Investigating the risk of reintubation by cough force assessment using cough peak expiratory flow: a single-center observational pilot study.

BACKGROUND: No objective indicator exists for evaluating cough strength during extubation of tracheally intubated patients. This study aimed to determine whether cough peak expiratory flow (CPEF) can predict the risk of reintubation due to decreased cough strength. METHODS: This was a retrospective cohort study of patients who were admitted to our Emergency Intensive Care Unit between September 1, 2020 and August 31, 2021 and were under artificial ventilation management for ≥ 24 h. The patients were divided into two groups: successful extubation and reintubation groups, and the relationship between CPEF immediately before extubation and reintubation was investigated. RESULTS: Seventy-six patients were analyzed. In the univariate analysis, CPEF was significantly different between the successful extubation (90.7 ± 25.9 L/min) and reintubation (57.2 ± 6.4 L/min) groups (p < 0.001). In the multivariate analysis with age and duration of artificial ventilation as covariates, CPEF was significantly lower in the reintubation group (p < 0.01). The cutoff value of CPEF for reintubation according to the receiver operating characteristic curve was 60 L/min (area under the curve, 0.897; sensitivity, 78.5%; specificity, 90.9%; p < 0.01). CONCLUSION: CPEF in tracheally intubated patients may be a useful indicator for predicting the risk of reintubation associated with decreased cough strength. The cutoff CPEF value for reintubation due to decreased cough strength was 60 L/min.

Chronic Cough and Obstructive Sleep Apnea.

Chronic cough, defined as a cough lasting more than 8 weeks, is a common medical condition occurring in 5% to 10% of the population. Its overlap with another highly prevalent disorder, obstructive sleep apnea (OSA), is therefore not surprising. The relationship between chronic cough and OSA extends beyond this overlap with higher prevalence of OSA in patients with chronic cough than in the general population. The use of continuous positive airway pressure can result in improvement in chronic cough although further studies are needed to understand which patients will experience benefit in their cough from the treatment of comorbid OSA.

[The role of spectral analysis of cough sounds in the diagnosis of COVID-19].

AIM: To evaluate the possibility of using spectral analysis of cough sounds in the diagnosis of a new coronavirus infection COVID-19. MATERIALS AND METHODS: Spectral toussophonobarography was performed in 218 patients with COVID-19 [48.56% men, 51.44% women, average age 40.2 (32.4; 51.0)], in 60 healthy individuals [50% men, 50% women, average age 41.7 (32.2; 53.0)] with induced cough (by inhalation of citric acid solution at a concentration of 20 g/l through a nebulizer). The recording was made using a contact microphone located on a special tripod at a distance of 15-20 cm from the face of the subject. The resulting recordings were processed in a computer program, after which spectral analysis of cough sounds was performed using Fourier transform algorithms. The following parameters of cough sounds were evaluated: the duration of the cough act (ms), the ratio of the energy of low frequencies (60-600 Hz) to the energy of high frequencies (600-6000 Hz), the frequency of the maximum energy of the cough sound (Hz). RESULTS: After statistical processing, it was found out that the parameters of the cough sound of COVID-19 patients differ from the cough of healthy individuals. The obtained data were substituted into the developed regression equation. Rounded to integers, the resulting number had the following interpretation: "0" - there is no COVID-19, "1" - there is COVID-19. CONCLUSION: The technique showed high levels of sensitivity and specificity. In addition, the method is characterized by sufficient ease of use and does not require expensive equipment, therefore it can be used in practice for timely diagnosis of COVID-19.

Characteristics and determinants of pulmonary long COVID.

