Radical treatment for blastomycosis following unsuccessful liposomal amphotericin.

Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces spp, which is acquired through inhalation of the fungal spores. Blastomycosis is relatively uncommon, with yearly incidence rate of 1-2 cases per 100 000 people. Blastomycosis is a disease that is endemic to the midwest and southern regions of the USA, most commonly affecting immunocompromised patients. About 50% of patients are asymptomatic, but for those who progress to acute respiratory distress syndrome (ARDS) mortality can be as high as 80%. Patients with severe blastomycosis are initially treated with intravenous amphotericin B, followed by long-term itraconazole maintenance therapy. In this Grand Round, we present the case of an immunocompetent 35-year-old man diagnosed with chronic pulmonary blastomycosis who had a poor response to 10 days of intravenous liposomal amphotericin B (L-AmB). He was endotracheally intubated and eventually cannulated for extracorporeal membrane oxygenation (ECMO), due to worsening respiratory function. L-AmB was replaced with a continuous infusion of intravenous amphotericin B deoxycholate (AmB-d). He improved significantly and was decannulated from ECMO on day 9 of AmBd continuous infusion and extubated on day 12 Although L-AmB is considered first-line treatment for blastomycosis, mortality remains high for patients with ARDS associated with blastomycosis. This case highlights the importance of considering AmB-d continuous infusions for patients with severe blastomycosis who might have poor clinical responses to L-AmB.

Endobronchial Lesions in Patients Presenting with Hemoptysis.

OBJECTIVES: The aim of this study was to determine the incidence of endobronchial lesions in patients presenting with hemoptysis. We also aimed to characterize features that would predict whether bronchoscopy would be useful. METHODS: A retrospective chart review was conducted on 185 consecutive patients who presented with hemoptysis from January 1, 2006 to December 31, 2015 at Methodist Le Bonheur Healthcare-affiliated hospitals in Memphis, Tennessee. Data collection included demographic information, description of hemoptysis, imaging results, bronchoscopy results, and the final diagnosis. RESULTS: A total of 185 patients presented with hemoptysis during our study period. Of these, 14 patients were excluded because of age (younger than 18 years) and incomplete data (inadequate information about the procedure performed, lack of imaging studies, incorrect International Classification of Diseases, Ninth Revision coding). The final analysis was performed in 171 patients; 87 underwent bronchoscopy either to determine etiology or to aid in management. Most patients (73%) had mild hemoptysis, with approximately half of the patients having hemoptysis for ≤1 day. Of 87 people who underwent bronchoscopy, 12 (13.8%) were found to have endobronchial lesions, and 35 (51.7%) patients were found to have either active bleeding or had fresh blood in their airway during bronchoscopy. Final diagnoses included pneumonia/bronchitis in 30 (18.9%) patients, malignancy in 24 (15.1 %), and anticoagulation toxicity in 23 (14.5%) patients. CONCLUSIONS: Bronchoscopy should be strongly considered in patients presenting with hemoptysis, especially if it is frank blood, of >1 week's duration, or both, because the information obtained can be vital for management. This appears to hold true even for patients who have no abnormalities seen on computed tomography chest imaging upon initial workup.

An unusual case of interstitial lung disease in a patient with cardiopulmonary syndrome as the initial presentation of Erdheim-Chester disease.

Erdheim-Chester disease (ECD) is a very rare disorder with only approximately 600 cases reported in the literature. ECD has been recently reclassified as a histiocytic dendritic cell neoplasm. The clinical spectrum ranges from asymptomatic tissue accumulation of histiocytes to invasive tissue infiltration, which can cause fulminant multisystem failure. It typically presents with bone pain and constitutional symptoms. Extraosseous manifestations are not uncommon. ECD-associated interstitial lung disease has been described in 20%-35% of patients. Diagnosis is primarily by tissue biopsy and immunohistochemistry showing xanthogranulomas composed of foamy histiocytes that stain positive for CD68, CD14 and CD163 and negative for CD1á and langerin. We report a case of ECD in a young man with cardiopulmonary involvement who presented with haemoptysis and dyspnoea.

Aging is associated with impaired thrombus resolution in a mouse model of stasis induced thrombosis.

INTRODUCTION: To evaluate the effects of aging on venous thrombosis. MATERIAL AND METHODS: Anesthetized male mice (C57BL/6, n=125) underwent complete inferior vena cava occlusion to produce venous thrombosis. Experimental groups included 11-month-old mice (OLD), 2-month-old mice (YOUNG), and age-matched non-thrombosed controls. Mice were euthanized and the following parameters were evaluated two days post-thrombosis: thrombus mass (grams/cm), vein wall inflammatory cells (cells per 5 high powered fields), active plasma plasminogen activator inhibitor-1 (PAI-1, ng/mL), vein wall P-selectin protein determination by ELISA (pg/mL), circulating plasma microparticles (MPs, MPs/200microL), MP tissue factor (TF) activity (pM), and in vivo MP re-injection experiments. RESULTS: Thrombosed OLD mice had greater thrombus mass than YOUNG mice (389+/-18 vs. 336+/-14 gx10(-4)/cm, P<.05). OLD mice had decreased vein wall monocyte, lymphocyte, and total inflammatory cell populations versus YOUNG mice (P<.05). Vein wall P-selectin levels were greater in OLD thrombosed mice versus YOUNG (7306+/-938 vs. 3805+/-745pg/mL, P<.05). Active plasma PAI-1 concentrations were increased in OLD mice versus YOUNG thrombosed animals (20+/-4 vs. 8+/-2ng/mL, P<.05). OLD mice had significantly higher circulating leukocyte-derived MPs versus YOUNG mice (5817+/-850 vs. 2563+/-283 MPs/200muL PPP, P<.01). OLD mice had plasma MPs with increased TF activity versus YOUNG animals post-thrombosis (34+/-4 vs. 24+/-2 pM, P<.05). Finally, YOUNG recipient animals, whether re-injected with OLD or YOUNG donor MPs, had a significant increase in thrombus mass versus OLD recipient animals (P<.01). CONCLUSION: Aging influenced several circulating and vein wall factors that decreased thrombus resolution in older animals compared to younger ones in our mouse thrombosis model.