of the carriers, making them unaware of their risk of spreading to other more vulnerable individuals. The other important finding has been the reported cases of infectivity despite lack of symptoms. We describe the SARS-CoV-2 pneumonia patterns in asymptomatic individuals. The common computed tomography (CT) thorax patterns found are peripheral ground-glass opacification (GGO) with upper or lower lobe predominance. We believe screening for 2019-novel coronavirus (COVID-19) in high-risk individuals may help identify the patients needing longer follow-up.

Annual Southeast Asia haze increases respiratory admissions: A 2-year large single institution experience.

BACKGROUND AND OBJECTIVE: The Southeast Asia (SEA) haze is an annual problem and at its worst could produce respirable particles of concentrations up to 500 µg/m3 which is five times the level considered as 'unhealthy'. However, there are limited reports examining the direct clinical impact of the annual haze. This study examines the effects of the SEA haze on respiratory admissions. METHODS: Data from all respiratory admissions in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from 1st January 2014 to 31st December 2015 were collected retrospectively from chart and electronic database. A total of 16 weeks of haze period had been formally dated by the Department of Environment using the definition of weather phenomenon leading to atmospheric visibility of less than 10 km. Multivariable regression analyses were performed to estimate rate ratios and 95% CI. RESULTS: There were 1968 subjects admitted for respiratory admissions in UKMMC during the study period. Incidence rates per week were significantly different between the two groups with 27.6 ± 9.2 cases per week during the haze versus 15.7 ± 6.7 cases per week during the non-haze period (P < 0.01). A total of 4% versus 2% was admitted to the intensive care unit in the haze and the non-haze groups, respectively (P = 0.02). The mean ± SD lengths of stay was 12.1 ± 5.2 days; the haze group had a longer stay (18.2 ± 9.7 days) compared to the non-haze groups (9.7 ± 3.9) (P < 0.001). CONCLUSION: The annual SEA haze is associated with increased respiratory admissions.

Metastatic melanoma: a rare cause of central airway obstruction.

A middle-aged woman with recurrent malignant melanoma presented initially with massive left pleural effusion. There was a complete obliteration of the left main bronchus on flexible bronchoscopy caused by a mass. Serial cryo-debulking of the tumour was done under rigid bronchoscopy; however, the outcome was not favourable due to the aggressive tumour growth. Vemurafenib was planned after thoracic radiation. She was not keen for the biologics treatment due to financial constraints. We report a case of central airway obstruction due to recurrent aggressive melanoma. More evaluations are needed on the role of interventional pulmonologist for bronchoscopic debulking of this rapidly growing tumour as well as the role of biological agents in treating such cases.