BACKGROUNDPersistent cough and dyspnea are prominent features of postacute sequelae of SARS-CoV-2 (also termed "long COVID"); however, physiologic measures and clinical features associated with these pulmonary symptoms remain poorly defined. Using longitudinal pulmonary function testing (PFT) and CT imaging, this study aimed to identify the characteristics and determinants of pulmonary long COVID.METHODSThis single-center retrospective study included 1,097 patients with clinically defined long COVID characterized by persistent pulmonary symptoms (dyspnea, cough, and chest discomfort) lasting for 1 or more months after resolution of primary COVID infection.RESULTSAfter exclusion, a total of 929 patients with post-COVID pulmonary symptoms and PFTs were stratified as diffusion impairment and pulmonary restriction, as measured by percentage predicted diffusion capacity for carbon monoxide (DLCO) and total lung capacity (TLC). Longitudinal evaluation revealed diffusion impairment (DLCO ≤ 80%) and pulmonary restriction (TLC ≤ 80%) in 51% of the cohort overall (n = 479). In multivariable modeling regression analysis, invasive mechanical ventilation during primary infection conferred the greatest increased odds of developing pulmonary long COVID with diffusion impairment and restriction (adjusted odds ratio [aOR] = 9.89, 95% CI 3.62-26.9]). Finally, a subanalysis of CT imaging identified radiographic evidence of fibrosis in this patient population.CONCLUSIONLongitudinal PFTs revealed persistent diffusion-impaired restriction as a key feature of pulmonary long COVID. These results emphasize the importance of incorporating PFTs into routine clinical practice for evaluation of long COVID patients with prolonged pulmonary symptoms. Subsequent clinical trials should leverage combined symptomatic and quantitative PFT measurements for more targeted enrollment of pulmonary long COVID patients.FUNDINGNational Institute of Allergy and Infectious Diseases (AI156898, K08AI129705), National Heart, Lung, and Blood Institute (HL153113, OTA21-015E, HL149944), and the COVID-19 Urgent Research Response Fund at the University of Alabama at Birmingham.

A Preliminary Study of Voluntary Cough Motor Performance and Learning With Skill Training and Biofeedback.

PURPOSE: Sensorimotor cough skill training (CST) has been shown to improve cough strength, as well as facilitate changes during training (i.e., motor performance) and generalization to untrained tasks (i.e., motor learning). However, there is a gap in our understanding of the effects of voluntary CST (without sensory stimuli) on motor performance and learning. Furthermore, the contribution of physiologic factors, such as lung volume, a driver of cough strength in healthy adults, and treatment-specific factors, such as biofeedback, remains unexamined. METHOD: Twenty individuals with Parkinson's disease (PD) completed pre- and post-CST single voluntary, sequential voluntary, and reflex cough testing. Participants were randomized to biofeedback or no biofeedback groups. They completed one CST session involving 25 trials of voluntary coughs, with the treatment target set 25% above baseline peak flow. Participants were instructed to "cough hard" to exceed the target. In the biofeedback group, participants received direct visualization of the target line in real time. RESULTS: Cough peak flow showed positive improvements in motor performance (ß = .02; 95% credible interval [CI]: 0.01, 0.03) and learning (ß = .26; 95% CI: 0.03, 0.47). Changes in lung volume from pre- to post-CST did not predict treatment response. No differences in treatment response were detected between the biofeedback groups. CONCLUSIONS: A single session of voluntary CST improved voluntary cough motor performance and learning. Although lung volume increased during CST, changes to lung volume did not predict treatment response. These findings demonstrate the potential of voluntary CST to improve motor performance and motor learning among individuals with PD and cough dysfunction. SUPPLEMENTAL MATERIAL AND OPEN SCIENCE FORM: https://doi.org/10.23641/asha.25447444.

Proximal esophageal impedance baseline increases the yield of impedance-pH and is associated with response to PPIs in chronic cough patients.

