A Rare Case of Idiopathic Pleuro-Parenchymal Fibroelastosis Presenting With Bilateral Spontaneous Pneumothoraces.

Pleuroparenchymal fibroelastosis (PPFE) is a rare interstitial lung disease (ILD), characterized by predominantly upper lobe pleural and subjacent sub-pleural parenchymal fibrosis. Its name refers to a combination of fibrosis involving the visceral pleura with fibroelastotic changes, predominantly in the subpleural lung parenchyma. We describe the case of a 67-year-old lady who presented to the accident and emergency department of Weston General Hospital with worsening shortness of breath (SOB) and cachexia of six to eight months' duration. The initial imaging studies showed bilateral spontaneous pneumothoraces on a background of pleural-based consolidation and fibrotic changes. A subsequent high-resolution CT (HRCT) chest showed evidence of pleuroparenchymal fibroelastosis in the background. She was not considered for anti-fibrotic medications due to the advanced stage of the disease and was managed with supportive measures, including oxygen support, oral steroids and antibiotics to cover for any infections. After initial management of symptoms and long discussions with the patient, family and the palliative team, she was discharged home with community follow-up.

Metastatic Renal Cell Carcinoma Presenting as an Intracardiac Tumour Without Involving the Inferior Vena Cava.

Renal cell carcinoma (RCC) is an aggressive tumour, with 25% of the cases presenting with distant metastases at the time of diagnosis. Approximately 33% of the patients with RCC eventually develop metastatic spread. RCC can metastasize to various sites including the lung, liver, bone, brain, adrenal gland, and more. Cardiac metastasis is rare in RCC, but even rarer in the absence of inferior vena cava (IVC) involvement. This case report presents a 60-year-old male patient who was referred by his general practitioner due to breathing difficulties. An initial echocardiogram revealed a right ventricular outflow tract obstruction caused by a mass. A subsequent cardiac MRI showed a right ventricular mass with features suggestive of a metastatic spread. A CT scan of the thorax, abdomen and pelvis was done to ascertain the primary tumour which revealed RCC, without involving the IVC. Due to the presence of metastases, advanced disease, and heavy tumour burden, the multidisciplinary team concluded that there were almost negligible treatment options available at that stage and recommended the best supportive care and community hospice support. The patient was discharged once his symptoms improved, as per his request, and he passed away peacefully at home within a month. This case highlights the very rare occurrence of cardiac metastasis of RCC without IVC involvement. It also illustrates the approach and investigations involved in the evaluation of complex cardiac masses.

Pneumocystis jirovecii Pneumonia (PCP) in a Non-HIV Lung Cancer Patient in the Absence of Common Risk Factors.

Pneumocystis jirovecii pneumonia (PCP) has been described mainly in AIDs and in immunocompromised patients with hematological malignancies, organ transplant recipients, collagen vascular disease, and primary immune deficiencies or those under treatment with steroids or chemotherapy. The incidence of PCP pneumonia is increasing in solid organ tumors and hematological malignancies receiving chemotherapy. Pneumocystis pneumonia has been rarely reported in patients with non-small cell lung cancer (NSCLC). We describe a 68-year-old woman with a recent diagnosis of squamous cell lung cancer, who received radiotherapy two weeks prior to the current hospital admission with shortness of breath and dry cough. The initial investigations, including chest X-ray and CT images, were suggestive of atypical pneumonia, with PCP pneumonia as the top differential. Treatment was started with high-dose trimethoprim-sulfamethoxazole (cotrimoxazole) and oxygen support. Serum beta-glucan was found to be more than 500 pg/ml in favor of PCP infection. Oral steroids were added to the treatment in view of hypoxia (arterial oxygen pressure (PaO2) < 70 mmHg) requiring high-flow nasal cannula support. Subsequently, bronchoscopy was done and the bronchoalveolar lavage (BAL) sample came positive for PCP polymerase chain reaction (PCR). The patient made a significant recovery after four weeks of treatment with cotrimoxazole and was discharged home in stable condition with cotrimoxazole prophylaxis. The reported cases of PCP pneumonia in lung cancers were following chemotherapy, chemoradiation, or steroid treatment. The incidence of PCP pneumonia in lung cancer patients receiving radiotherapy is relatively rare. Our patient could not tolerate chemotherapy for the cancer due to an anaphylactic reaction and hence was treated with radiotherapy alone for the lung cancer prior to getting PCP pneumonia. Therefore, it is important to carry a high index of suspicion for PCP infection in a lung cancer patient presenting with features of atypical pneumonia following cancer treatments, including radiotherapy alone.

Bilateral Pulmonary Embolism in a Newly Diagnosed Case of Pulmonary Tuberculosis.

Pulmonary embolism in the cases of tuberculosis (TB) infection has incited physicians and researchers to derive a reasonable association in the past few years. However, despite the efforts, pulmonary embolism is often misdiagnosed in the context of active TB. Pulmonary embolism in TB is still considered a rare phenomenon, even though it seems to be a probable risk factor based on the emerging literature. We report a case of a young man who presented with recurrent respiratory symptoms. He had no risk factors except a former history of smoking. We believe that the symptoms he had on the initial visit were misinterpreted in the background of TB infection. We followed the case for two months after he was discharged on anticoagulants and anti-TB medication. In this case report, we would like to emphasize the need to consider this occult phenomenon in order to rule out TB in cases of pulmonary embolism and vice versa. We hope that the management of TB in the future might take into account the chances of concomitant pathology of pulmonary embolism in patients with active TB.

Kawasaki Disease-Like Features in 10 Pediatric COVID-19 Cases: A Retrospective Study.

Children with coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), usually present with symptoms of mild upper respiratory tract infection without developing any significant complications. However, this observation has been rendered incautious by hundreds of clinical cases from around the world that have depicted a less benign multisystem inflammatory illness mimicking Kawasaki disease in COVID-positive pediatric patients. Our study aimed at retrospectively reviewing the different features of Kawasaki disease-like illness in children suffering from COVID-19, including the complications, laboratory investigations, treatment strategies used during their hospital stay, and outcomes. We searched the electronic database of the two pediatric units of Mayo Hospital, Lahore, Pakistan, for children who had been admitted to the ward between April 2020 and July 2020 and were diagnosed with COVID-19. A total of 10 such pediatric cases were found, whose clinical details were then reviewed and the obtained data were presented in the form of tables and percentages. The median age was between 4 months to 11 years (mean: 6 years). Of the 10 patients, 8 (80%) were boys. Criteria for Kawasaki disease were met in all of them (100%), with a complete presentation in five (50%). Fever (100%), conjunctival and oral cavity changes (90%), and rash (80%) were the most common features. Seven (70%) patients required admission to a critical care unit, but no mortality occurred. This article can assist in understanding and dealing with Kawasaki disease-like manifestation of pediatric COVID-19 infection, especially in critical care settings, and its possible complications. It will help in a timely and appropriate decision-making regarding treatment and management of such cases.