Facial flushing on upper limb exertion: a rare presentation of superior vena cava obstruction.

Infection remains a significant problem for patients with cardiac-implantable electronic devices (CIEDs) but can be difficult to diagnose. We describe an unusual presentation of CIED infection in a patient with abandoned pacemaker leads. A 27-year-old male presented with facial flushing on upper but not lower limb exertion due to superior vena cava (SVC) obstruction, as well as pleuritic chest pain due to septic emboli. This was successfully treated with antibiotics and complete endovascular extraction of the pacemaker leads. Upper limb exertional facial flushing may be a useful clinical sign for the diagnosis of SVC obstruction. This case report also describes a rare presentation of CIED infection.

Primary pleural epithelioid hemangioendothelioma mimicking as a posterior mediastinal tumor.

A 41-year-old man with no previous asbestos exposure presented with 6 months of dull right lower chest pain and weight loss. The initial computed tomography (CT) scan was reported as showing a soft tissue thickening in the posterior mediastinum with non-specific nodules in the horizontal and oblique fissures. An endoscopic ultrasound-guided fine needle aspiration from the 12 × 25 mm heterogeneous posterior mediastinal mass was suspicious for a ganglioneuroma. The procedure was complicated by a large hemothorax requiring drainage. A subsequent positron emission tomographic CT revealed a moderately fluorodeoxyglucose avid area of pleural thickening extending from the sixth to ninth thoracic vertebral body in the paraspinal region along with nodules along the right horizontal and oblique fissures. A thoracoscopic biopsy of the pleural lesion confirmed a pleural epithelioid hemangioendothelioma. There was a 5-mm reduction in tumor thickness and improvement in his pain following 54 Gy of radiotherapy.

Mycobacterium phocaicum and Mycobacterium avium-intracellulare in a patient with hot tub lung.

A 77-year-old woman who used her spa pool at least twice a day to relieve pain from osteoarthritis, developed progressive breathlessness, impaired pulmonary function, and radiographic changes consistent with hypersensitivity pneumonitis-like lung disease. M ycobacterium avium-intracellulare complex (MAC) was cultured from bronchoalveolar lavage fluid. Transbronchial biopsies revealed non-necrotizing granulomatous inflammation. Sputum and spa pool water cultured M ycobacterium phocaicum but not MAC. She stopped using the spa pool and was treated with oral prednisone, which led to symptomatic, pulmonary function, and radiographic improvement. This is the first case of hypersensitivity pneumonitis-like granulomatous lung disease associated with exposure to M . phocaicum in spa pool water.