Pulmonary metastatic melanoma: current state of diagnostic imaging and treatments.

Melanoma is the deadliest form of skin cancer with an estimated incidence of over 160,000 cases annually and about 41,000 melanoma-related deaths per year worldwide. Malignant melanoma (MM) primarily occurs in the skin but has been described in other organs. Although the respiratory system is generally afflicted by tumors such as lung cancer, it is also rarely affected by primary MM. The estimated incidence of pulmonary MM of the lung accounts for 0.01% of all primary lung tumors. The current understanding of pulmonary MM of the lung pathophysiology and its management are not well established. We aim to survey current clinical modalities with a focus on diagnostic imaging and therapeutic intervention to guide providers in the management of patients with a high index of suspicion.

The peripheral neutrophils in subjects with COPD-OSA overlap syndrome and severe comorbidities: A feasible inflammatory biomarker?

BACKGROUND: Overlap syndrome (OS) describes the association of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) in a single individual. Subjects with OS have increased cardiovascular mortality which is presumed to be inflammation-mediated. As a clinical biomarker, an increased neutrophil count correlates with the severity of coronary artery stenosis. OBJECTIVES: As little is known about the role of neutrophils in the underlying inflammatory mechanisms in OS, we aimed to assess the percentage of peripheral neutrophils (PPN) in OS vs in COPD alone. MATERIAL AND METHODS: A cross-sectional study of patients with COPD and severe comorbidities, as defined by a Care Assessment Need score over 95, were seen in the Pulmonary Tele-Health Clinic at the Salem Veteran Affairs Medical Center, USA, over a 1-year period. Demographic and polysomnographic data, FEV1 and the Charlson Comorbidity Index (CCI) were extracted from the Electronic Medical Records. Obstructive sleep apnea was defined according to the American Academy of Sleep Medicine (AASM) guidelines. Serum inflammatory markers (PPN, CRP, fibrinogen and procalcitonin) were obtained after the Tele-Health appointment. RESULTS: Out of the 38 subjects with COPD, 17 (44%) had OS. Compliance with continuous positive airway pressure therapy (CPAP) was excellent in 7 OS subjects (41%). There was a significant difference in the PPN of subjects with OS vs COPD alone, regardless of whether they were compliant (p = 0.03) with the CPAP therapy or not (p = 0.005). No differences in the severity of COPD, baseline comorbidity, smoking, or inflammatory markers were found between the OS and COPD-only subjects. Body mass index (BMI), COPD severity, smoking, and home oxygen therapy (HOT) use were not associated with PPN (p > 0.2). CONCLUSIONS: Overlap syndrome subjects have higher PPN than those with COPD alone, regardless of their CPAP compliance. Our results could be used to motivate OS subjects to improve their lifestyles and to comply with drug therapies aimed at reducing cardiovascular disease (CVD).

Three decades of transtracheal oxygen therapy: A review of the associated complications with an illustrative case presentation.

Transtracheal oxygen therapy is a well-established modality for improving oxygenation in patients with chronic obstructive pulmonary disease, sleep apnea, pulmonary fibrosis, and other conditions causing hypoxic respiratory failure. In spite of its proven track record, the device remains underutilized. This article reviews benefits and complications related to the use of this modality with an illustrative case presentation.

How a mild influenza B infection can kill: A case of pulmonary hemorrhage.

Viral influenza is a seasonal infection associated with significant morbidity and mortality. Rapidly fatal hemorrhagic pneumonia has been described in previously healthy individuals with ß-hemolytic Streptococcus pneumoniae in a small series of patients, but it is not common in patients coinfected with influenza B and ß-hemolytic Streptococcus, particularly since influenza B is considered less pathogenic than influenza A. However, despite being uncommon, this coinfection seems to be associated with high morbidity and mortality, particularly in healthy individuals. We present a case of a 46-year-old previously healthy white woman presenting with 4 days of shortness of breath, sore throat, subjective fevers, and nonproductive cough with rapidly fatal hemorrhagic pneumonia confirmed to have Group A ß-hemolytic Streptococcus and influenza B coinfection. On admission, she had a temperature of 103° F, room air oxygen saturation of 95%, a positive nasal swab for influenza B, and negative rapid strep test. Initial chest radiograph showed increased bibasilar interstitial markings. She was admitted to a regular floor and started on oseltamivir. Preliminary throat culture was positive for Group A ß-hemolytic Streptococcus and penicillin V was started. Respiratory status deteriorated requiring intubation and transfer to Intensive Care Unit. Subsequently, copious bleeding was noted in her endotracheal tube. A bedside bronchoscopy with bronchoalveolar lavage revealed a hemorrhagic pneumonitis. Despite aggressive efforts, she developed shock, arrested, and died Western District Office of the Chief Medical Examiner, Roanoke, VA, USA postadmission. Blood cultures, bronchoalveolar lavage, and postmortem pulmonary tissue grew Group A ß-hemolytic Streptococcus, only resistant to erythromycin.

