Autosplenectomy Causing Catastrophic Pneumococcal Meningitis in a Patient with Lupus/Antiphospholipid Antibody Syndrome.

We present the case ofa26-year-old female who presented to the hospital with pneumococcal meningitis. A review of her records showed atrophic spleen, and a hypercoagulable workup was positive for Systemic Lupus Erythematous (SLE)/Antiphospholipid Antibody Syndrome (APS). An autosplenectomy from thrombotic occlusion of the splenic artery made her susceptible to pneumococcal meningitis. Autoimmune conditions, particularly SLE and APS, are important causes of hypercoagulable states in a young population, and earlier detection of these conditions and appropriate treatment helps to decrease morbidity and mortality among these patients.

Legionella pneumonia complicated by myocarditis and torsades de pointes: A case report and review of literature.

Legionella infection most commonly manifests as pneumonia. Extrapulmonarylegionellosis is rare, but the clinical manifestations are often dramatic. Myocardialinvolvementis the most common extrapulmonary manifestation of legionellosis and can result in left ventricular dysfunction. We report a case of Legionellapneumopbila-induced myocarditis and acute left ventricular dysfunction with subsequent development of torsades de pointes (TdP) in a young adult with no other risk factors. Early recognition of this complication is paramount as timely initiation of appropriate antibiotics is crucial to ensure full recovery from this form of reversible carditis.

Neurosarcoidosis presenting with isolated spinal involvement: report of a case and review of the literature.

Spinal sarcoidosis is a rare manifestation of sarcoidosis that can present a major diagnostic challenge. Herein we present a case of a previously healthy 55-year-old man who presented with leg weakness and was found to have diffuse involvement of his spinal cord by neurosarcoidosis. He was treated with steroids and recovered completely. The clinical characteristics, radiographic and laboratory findings of spinal sarcoidosis are discussed. Management strategies, including the use of newer targeted therapies, are also reviewed.

A 64-year-old woman with a left upper-lung field lobulated mass.

Pulmonary mucinous cystic neoplasia (PMCN) is an uncommon primary lung malignancy. Approximately 80 cases have been reported in the literature. We describe a case and review the literature on this malignancy. Our patient was asymptomatic and presented with a left upper-lung field lobulated mass. Primary PMCN is a spectrum of mucinous cystic lesions that should be considered as a separate lung tumor entity due to its unique morphologic features and its distinct clinical behavior. Prognosis is generally better than other more common lung malignancies.

Small cell lung cancer with paraneoplastic lipase production.

Kulchitsky cells represent the cells of origin of small cell lung cancer (SCLC). They display an antigenic makeup characteristic of both the neural crest and epithelium and have been shown to secrete both polypeptide hormones and enzymes. The coexistence of two or more (concomitant or sequential) paraneoplastic endocrine syndromes is possible with SCLC, and paraneoplastic amylase production has also been described with this malignancy. We present here the first patient with an extensive stage SCLC, exhibiting a marked paraneoplastic lipase production and a syndrome of inappropriate antidiuretic hormone (SIADH) secretion. In our patient, the paraneoplastic hyperlipasemia paralleled both the initial SCLC response to chemotherapy and its subsequent clinicoradiological relapse.

Tumor fever, paraneoplastic leukocytosis and necrotic liver metastases: a triad worth remembering.

Arriving at the diagnosis of tumor fever may prove difficult for the clinician and should always be based upon investigations that exclude other potential causes of fever. Timely recognition of this entity is essential for the effective delivery of care to cancer patients. In solid malignancies, tumor fever is commonly associated with rapidly progressive metastatic disease and a limited survival. Liver metastases are present in many of these patients and some of them may display significant systemic inflammation. We report two unique patients with adenocarcinoma of the lung associated with tumor fever, necrotic liver metastases and granulocyte-colony stimulating factor (G-CSF) driven leukocytosis.

When the diagnosis is a zebra: pulmonary artery aneurysm.

Some ailments maypresent so distinctively that the diagnosis is often unquestionable. Other cases, however, may present typically, but have atypical findings. We describe a case of a patient who presented to our institution with recurrent hemoptysis. The clinical features were suggestive of an underlying infection or malignancy. When these were ruled out, the search for a zebra had begun. The patient underwent sixty four-slice computerizedtomographic angiography (CTA) which revealed a right pulmonary artery aneurysm (PAA). Timely involvement of interventional radiologists and thoracic surgeons prevented a potentiallylife-threatenninghemorrhage. This case underlines the importance of awareness of this condition in the formulation of a differential diagnosis forhemoptysis. PAAis a rare condition that is either congenital or acquired. Common acquired etiologies include chronic thromboembolic pulmonary hypertension, infections (syphilis and tuberculosis), vasculitis (Behcet's and Hughes-Stovin syndromes), neoplasms (primaryandmetastatic), andtrauma(most often iatrogenic).

