Pulmonary effects of synthetic marijuana: chest radiography and CT findings.

OBJECTIVE: The purpose of this article is to present the first chest radiographic and CT descriptions of organizing pneumonia in response to smoking synthetic marijuana. CONCLUSION: Chest radiographs showed a diffuse miliary-micronodular pattern. Chest CT images showed diffuse centrilobular nodules and tree-in-bud pattern and a histopathologic pattern of organizing pneumonia with or without patchy acute alveolar damage. This distinct imaging pattern should alert radiologists to include synthetic marijuana abuse in the differential diagnosis.

Mycobacterium paraffinicum causing symptomatic pulmonary infection.

Mycobacterium paraffinicum has been newly recognized as a species. A case of symptomatic pulmonary infection caused by M. paraffinicum is described, and as far as we know, this is the first case of the organism as a human pathogen.

Pulmonary stenting for the treatment of sarcoid induced pulmonary vascular stenosis.

BACKGROUND: The best treatment of patients with external pulmonary vascular compression due to advanced sarcoidosis is unknown. OBJECTIVES: To report a single-center experience of percutaneous treatment for pulmonary vascular stenosis caused by external compression due to advanced sarcoidosis. METHODS: We report a case series of 5 patients with biopsy confirmed advanced sarcoidosis, seen at our academic institution with worsening dyspnea despite increase of immunosuppressive therapy. All patients were evaluated by a multidisciplinary team (cardiology, pulmonary and radiology) using a multi-modality approach, including chest-computed tomography angiography, ventilation/perfusion scintigraphy, pulmonary function test, 6-minute walk test and heart catheterization. RESULTS: Three out of five patients underwent pulmonary artery or vein angioplasty and stenting resulting in symptomatic improvement: Patient 1 had persistent symptomatic improvement measured by subjective and objective methods at 30 months; patient 2 required re-intervention due to recurrent pulmonary vein stenosis at 6-months followed by persistent improvement; and patient 3, had a procedure complicated with in-stent thrombosis requiring thrombolysis and anticoagulation with improvement. The remaining two patients were medically treated because underlying thromboembolic disease (patient 4) and diffuse pulmonary vein stenosis not amenable to percutaneous intervention (patient 5). CONCLUSIONS: Pulmonary vascular stenosis from external compression can be a rare but unrecognized caused of worsening symptoms in advanced sarcoidosis. Pulmonary vascular angioplasty and stenting can provide clinical benefit in select patients.

An unusual case of pulmonary-renal syndrome associated with defects in type IV collagen composition and anti-glomerular basement membrane autoantibodies.

Commercial serological assays for the presence of anti-glomerular basement membrane (GBM) antibodies are thought to be indicative of Goodpasture's syndrome. We report a case in which commercial tests inaccurately suggested that a patient with a pulmonary-renal syndrome had Goodpasture's disease. Additional laboratory testing using recombinant type IV collagen NC1 domain proteins showed that the autoantibodies in question were not directed against the Goodpasture antigen (the alpha3NC1 domain), but against the alpha2NC1 domain of type IV collagen. Our findings represent the first known case of human autoantibodies to the alpha2NC1 domain. Further investigation showed that this patient has decreased alpha3 and alpha5 chain expression in the GBM and defects in type IV collagen, resembling abnormalities in patients with Alport's syndrome.

Pulmonary outcomes of off-pump vs on-pump coronary artery bypass surgery in a randomized trial.