Meropenem: A possible new culprit in eosinophilic lung diseases.

Eosinophilic lung diseases are a diverse group of pulmonary disorders with an extensive list of differential diagnoses. Multiple drugs particularly antibiotics can cause pulmonary eosinophilia with variable pulmonary manifestations. Cutaneous drug reactions are common. Diagnosis is usually made on clinical history and blood eosinophilia with an accumulation of eosinophils in alveolar spaces on histologic analysis. Imaging findings are nonspecific. Stopping the offending agent is often enough while a short course of corticosteroids can hasten recovery. We present a unique case of eosinophilic pneumonia due to meropenem that highlights the importance of keeping a low threshold of suspicion regarding the etiology of drug-induced lung diseases as the current list is not exhaustive, and new agents are being identified continuously. A 51-year-old African American woman presented with fever, dyspnea, and diffuse pustular rash. She had been treated with meropenem intravenously through a peripherally inserted central catheter for 6 weeks before presentation for Pseudomonas aeruginosa septic arthritis of the left knee. She had a temperature of 102.2 F and SpO2of 86% on room air. Chest roentgenogram had scattered infiltrates and chest tomography showed bilateral ground-glass opacities. Laboratory workup showed peripheral eosinophilia. Bronchoalveolar lavage revealed a white blood cell of 2230 with 89% eosinophils. Skin lesions' biopsies showed pustular dermatosis, compatible with acute drug-induced eosinophilic lung disease with skin involvement. As meropenem was the only medication she had been exposed to, it was stopped and systemic steroids were initiated with improvement in respiratory and clinical status and complete recovery on follow-up.

Cryotherapy: A viable tool to remove broncholiths under flexible bronchoscopy.

Broncholithiasis is the presence of calcific material within the tracheobronchial tree. Asymptomatic patients can be managed with observation only, whereas symptomatic disease requires surgery, rigid or flexible bronchoscopic removal. Recent reports have shown that flexible bronchoscopy can be a safe and effective option for removal of loose in addition to partially imbedded broncholiths. We present a case of a 65-yearold man with chronic cough that underwent successful cryotherapy assisted bronchoscopic removal of an imbedded broncholith. We will also review current literature regarding the management broncholithiasis.

Lacrimal Gland Inflammation Deregulates Extracellular Matrix Remodeling and Alters Molecular Signature of Epithelial Stem/Progenitor Cells.

PURPOSE: The adult lacrimal gland (LG) is highly regenerative and is able to repair itself even after substantial damage; however, this ability to regenerate is lost with the development of dry eye conditions in chronically inflamed LGs.This study compares changes in the cell adhesion and cell matrix molecules and stem cell transcription factors in the LGs of healthy mice and of two mouse models of Sjögren's syndrome: nonobese diabetic (NOD) and MRL-lpr/lpr (MRL/lpr) mice during the early stage of inflammation. METHODS: The LGs from 12- to 13-week-old female MRL/lpr and male NOD mice along with their respective control strains were harvested and divided into three pieces and processed for quantitative (q) RT-PCR and qRT-PCR Arrays, histology, immunohistochemistry, and Western blotting. RESULTS: The extracellular matrix (ECM) and adhesion molecules RT2-PCR array combined with protein expression data revealed changes in the expression of integrins, matrix metalloproteinases, and other molecules, which are associated largely with invasion, attachment, and expansion of the lymphocytic cells, whereas changes in the stem cell transcription factors revealed substantial decrease in expression of transcription factors associated with epithelial stem/progenitor cell lineage. CONCLUSIONS: We concluded that the expression of several important ECM components is significantly deregulated in the LG of two murine models of Sjögren's syndrome, suggesting an alteration of the epithelial stem/progenitor cell niche. This may result in profound effects on localization, activation, proliferation, and differentiation of the LG stem/progenitor cells and, therefore, LG regeneration.

Clinical review of pulmonary manifestations of IgG4-related disease.

IgG4-related disease (IgG4-RD) is a recently recognized systemic disease characterized by tumefactive lesions in various organ systems. The list of organs that can be involved continues to expand, and recently computed tomography (CT) descriptions of the pulmonary lesions found in the disease have been described. The clinical symptoms are nonspecific and may include cough, dyspnea, chest pain, and fever. The appropriate clinical presentation along with elevated serum IgG4 concentrations and pathologic evidence of lymphoplasmacytic infiltrates with abundant IgG4-positive plasma cells and storiform fibrosis is consistent with the disease. Steroids are used to treat this disease in addition to immunosupressives such as cyclosporine or rituxumab for steroid refractory disease. The pulmonary manifestations and imaging features can often mimic malignancy, and as such knowledge of the diagnostic, clinicopathologic, and radiographic features of the disease is required in order to provide appropriate diagnostic workup and treatment.