BACKGROUND: Chronic cough significantly impairs the quality of life. Although various studies focused on MNBI as assessed in the distal esophagus, scarce data are available on the clinical value of proximal measurements. AIM: To investigate the role of proximal MNBI in the workup of patients with chronic cough and its ability to predict PPI response. METHODS: Demographic, clinical, endoscopy findings, impedance-pH and HRM tracings from consecutive cough patients were evaluated. MNBI was calculated at proximal and distal esophagus. RESULTS: One hundred and sixty four patients were included. In addition to traditional variables, when considering also the PSPW index or MNBI at 3 cm or 15 cm, the proportion of patients with pathological impedance-pH monitoring significantly increased. 70/164 patients were responders, while 94 (57.3%) were non-responder to double PPI dose (p < 0.05). Patients with pathologic MNBI at 3 cm and/or 15 cm as well as those with pathologic PSPW index were characterized by a significantly higher proportion of responders than that observed among patients with normal impedance-pH variables (p < 0.001). The proportion of responders with pathological MNBI at 15 cm was significantly higher than the proportion of responders with pathological MNBI at 3 cm (82.8% vs. 64.3%, p < 0.05). At multivariable model, pathological MNBI at both 3 cm and 15 cm as well as PSPW index were associated with PPI responsiveness. The strongest association with PPI response was observed for MNBI at 15 cm. CONCLUSIONS: The assessment of MNBI at proximal esophagus increases the diagnostic yield of impedance-pH monitoring and may represent a useful predictor of PPI responsiveness in the cumbersome clinical setting of suspected reflux-related cough.

Clinical correlates of respiratory disorders in patients with severe multiple sclerosis: A cross-sectional cohort.

BACKGROUND: Respiratory disorders remain incompletely described in multiple sclerosis (MS), even though they are a frequent cause of death. METHODS: The objective was to describe respiratory disorders in MS patients with Expanded Disability Status Score (EDSS) ⩾ 6.5. Diaphragm dysfunction was defined by at least two of the seven criteria: clinical signs, inspiratory recruitment of neck muscles during wakefulness, reduced upright vital capacity (VC) < 80%, upright-to-supine VC ⩾ 15% of upright VC, decrease in Maximal Inspiratory Pressure < 60%, phasic activation of inspiratory neck muscles during sleep, and opposition of thoracic and abdominal movements during sleep. Cough weakness was defined by a peak cough flow < 270 L/min and/or need for cough assist. Sleep apnea syndrome was defined by an apnea-hypopnea index ⩾ 15. RESULTS: Notably, 71 MS patients were included: median age 54 [48, 61] years; median disease duration 21.4 [16.0, 31.4] years. Of these, 52 patients had one or more respiratory disorders; diaphragm dysfunction was the most frequent (n = 34). Patients with diaphragm dysfunction and cough weakness were more disabled. The fatigue score and the cognitive evaluations did not differ between the groups. Five patients required non-invasive ventilation. CONCLUSION: Respiratory disorders are frequent in severe MS, mostly diaphragm dysfunction. Of interest, instrumental interventions are available to address these disorders.

Incidence and risk factors for long COVID in children with COVID-19 pneumonia.

BACKGROUND AND OBJECTIVE: There are only a few reports of long COVID including pulmonary function in children after COVID-19 pneumonia. We determined the incidence of long COVID and abnormal pulmonary function in those children and identify risk factors. METHODS: This cohort study enrolled children admitted with COVID-19 pneumonia during 2021-2022. We gathered clinical characteristics during admission and at follow-up 3 months after. RESULTS: We determined the incidence of long COVID at 39.7% (95% confidence interval [CI]: 30.7%-49.1%). All severe pneumonia cases consistently reported persistent symptoms. Exercise intolerance, cough, and fatigue were the three most common persistent symptoms in 26 (22.4%), 21 (18.1%), and 18 (15.5%) of the patients, respectively. At the follow-up, 21 cases (18.1%) demonstrated persistent abnormal chest radiographs. Three cases (6.9%) demonstrated restrictive ventilatory defects. Among those, one case (2.3%) demonstrated concomitant diffusion defect. Three cases (6.0%) demonstrated exercise-induced hypoxemia after the 6-minute walk test. Comparing spirometry variables between children with long COVID and without revealed significant difference of FEF25-75 (z score) between two groups. Age [adjusted OR (95% CI): 1.13 (1.05-1.22), p value 0.002], allergic diseases [adjusted OR (95% CI): 4.05 (1.36-12.06), p value 0.012], and living in polluted areas [adjusted OR (95% CI): 2.73 (1.18-6.33), p value 0.019] were significantly associated with long COVID. CONCLUSION: A significant percentage of children developed long COVID after COVID-19 pneumonia. We should give additional attention to those who have exercise intolerance, chronic cough, or fatigue, especially older children, severe cases, children with allergic diseases, and those living in polluted areas.