Mediastinal angiosarcoma presenting as diffuse alveolar hemorrhage.

Angiosarcomas are malignant vascular tumors. Angiosarcomas arising in the thorax such as angiosarcoma of the lungs, heart and mediastinum are extremely rare. There are no reports of mediastinal angiosarcomas presenting with diffuse alveolar hemorrhage, which is a clinical syndrome characterized by the presence of hemoptysis, dyspnea, hypoxia, diffuse lung infiltrates and anemia. Usually, diffuse alveolar hemorrhage is caused by pulmonary capillaritis. Local invasion is more common with these tumors than distant metastasis. These tumors are very aggressive and have a poor response to treatment modalities including surgical resection, chemotherapy, and radiation. Consequently, they carry a poor prognosis. Due to the rarity of these tumors, no standard chemotherapy or radiation protocol exists. We report a case of diffuse alveolar hemorrhage caused by a previously unreported entity: angiosarcoma of the mediastinum.

Combined thrombolysis and inferior vena caval interruption as a therapeutic approach to massive and submassive pulmonary embolism.

BACKGROUND: Massive and a submassive pulmonary embolism (PE) is a life-threatening emergency. This condition is usually treated urgently with measures to attain hemodynamic stability and anticoagulation. In selected subjects, thrombolysis, inferior vena caval interruption and embolectomy have been used. We report a consecutive case series of subjects with massive and submassive pulmonary embolism treated with both inferior vena caval interruption and thrombolysis. METHODS: Chart review of consecutive cases of massive and submassive pulmonary embolism treated with both inferior vena cava filter placement and thrombolysis. Hospital course was reviewed and subjects were followed up six months after the acute event. Complications as a result of therapy were documented. RESULTS: Sixteen subjects were identified. Ten (62.5%) subjects were categorized as submassive and six subjects (37.5%) were categorized as massive. There was no attributable mortality to PE or its treatment. Minor bleeding was seen in the majority of subjects (75 %) but major bleeding was seen in only one (6.25%) subject. Other complications were not encountered. No recurrent thromboembolic events were clinically evident during a six-month follow-up period. CONCLUSIONS: The combination of inferior vena caval interruption and thrombolysis seems safe and effective for the treatment of PE. This modality was not associated with mortality in any of our patients. The only complication encountered was bleeding primarily at the sites of vascular access. We conclude that combined vena caval interruption and thrombolysis is a safe means of treating potentially life-threatening pulmonary embolism.

A 44-Year-Old Man With Sore Throat and Fatigue After Using an Old Camper Van.

A 44-year-old man from Connecticut with no significant past medical history presented to the ED with a 2-week history of sore throat and fatigue, subsequently developing cough, dyspnea, fevers, and chills. The patient reported buying an old camper van and noticed a large infestation of rodent droppings, which he had cleaned thoroughly from the cabin. He used the camper van on several camping trips in Vermont, and symptoms started on his return.

Preoperative evaluation of patients undergoing lung resection surgery.

Lung cancer continues to be the leading case of cancer deaths in the United States. In patients with resectable non-small cell lung cancer, surgical resection is the treatment of choice. An accurate preoperative general and pulmonary-specific evaluation is essential as postoperative complications and morbidity of lung resection surgery are significant. After confirming anatomic resectability, patients must undergo a thorough evaluation to determine their ability to withstand the surgery and the loss of the resected lung. The measurement of spirometric indexes (ie, FEV(1)) and diffusing capacity of the lung for carbon monoxide (DLCO) should be performed first. If FEV(1) and DLCO are > 60% of predicted, patients are at low risk for complications and can undergo pulmonary resection, including pneumonectomy, without further testing. However, if FEV(1) and DLCO are < 60% of predicted, further evaluation by means of a quantitative lung scan is required. If lung scan reveals a predicted postoperative (ppo) values for FEV(1) and DLCO of > 40%, the patient can undergo lung resection. If the ppo FEV(1) and ppo DLCO are < 40%, exercise testing is necessary. If this reveals a maximal oxygen uptake (O(2)max) of > 15 mL/kg, surgery can be undertaken. If the O(2)max is < 15 mL/kg, surgery is not an option. This review discusses the existing modalities for preoperative evaluation prior to lung resection surgery.

An evaluation of nebulized levalbuterol in stable COPD.

