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.

Recurrent bilateral idiopathic chylothorax: a therapeutic challenge.

Chylothorax is a rare condition caused by pleural effusion resulting from thoracic duct injury. Recurrent chylothorax is often resistant to conservative treatment and presents a clinical conundrum in its management. Here, we report a compelling case of recurrent chylothorax that persisted despite the administration of total parenteral nutrition, octreotide and thoracic duct embolisation. The patient eventually required thoracic duct ligation and talc pleurodesis, which resulted in the resolution of the effusion. Our case is an illustrative example of the effective multidisciplinary management of recurrent bilateral idiopathic chylothorax.

Combined intrapleural alteplase and DNase therapy in complicated pleural infection arising from postsurgery oesophageal leak.

Managing a complicated pleural infection related to postsurgery can pose a clinical challenge, especially when initial interventions such as intercostal chest drain and antibiotics prove ineffective. We describe a man in his mid-60s who developed a recurrence of exudative pleural effusion caused by an oesophageal leak following laparoscopic total gastrectomy with Roux-y oesophagojejunostomy for gastric adenocarcinoma. Surgical repairs and oesophageal stenting were performed to address the oesophageal leak. Despite attempts at intercostal chest tube drainage, ultrasonography-guided targeted drainage of the locule and antibiotics, he did not show any improvement. He was unfit for surgical decortication. Due to the risk of bleeding, we chose a modified dose of intrapleural alteplase 5 mg and DNase 5 mg at 12-hour intervals for a total of three doses. This led to the complete resolution of the effusion. This case highlights that intrapleural tPA/DNase can be an adjunctive therapy in postsurgery-related complicated pleural effusion.

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.

Satisfaction and tolerability using virtual reality (VR) as adjunctive treatment during flexible bronchoscopy: a randomized control trial.

BACKGROUND: Patient comfort during invasive and therapeutic procedures is important. The use of virtual reality (VR) devices during flexible bronchoscopy (FB) as a method of distraction to increase patient tolerability and improve satisfaction has not been investigated. We aim to assess the satisfaction and tolerability of participants undergoing FB with or without VR. METHODS: This was a single-center, open-label study on patients undergoing bronchoscopy, randomized into the control and interventional (VR) groups. The control group received standard care during FB. The interventional group was given a VR device during FB showing nature videos with soothing instrumental music. Pain, breathlessness, and cough were evaluated using a 10 cm visual analogue scale administered before and after FB. Anxiety was assessed using the State-Trait Anxiety Inventory. Satisfaction questionnaire (5-point Likert scale) was given to participants post FB. RESULTS: Eighty participants enrolled, 40 in each arm. Median (IQR) satisfaction score in the VR group was 5.0 (3.0-5.0), and in the control group was 4.0 (3.0-5.0); (p < 0.001). Breathlessness, cough, and anxiety post FB were significantly less severe in the interventional group (p = 0.042, p = 0.001, p < 0.001), but the pain was not significantly different (p = 0.290). CONCLUSION: VR used during FB led to better participants' satisfaction and tolerability (breathlessness and cough). There was a significantly lower anxiety score in the VR group.

Retrospective review comparing intrapleural fibrinolytic therapy (alteplase) and surgical intervention in complex pleural effusion.

BACKGROUND: Intrapleural fibrinolytic therapy (IPFT) is one of the treatment options for complex pleural effusion. In this study, the IPFT agent used was alteplase, a tissue plasminogen activator (t-PA). This study aims to determine the difference in the outcome of patients with complex pleural effusion between IPFT and surgery in terms of radiological improvement, inflammatory parameters, length of stay, and post-intervention complications. METHODS: A retrospective review of patients with complex pleural effusion treated at Universiti Kebangsaan Malaysia Medical Center from January 2012 to August 2020 was performed. Patient demographics, chest imaging, drainage chart, inflammatory parameters, length of hospital stay, and post-intervention and outcome were analyzed. RESULTS: Fifty-eight patients were identified (surgical intervention, n = 18; 31% and IPFT, n = 40, 69%). The mean age was 51.7 ± 18.2 years. Indication for surgical intervention was pleural infection (n = 18; 100%), and MPE (n = 0). Indications for IPFT was pleural infection (n = 30; 75%) and MPE (n = 10; 25%). The dosages of t-PA were one to five doses of 2-50 mg. The baseline chest radiograph in the IPFT group was worse than in the surgical intervention group. (119.96 ± 56.05 vs. 78.19 ± 55.6; p = 0.029) At week 1, the radiological success rate for IPFT and surgical intervention were 27% and 20%, respectively, and at weeks 4-8, the success rate was 56% and 80% respectively. IPFT was associated with lesser complications; fever (17.5%), chest pain (10%), and non-life-threatening bleeding (5%). CONCLUSION: IPFT was comparable to surgery in radiological outcome, inflammatory parameters, and length of stay with lesser reported complications.

Hydrofluorocarbons pneumonitis as a complication of inhalation injury following air-conditioning repairs.