Assessing the effect of transcranial magnetic stimulation on peak cough flow in patients with supratentorial cerebral infarction: A retrospective cohort study.

Respiratory dysfunction following supratentorial cerebral infarction leads to pneumonia and is a major cause of mortality. Decreased voluntary cough function impairs the ability to clear mucus or secretions from the airways and increases the risk of aspiration pneumonia. Peak cough flow (PCF) is one of the objective tools for evaluating voluntary cough function. Repetitive transcranial magnetic stimulation (rTMS) could be applied to the respiratory motor cortex to improve respiratory function. Little is known about the effect of rTMS on PCF in patients with supratentorial cerebral infarction during the subacute period. This study aimed to determine whether rTMS treatment could improve PCF in patients with supratentorial cerebral infarction. We retrospectively recruited patients with subacute supratentorial cerebral infarction who underwent a PCF test. The rTMS group received a combination of rTMS treatment for 2 weeks and conventional rehabilitation for 4 weeks. However, the control group underwent only conventional rehabilitation for 4 weeks. PCF tests were performed before and after treatment and the results were compared between the 2 groups. In total, 145 patients with supratentorial cerebral infarctions were recruited. The PCF parameters before and after treatment increased in both the rTMS and control groups. However, the rTMS group showed a greater increase in PCF values compared with the control group. In patients with supratentorial cerebral infarction, the combination of conventional rehabilitation and rTMS in the subacute period may be helpful in improving voluntary cough function compared with conventional rehabilitation alone.

A 21-Year-Old Man With Dyspnea, Wheezing, and Cough.

CASE PRESENTATION: A 21-year-old male college student presented for a second opinion with low alpha-1 antitrypsin (AAT) levels and complaints of episodic dyspnea with wheezing and cough. He was a never smoker with a medical history of frequent respiratory tract infections in early childhood and allergy to dander, dust mites, peanuts, and eggs. There was no travel history outside of the continental United States. His mother had asthma. His symptoms were not controlled on inhaled corticosteroids and bronchodilators. His AAT genotype was found to be PI∗SZ, and augmentation therapy (with pooled human-plasma derived AAT) was recommended locally.

Influence of intrathoracic vagotomy on the cough reflex in the anesthetized cat.

Recurrent laryngeal afferent fibers are primarily responsible for cough in response to mechanical or chemical stimulation of the upper trachea and larynx in the guinea pig. Lower airway slowly adapting receptors have been proposed to have a permissive effect on the cough reflex. We hypothesized that vagotomy below the recurrent laryngeal nerve branch would depress mechanically or chemically induced cough. In anesthetized, bilaterally thoracotomized, artificially ventilated cats, thoracic vagotomy nearly eliminated cough induced by mechanical stimulation of the intrathoracic airway, significantly depressed mechanically stimulated laryngeal cough, and eliminated capsaicin-induced cough. These results support an important role of lower airway sensory feedback in the production of tracheobronchial and laryngeal cough in the cat. Further, at least some of this feedback is due to excitation from pulmonary volume-sensitive sensory receptors.

Vedolizumab-associated pulmonary manifestations in children with ulcerative colitis.

