An Unusual Schwannoma.

Mediastinal masses are commonly encountered and have multiple differentials. Although histopathological examination is gold standard, the location of the mass narrows the diagnosis. While thyroid, thymus, germ cell tumour or lymph node related masses are common in superior mediastinum, vascular or pleuro-pericardial masses are seen in middle mediastinum. Posterior mediastinal masses are commonly neurogenic tumours, schwannoma being the commonest. We discuss a case of cystic schwannoma presenting as superior mediastinal mass.

Potential Clinical Utility of FDG-PET in Non-malignant Pulmonary Disorders: A Pilot Study.

BACKGROUND: Fluorodeoxyglucose (FDG) positron emission tomography (PET) is emerging as an important non- invasive investigation in benign pulmonary conditions too. The aim of this study was to investigate its utility in the diagnosis and monitoring of various benign pulmonary diseases. METHODS: In this prospective observational hospital-based study 50 consecutive patients (26 males) with benign lung diseases underwent computed tomography of chest followed by FDG-PET at baseline and after treatment where appropriate. The findings of FDG scan are reported in the context of clinical, histopathological, physiological and radiological findings. RESULTS: All patients showed increased FDG uptake in the lung corresponding to CT findings. Of the 9 patients with sarcoidosis stage 1 (n=1), stage 2 (n=3) and stage 3 (n=5), additional uptake in the myocardium and thyroid was noted in two patients which resulted in a change in the modality of treatment. Repeat FDG scan post-treatment showed decreased uptake in all patients which was consistent with clinico-radiologic, microbiological or spirometry findings. Increased uptake was seen in one patient with pulmonary tuberculosis (TB) and in one patient with TB mediastinal lymphadenopathy at the end of intensive phase discordant with clinical and microbiological response. Of nine cases of idiopathic interstitial pneumonias (IIPs), additional intense FDG uptake was found in two cases which corresponded to the areas of honeycombing. CONCLUSIONS: FDG-PET scan can be used as an important adjunct non-invasive investigation in diagnosing and monitoring of various benign lung conditions. It also helps in assessing whole body disease burden which may change therapeutic decisions.

Hydatid Cyst Presenting With Endobronchial Rupture.

Diagnosis of lung hydatidosis becomes difficult with unusual radiographic findings especially with rupture of hydatid cyst. Here we present the case of a patient who presented with hydatid cyst with endobronchial rupture. A 40-year-old woman presented with a 3-year history of cough with mucoid expectoration, breathlessness on exertion, intermittent fever and left-sided chest pain. Chest radiograph and computed tomography of chest showed a mass obstructing the left main bronchus and post-obstructive cavity formation. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed uptake [maximum standardised uptake value (SUVmax) 2.5 G/mL) in left lower lobe cavity. Fibreoptic bronchoscopy showed obstruction of the left main bronchus with white gelatinous material. After the bronchoscope was withdrawn, the patient expectorated large quantifies of this material. Histopathological examination of the aspirated membrane showed laminated acellular layer and focal inner germinal layer suggestive of hydatid cyst.

Pneumoconioses.

Occupational lung diseases are caused or made worse by exposure to harmful substances in the work-place. "Pneumoconiosis" is the term used for the diseases associated with inhalation of mineral dusts. While many of these broad-spectrum substances may be encountered in the general environment, many occur in the work-place for greater amounts as a result of industrial processes; therefore, a range of lung reactions may occur as a result of work-place exposure. Physicians in metropolitan cities are likely to encounter pneumoconiosis for two reasons: (i) patients coming to seek medical help from geographic areas where pneumoconiosis is common, and (ii) pneumoconiosis caused by unregulated small-scale industries that are housed in poorly ventilated sheds within the city. A sound knowledge about the various pneumoconioses and a high index of suspicion are necessary in order to make a diagnosis. Identifying the disease is important not only for treatment of the individual case but also to recognise and prevent similar disease in co-workers.

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in idiopathic pulmonary fibrosis: A new ray of hope!

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease with median survival of 2-3 years. It is described as fibroproliferative rather than pro-inflammatory disorder with limited treatment options. IPF diagnostics and therapeutics are a hot topic of current research. We describe a case elaborating the utility of the whole body positron emission tomography with 2-deoxy-2-(fluorine-18) fluoro-D-glucose (F-18 FDG) integrated with computed tomography technique in IPF. The area of most intense pulmonary F--18 FDG uptake corresponded to regions of honeycombing suggesting metabolically active disease amenable to pharmacologic intervention. Additional F--18 FDG uptake was seen in mediastinal nodes implying an extrapulmonary component of disease.

Pleural effusion: diagnosis, treatment, and management.

A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula.

Combined pulmonary fibrosis and emphysema in a tyre industry worker.

We report a case of combined pulmonary fibrosis and emphysema (CPFE) with severe pulmonary hypertension in a 46-year-old man, nonsmoker, tyre industry worker. CPFE is commonly reported to be associated with tobacco smoking. This case highlights the possible role of environmental dust exposure (talc) in the pathogenesis of the disease and confirms the clinical characteristics of CPFE described in previous studies.