BACKGROUND: Levalbuterol, the R-isomer of albuterol, has advantages over racemic albuterol in asthma; however, the effectiveness of this beta-agonist in COPD has received little attention. OBJECTIVES: To evaluate the effectiveness of a single dose of nebulized levalbuterol in COPD. DESIGN: A randomized, double-blind, placebo-controlled trial comparing nebulized levalbuterol to racemic albuterol, combined racemic albuterol and ipratropium, and placebo. PATIENTS: Thirty patients with stable COPD (FEV(1) between 45% and 70% of predicted) were studied. METHODS: After withholding usual bronchodilator medications for appropriate washout periods, patients were randomized on separate visits to receive single doses of each the following nebulized bronchodilator medications: (1) levalbuterol, 1.25 mg; (2) racemic albuterol, 2.5 mg; (3) combined racemic albuterol, 2.5 mg, and ipratropium, 0.5 mg; or (4) placebo. FEV(1), FVC, pulse rate, and oxygen saturation were measured at baseline, 0.5 h following nebulization, and hourly for 6 h. Hand tremor, using a 7-point scale, was measured at baseline, 0.5 h, 1 h, and 2 h. Treatment-placebo differences were analyzed using repeated-measures analysis of variance and least-squares means. RESULTS: The mean age (+/- SD) of patients was 69 +/- 15 years. Mean FEV(1) was 1.15 +/- 0.49 L. By 0.5 h following study drug administration, all three nebulized bronchodilator treatments led to similar, significant improvements in FEV(1) compared to placebo. These effects persisted at 1 h and 2 h for all three treatments; however, by 3 h, only the combined albuterol/ipratropium group had a mean change in FEV(1) significantly greater than placebo. There were no significant differences between bronchodilator groups at any time period. A mild increase in pulse rate was observed in all treatment groups. There were no significant treatment-placebo differences in oxygen saturation or hand tremor. CONCLUSION: For single-dose, as-needed use in COPD, there appears to be no advantage in using levalbuterol over conventional nebulized bronchodilators.

Recurrent thyroid carcinoma presenting as an endotracheal nodule.

Papillary carcinoma is a common primary malignancy of the thyroid gland, with extrathyroidal invasion occurring in 5% to 34% of cases. It is known to recur locally. Laryngotracheal invasion by recurrent papillary thyroid carcinoma is uncommon, occurring in 5.7% to 7% of cases. Invasion of the larynx by tumor can occur by direct extension while tracheal involvement may occur by direct invasion or a metastatic paratracheal lymph node eroding the trachea. Involvement of the trachea can result in hemoptysis. We report a case of recurrent papillary thyroid carcinoma presenting with hemoptysis due to tracheal involvement.

Ruptured thoracic aortic dissection presenting as opacified left hemothorax.

Acute aortic dissections are uncommon, with a reported incidence of 2000 cases per year in the United States. Hemothorax is an unusual but well-described complication of ruptured thoracic aortic dissection. It usually occurs on the left and can be seen in both proximal and distal dissections. Chest radiographs (CXR) in thoracic aortic dissections often reveal a widened mediastinum or abnormal aortic silhouette, evident in 80%-90% of cases. However, CXR may be normal in about 12% of patients with aortic dissection. Clues that would indicate aortic dissection such as abnormal aortic silhouette and widened mediastinum may be obscured by an opacified hemothorax caused by rupture of a thoracic aortic dissection. A high index of suspicion is necessary to make a diagnosis of ruptured thoracic aortic dissection in a patient presenting with hemothorax. This is illustrated in the case described.

Are depressive symptoms related to physical inactivity in chronic obstructive pulmonary disease?

PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) are physically inactive, and this predicts poor outcome. Factors influencing activity levels in COPD patients are poorly understood. Depression is common in COPD patients and may influence activity. Accordingly, in this pilot study, we evaluated the relationship between depressive symptoms and activity in clinically stable COPD (forced expiratory volume in 1 second [FEV(1)]/forced vital capacity < 0.70, FEV(1) < 80%). An additional inclusion criterion was the Hospital Anxiety and Depression Scale depression score, which had to be ≤7 or ≥10, representing low and high levels of depressive symptoms, respectively. METHODS: Sixteen patients with high depression scores (DEPR) and 20 with low depression scores (non-DEPR), were studied. Physical activity was measured over 7 consecutive days, using the SenseWear armband (BodyMedia Inc, Pittsburgh, PA) worn on the arm. RESULTS: The mean age was 69 ± 9 years and the FEV(1) was 49 ± 16%. The Hospital Anxiety and Depression Scale depression scores in DEPR and non-DEPR patients were 12.0 ± 2.3 and 3.7 ± 2.0, respectively. There were no significant between-group differences in age, gender, body mass index, FEV(1), supplemental oxygen requirement, and walk distance. DEPR and non-DEPR patients did not differ in estimated steps per day (3490 ± 2020 vs 3634 ± 2000; P = .83) or minutes per day, with activity >3 metabolic equivalents (11 ± 7 vs 13 ± 9; P = .42). Steps correlated with the FEV(1) (r = 0.49; P = .002) and the 6-minute walk distance (r = 0.69; P = .0001). CONCLUSIONS: We were unable to demonstrate a relationship between depressive symptoms and directly measured physical activity level in patients with COPD.