WHAT IS KNOWN AND OBJECTIVE: The off-label use of vedolizumab (VDZ) for inflammatory bowel disease in children is increasing. We report on possibly the first case of VDZ-associated pulmonary manifestations in paediatrics. CASE SUMMARY: This report details the case of a 13-year-old child with ulcerative colitis who was initiated on VDZ due to persistent active disease. After the first three doses, he developed a persistent and productive cough. Microbiological work-up was normal. VDZ discontinuation led to the resolution of symptoms. WHAT IS NEW AND CONCLUSION: To our knowledge, this is the first case report of VDZ-associated pulmonary manifestations in paediatrics. A direct, pro-inflammatory effect of VDZ has been hypothesized, but further studies are warranted.

Respiratory Characteristics in Patients With Major Burn Injury and Smoke Inhalation.

This study aimed to evaluate pulmonary function measurements and respiratory muscle parameters in patients with major burn injury and smoke inhalation. The inclusion criteria included patients who were diagnosed with a smoke inhalation burn or a major burn of more than 20% of total body surface area (TBSA). All subjects underwent a pulmonary function test, respiratory muscle strength test, peak cough flow and fluoroscopic diaphragmatic movement measurement, and 6-minute walk test before starting pulmonary rehabilitation. Evaluations were conducted on the 88th day after the injury, the average time of admission to the Department of the Rehabilitation Medicine for burn rehabilitation after the completion of the acute treatment. The average degree of burns of the total 67 patients was 34.6% TBSA. All parameters in the patient group were significantly lower than the healthy controls, and a mild restrictive pattern of impairment with a reduction in diffusing capacity and more reduced expiratory muscle, than inspiratory muscle strength were observed. Peak cough flow, respiratory muscle strength, and forced vital capacity in the patient group with inhalation burn were significantly lower than in those without inhalation burn. The conditions of the majority of patients with major burn and inhalation injury were consistent with restrictive impairment and significant reduction in diffusion capacity. The patients had expiratory muscle weakness, decreased diaphragmatic movement, and exercise capacity impairment.

The role of neuronal excitation and inhibition in the pre-Bötzinger complex on the cough reflex in the cat.

Brainstem respiratory neuronal network significantly contributes to cough motor pattern generation. Neuronal populations in the pre-Bötzinger complex (PreBötC) represent a substantial component for respiratory rhythmogenesis. We studied the role of PreBötC neuronal excitation and inhibition on mechanically induced tracheobronchial cough in 15 spontaneously breathing, pentobarbital anesthetized adult cats (35 mg/kg, iv initially). Neuronal excitation by unilateral microinjection of glutamate analog d,l-homocysteic acid resulted in mild reduction of cough abdominal electromyogram (EMG) amplitudes and very limited temporal changes of cough compared with effects on breathing (very high respiratory rate, high amplitude inspiratory bursts with a short inspiratory phase, and tonic inspiratory motor component). Mean arterial blood pressure temporarily decreased. Blocking glutamate-related neuronal excitation by bilateral microinjections of nonspecific glutamate receptor antagonist kynurenic acid reduced cough inspiratory and expiratory EMG amplitude and shortened most cough temporal characteristics similarly to breathing temporal characteristics. Respiratory rate decreased and blood pressure temporarily increased. Limiting active neuronal inhibition by unilateral and bilateral microinjections of GABAA receptor antagonist gabazine resulted in lower cough number, reduced expiratory cough efforts, and prolongation of cough temporal features and breathing phases (with lower respiratory rate). The PreBötC is important for cough motor pattern generation. Excitatory glutamatergic neurotransmission in the PreBötC is involved in control of cough intensity and patterning. GABAA receptor-related inhibition in the PreBötC strongly affects breathing and coughing phase durations in the same manner, as well as cough expiratory efforts. In conclusion, differences in effects on cough and breathing are consistent with separate control of these behaviors.NEW & NOTEWORTHY This study is the first to explore the role of the inspiratory rhythm and pattern generator, the pre-Bötzinger complex (PreBötC), in cough motor pattern formation. In the PreBötC, excitatory glutamatergic neurotransmission affects cough intensity and patterning but not rhythm, and GABAA receptor-related inhibition affects coughing and breathing phase durations similarly to each other. Our data show that the PreBötC is important for cough motor pattern generation, but cough rhythmogenesis appears to be controlled elsewhere.