Hydrofluorocarbon (HFC) pneumonitis is an uncommon cause of inhalation injury. HFCs are a group of chemicals predominantly used for refrigeration and cooling. A 19-year-old air-conditioning technician developed acute onset of dyspnoea and chest tightness while servicing an air conditioner in a confined space. We diagnosed him with HFC pneumonitis based on the history of exposure and the high-resolution computed tomography (HRCT) thorax findings. He was treated with steroids and supportive oxygen therapy. He recovered fully after 5 days of hospitalization and was discharged. Review at 2 weeks in the outpatient setting showed significant radiological improvement on HRCT thorax.

Modified regimen intrapleural alteplase with pulmozyme in pleural infection management: a tertiary teaching hospital experience.

BACKGROUND: Current management of poorly draining complex effusions favours less invasive image-guided placement of smaller tubes and adjunctive intrapleural fibrinolysis therapy (IPFT). In MIST-2 trial, intrapleural 10 mg alteplase (t-PA) with 5 mg of pulmozyme (DNase) twice daily for 72 h were used. We aimed to assess the effectiveness and safety of a modified regimen 16 mg t-PA with 5 mg of DNase administered over 24 h in the management of complex pleural infection. METHODS: This was a single centre, prospective study involving patients with poorly drained pleural infection. Primary outcome was the change of pleural opacity on chest radiograph at day 7 compared to baseline. Secondary outcomes include volume of fluid drained, inflammatory markers improvement, surgical referral, length of hospitalisation, and adverse events. RESULTS: Thirty patients were recruited. Majority, 27 (90%) patients were successfully treated. Improvement of pleural opacity on chest radiograph was observed from 36.9% [Interquartile range (IQR 21.8-54.9%)] to 18.1% (IQR 8.8-32.7%) of hemithorax (P < 0.05). T-PA/DNase increased fluid drainage from median of 45 mls (IQR 0-100) 24 h prior to intrapleural treatment to 1442 mls (IQR 905-2360) after 72 h; (P < 0.05) and reduction of C-reactive protein (P < 0.05). Pain requiring escalation of analgesia affected 20% patients and 9.9% experienced major adverse events. None required surgical intervention. CONCLUSION: This study suggests that a modified regimen 16 mg t-PA with 5 mg DNase can be safe and effective for patients with poorly drained complex pleural infection. Trial registration The study was registered retrospectively on 07/06/2021 with ClinicalTrials number NCT04915586 ( https://clinicaltrials.gov/ct2/show/NCT04915586 ).

Organising pneumonia manifesting as a late-phase complication of COVID-19.

Acute COVID-19 usually lasts 4 weeks from the onset of symptoms. We report two cases of COVID-19-associated organising pneumonia (OP) occurring beyond 4 weeks from the acute onset of symptoms. Both tested positive for SARS reverse transcription-PCR 2 months before presentation with a resolution of respiratory symptoms. The first case presented with residual fatigue and worsening exertional dyspnoea. Chest CT revealed an OP pattern. The second case presented with worsening cough and new-onset pleuritic chest pain with persistent radiological consolidation. A transbronchial lung biopsy confirmed OP. Both patients responded well to 12 weeks of steroid therapy. This case illustrates the rare presentation of OP as a late sequela of COVID-19 and the good response to steroid therapy.

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.

Re-establishing indwelling pleural catheter patency with alteplase after failure of streptokinase.

Indwelling pleural catheter (IPC) has revolutionized the management of malignant pleural effusion (MPE). IPC is relatively safe, although complications can occur. We report a 53-year-old woman with stage IVA lung adenocarcinoma and recurrent MPE. Two months post insertion, the IPC was blocked with residual effusion and presence of new loculations. Attempts to restore patency with six doses of intrapleural (IP) streptokinase failed. She was referred to our centre for further management. We used a single dose of 2.5 mg IP alteplase which was successful in establishing patency of the IPC and draining the effusion. This case highlights the safety and efficacy of IP alteplase via IPC following a failed instillation of streptokinase.

Indwelling pleural catheter and successful autopleurodesis of refractory inflammatory lupus effusion.

Indwelling pleural catheter (IPC) is a useful tool for refractory malignant pleural effusions (MPEs). It allows palliation by intermittent symptomatic relief of the effusion and improves quality of life. Its use in benign pleural effusions comes mainly from retrospective studies, case series, and case reports. Lupus effusion is common, causes minimal symptoms, and usually responds to either steroid therapy or immunosuppressants. Refractory lupus effusion is less common and treatment may require invasive surgical pleurectomy. We describe a 52-year-old woman whose first presentation of systemic lupus erythematosus (SLE) was a pleural effusion refractory to steroids and immunosuppressants. She successfully achieved spontaneous pleurodesis with intermittent IPC drainage at three months.

Resolution of refractory chylothorax with a combination of talc pleurodesis and CPAP.

Chylothorax is an uncommon cause of pleural effusion. Recurrent chylous effusions are often resistant to conservative treatment and many need surgical intervention. We report a 69-year-old woman with refractory idiopathic chylothorax resistant to medium-chain triglyceride diet and intermittent thoracentesis. Lymphangiography and lymphoscintigraphy failed to identify the site of leakage. We initiated continuous positive airway pressure (CPAP) 12 h before and 48 hours after talc pleurodesis. Chest drain was removed at day 3 and she was discharged at day 5. To our knowledge, this is the first case of successful resolution of idiopathic refractory chylothorax with CPAP ventilation used in tandem with talc pleurodesis.

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.