Longitudinal changes in directly measured physical activity in patients with chronic obstructive pulmonary disease: the trajectory of change.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a systemic disease with various outcomes of importance, for example, exercise capacity and dyspnea. These variables may follow different trajectories over time. It is established that physical activity decreases in COPD, although its process over time has not been evaluated. Accordingly, we compared longitudinal changes in physical activity with changes in standard outcome assessments: forced expiratory volume in 1 second (FEV(1)), 6-minute walk distance, and dyspnea. METHODS: Physical activity was measured with tri-axial accelerometers worn on a lateral position at the waist for 7 consecutive days. Nonuse was eliminated using a computer algorithm for this device. Activity was assessed in 2 ways: (1) as vector magnitude units (VMU), the sum of movements per minute in 3 planes, and (2) VM250, the percent of time worn when VMU was 250 or more counts per minute. Eighteen patients with COPD (FEV(1) 61 ± 17% predicted) from a larger population were restudied. The interval between the baseline and followup assessments was 609 ± 58 days. RESULTS: Mean VMU at followup was less than at baseline: 146 ± 70 vs 198 ± 85 counts per minute, respectively (P = .002). VM250 was also reduced: 19 ± 9% vs 25 ± 11%, respectively (P = .003). There was no significant longitudinal change in FEV(1). The 6-minute walk distance decreased by 39 m (P = .04). The Medical Research Council dyspnea increased by 0.5 units (P = .04). CONCLUSION: Directly measured physical activity decreases over time in COPD, similar to other outcomes of importance.

Physiologic responses during the six minute walk test in obese and non-obese COPD patients.

Although obesity is a common co-morbid condition in COPD, relatively little is known how it may affect functional exercise capacity. Accordingly, we compared physiologic responses during a 6 min walk test in 10 obese and 10 non-obese COPD patients matched by gender, age, and spirometric severity category. Patients first exercised on a treadmill to determine maximal exercise responses, then following a rest period they completed a 6 min walk test. Breath by-breath analyses of expired air via a facemask was obtained using a portable, battery operated device. Oxygen consumption (VO(2)), carbon dioxide production (VCO(2)), tidal volume (VT), respiratory rate (RR), minute ventilation (VE), and inspiratory capacity (IC) were compared. The mean FEV1 in the obese and non-obese groups was 52 ± 13 and 58 ± 18 percent of predicted, respectively, and the BMI of the obese patients was 37 ± 02 kg/m(2). Obese patients had shorter 6 min walk distances than non-obese patients (247 ± 73 vs 348 ± 51 m, respectively, p = 0.003), but walk-work, defined as 6 min walk distance × weight (in kg), was not different. There were no significant between-group differences in any exercise variable measured during the 6 min walk test. In both groups, VO(2) and VE increased linearly over the first 2-3 min, then plateaued at approximately 80% of maximum. Although 6 min walk distance is shorter in obese COPD patients, their physiologic responses are similar to those of non-obese patients.

Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis.

BACKGROUND AND OBJECTIVES: This prospective, randomized, double blind study was designed to determine whether reduction in volume from 20 to 10 mL of ropivacaine 0.5% for ultrasound-guided interscalene block might decrease the incidence of diaphragmatic paresis and preserve pulmonary function. METHOD: Thirty patients scheduled for arthroscopic shoulder surgery were randomized to receive either 10 or 20 mL of ropivacaine 0.5% for interscalene block at the level of the cricoid cartilage. General anesthesia was administered for surgery, and the surgeon infiltrated lidocaine at the port sites. Hemidiaphragmatic excursion and pulmonary function tests were measured before block, 15 mins after block, and at the time of discharge from recovery room. Onset and duration of sensory dermatomal spread, motor block, pain scores, and analgesic consumption were recorded. RESULTS: Hemidiaphragmatic paresis occurred 15 mins after block performance in 14 of 15 patients in each group. At postanesthesia care unit discharge, 13 of 15 patients in each group continued to demonstrate hemidiaphragmatic paresis. Significant reduction of spirometric values(forced vital capacity, forced expiratory volume at 1 sec, and peak expiratory flow) occurred to a similar degree in both groups after block.Sensory dermatomal spread, motor block, pain scores, and analgesic consumption were not significantly different between groups. CONCLUSIONS: Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.