Description of Epidemiological Features, Symptoms and Mortality of the Patients with COVID-19 in Some Provinces of Iran.

BACKGROUND: Clinical manifestations of COVID-19 are different. There are some risk factors for COVID-19. This study aimed to describe the epidemiological features, symptoms and mortality of the patients with COVID-19 in Iran. METHODS: This were a cohort study performed on 103,179 patients with COVID-19. The demographic and clinical data were collected in selected provinces. The required data of all patients was extracted from the COVID registry system and analyzed using STATA version 14 and Excel 2016. RESULTS: The mean age was 52.40 years for men and 52.41 years for women. About 55.2% of the study population were male and 44.8% were female. Totally, 60.9% (5085) of deaths happened in men and 39.1% (3263) in women. The mean time from onset of symptoms to hospitalization in men and women were 3.47 and 3.48 days, respectively. The mean time from onset of symptoms to isolation was 2.81 days in men and was 2.87 days in women, from onset of symptoms to death was 9.29 and 9.54 days, respectively, from onset of symptoms to discharge was 7.47 and 7.39 days, and from hospitalization to death was 6.76 and 7.05 days. Cough and shortness of breath were the most common symptoms in the patients. CONCLUSION: According to the results, the overall mortality rate was higher in men than women. Women with cardiovascular disease and diabetes were more likely to die. The mean time from onset of symptoms to hospitalization, isolation, and discharge was similar in men and women.

Prostaglandin E2 sensitizes the cough reflex centrally via EP3 receptor-dependent activation of NaV 1.8 channels.

BACKGROUND: Cough hypersensitivity is a major characteristic feature associated with several types of cough, including chronic cough, but its underlying mechanisms remain to be fully understood. Inflammatory mediators, such as prostaglandin E2 (PGE2), have been implicated in both peripheral induction and sensitization of the cough reflex. In this study, using a conscious guinea pig model of cough, we investigated whether PGE2 can sensitize the cough reflex via central actions and, if so, via which mechanisms. METHODS: All drugs were administered by intracerebroventricular (i.c.v.) route and whole-body plethysmograph set-up was used for both induction, using aerosolized citric acid (0.2 M), and recording of cough. Immunohistochemistry was performed to confirm the expression of NaV 1.8 channels in the nucleus tractus solitarius (nTS). RESULTS: We show that both PGE2 and the non-selective EP1/EP3 agonist, sulprostone, dose-dependently enhanced the citric acid-induced cough (P ≤ 0.001, P ≤ 0.01, respectively). Pretreatment with the EP1 antagonist, ONO-8130, did not affect the sulprostone-induced cough sensitization, whilst the EP3 antagonist, L-798,106, dose-dependently inhibited this effect (P ≤ 0.05). Furthermore, treatment with either the EP2 agonist, butaprost or the EP4 agonist, L-902,688, had no effect on cough sensitization. Additionally, pretreatment with either the TRPV1 antagonist, JNJ-17203212 or the TRPA1 antagonist, HC-030031, alone or in combination, nor with the NaV 1.1, 1.2, 1.3, 1.4, 1.6 and 1.7 channel blocker, tetrodotoxin, had any effect on the cough. In contrast, pretreatment with the NaV 1.8 antagonist, A-803467, dose-dependently inhibited this effect (P ≤ 0.05). Furthermore, NaV 1.8 channels were shown to be expressed in the nTS. CONCLUSION: Collectively, our findings show that PGE2 sensitizes the cough reflex centrally via EP3 receptor-dependent activation of NaV 1.8 but independently of TRPV1,TRPA1 and TTX-sensitive sodium channel activation. These results indicate that PGE2 plays an important role in central sensitization of the cough reflex and suggest that central EP3 receptors and/or NaVv 1.8 channels may represent novel antitussive molecular targets.

Predictive power of extubation failure diagnosed by cough strength: a systematic review and meta-analysis.

BACKGROUND: The predictive power of extubation failure diagnosed by cough strength varies by study. Here we summarise the diagnostic power of extubation failure tested by cough strength. METHODS: A comprehensive online search was performed to select potentially eligible studies that evaluated the predictive power of extubation failure tested by cough strength. A manual search was also performed to identify additional studies. Data were extracted to calculate the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC) to evaluate the predictive power of extubation failure. RESULTS: A total of 34 studies involving 45 study arms were enrolled, and 7329 patients involving 8684 tests were analysed. In all, 23 study arms involving 3018 tests measured cough peak flow before extubation. The pooled extubation failure was 36.2% and 6.3% in patients with weak and strong cough assessed by cough peak flow, respectively. The pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 0.76 (95% confidence interval [CI]: 0.72-0.80), 0.75 (0.69-0.81), 2.89 (2.36-3.54), 0.37 (0.30-0.45), 8.91 (5.96-13.32), and 0.79 (0.75-0.82), respectively. Moreover, 22 study arms involving 5666 tests measured the semiquantitative cough strength score (SCSS) before extubation. The pooled extubation failure was 37.1% and 11.3%, respectively, in patients with weak and strong cough assessed by the SCSS. The pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 0.53 (95% CI: 0.41-0.64), 0.83 (0.74-0.89), 2.50 (1.93-3.25), 0.65 (0.56-0.76), 4.61 (3.03-7.01), and 0.74 (0.70-0.78), respectively. CONCLUSIONS: Weak cough is associated with increased extubation failure. Cough peak flow is superior to the SCSS for predicting extubation failure. However, both show moderate power for predicting extubation failure.

A 30-Year-Old Immune Deficient Woman With Persistent Cough and Shortness of Breath.

CASE PRESENTATION: A 30-year-old woman was referred with increasing shortness of breath and cough in the setting of GATA2 deficiency. She initially presented 9 years previously with recurrent episodes of pneumonia and sinusitis. Genetic testing revealed a heterozygous GATA2 mutation (c.988C>T). She has since had multiple infections that have included necrotizing fasciitis of the right thumb, recurrent pilonidal infections (which required 23 procedures), esophageal candidiasis, and human papillomavirus-positive high-grade squamous intraepithelial lesion of the cervix. Serial bone marrow biopsy specimens showed persistent hypocellularity (20% to 60%) with intermittent erythroid atypia and variable detection of trisomy 8, which were concerning for evolving myelodysplastic syndrome. One year before the current admission, she was diagnosed with disseminated Mycobacterium avium complex and was treated with rifabutin, ethambutol, and azithromycin. She was taking voriconazole, acyclovir, and trimethoprim-sulfamethoxazole prophylaxis.

A 70-Year-Old Man With Cough and Recurrent Respiratory Infections.

CASE PRESENTATION: A 70-year-old man was referred for evaluation of recurrent respiratory infections requiring antibiotics and chronic cough over 3 years. Two months prior to presentation, he started to develop blood-tinged sputum but not frank hemoptysis. He otherwise denied any fever, chills, night sweats, or weight loss. He had dyspnea during the respiratory infections but not otherwise. His medical history was significant for chronic rhinitis without sinusitis and a low serum IgM level. He was a never smoker and a farmer but otherwise had no significant or specific exposures or travel history. His family history was significant for alpha-1 antitrypsin deficiency in his mother.

A 51-Year-Old Man With a Large Posterior Mediastinal Mass.

CASE PRESENTATION: A 51-year-old White male never-smoker presented with intermittent cough and progressive dyspnea. His symptoms started after an exposure to bat guano while cleaning his attic approximately 9 months earlier. He has received several courses of antibiotic and corticosteroid for these symptoms, with short-term relief.