STUDY OBJECTIVES: Comparison of pulmonary outcomes after off-pump coronary artery bypass (OPCAB) vs on-pump coronary artery grafting with cardiopulmonary bypass (CABG/CPB). STUDY DESIGN: We examined preoperative and postoperative respiratory compliance, fluid balance, hemodynamics, arterial blood gases, chest radiographs, spirometry, pulmonary complications, and time to extubation in a prospective trial of 200 patients randomized to OPCAB vs CABG/CPB performed by one surgeon. RESULTS: One CABG/CPB patient and two OPCAB patients required mitral valve repair or replacement and were withdrawn. After three crossovers from CABG/CBP to OPCAB and one crossover from OPCAB to CABG, 97 CABG/CPB patients and 100 OPCAB patients remained. There were no significant preoperative demographic differences between groups. Postoperative compliance was reduced more after OPCAB than after CABG/CPB (- 15.4 +/- 10.7 mL/cm H(2)O vs - 11.2 +/- 10.1 mL/cm H(2)O [mean +/- SD]; p = 0.007), associated with rotation of the heart into the right chest to perform posterolateral bypasses (p < 0.001) and the concomitant increased fluid requirements necessary to maintain hemodynamic stability during rotation of the heart. In addition to higher intraoperative fluid intake (4,541 +/- 1,311 mL vs 3,585 +/- 1,033 mL, p < 0.0001), OPCAB patients had higher intraoperative fluid balance (3,903 +/- 1,315 mL vs 1,772 +/- 1,373 mL, p < 0.0001), and higher postoperative pulmonary arterial diastolic pressure (15.0 +/- 5.5 mm Hg vs 11.8 +/- 5.2 mm Hg, p < 0.0001) and central venous pressure (10.4 +/- 4.5 mm Hg vs 8.4 +/- 4.7 mm Hg, p < 0.0001). Despite lower compliance, immediate postoperative Pao(2) on fraction of inspired oxygen of 1.0 (275 +/- 97 torr vs 221 +/- 92 torr, p = 0.001) was higher after OPCAB and extubation was earlier (p = 0.001). Postoperative chest radiographs, spirometry, mortality, reintubation, or readmission for pulmonary complications were not different between groups. CONCLUSIONS: Compared to CABG/CPB, OPCAB was associated with a greater reduction in postoperative respiratory compliance associated with increased fluid administration and rotation of the heart into the right chest to perform posterolateral grafts. OPCAB yielded better gas exchange and earlier extubation but no difference in chest radiographs, spirometry, or rates of death, pneumonia, pleural effusion, or pulmonary edema.

Current concepts in the classification of interstitial lung disease.

The diagnosis and classification of idiopathic interstitial pneumonias continue to be problematic areas for pathologists. The recently proposed American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias defines specific clinical, radiologic, and pathologic criteria for each of the pulmonary disorders that encompass the idiopathic interstitial pneumonias. In this review, the highlights of this classification are presented, along with recommended guidelines for handling lung biopsy specimens and diagnosing interstitial lung diseases.

Surgical biopsy of suspected interstitial lung disease is superior to radiographic diagnosis.

BACKGROUND: Different modalities are used to diagnose interstitial lung disease. We compared the effectiveness of minimally invasive surgical biopsy versus high-resolution computed tomography for the diagnosis of interstitial lung disease and report the mortality of the procedure. METHODS: We reviewed 194 patients undergoing video-assisted thoracoscopic lung biopsies for the suspicion of interstitial lung disease from January 2003 to February 2012 at Emory University. Demographics and patient characteristics were analyzed in addition to final diagnoses and clinical outcomes. RESULTS: Concordance of radiographic diagnosis with final diagnosis was poor, matching pathologic diagnosis in 15% of cases, and specific diagnoses were included in the radiographic differential in only 34% of cases. A specific diagnosis was made after surgical biopsy in 88% of cases. Overall mortality of surgical biopsy was 6.7% (13/194). Major risk factors for death were preoperative supplemental oxygen, ventilator dependence, and age (p < 0.0001, p < 0.0001, and p = 0.03, respectively). Among patients with ventilator dependence preoperatively, the mortality rate was 100% versus 4.8% in patients not ventilator dependent. All biopsy specimens were concordant 91% of the time, and the first two biopsy specimens were concordant 96% of the time. CONCLUSIONS: Surgical biopsy should remain the gold standard for diagnosis of interstitial lung disease. The mortality is low with proper patient selection. More than two surgical biopsy specimens may not be needed because the concordance rates among pathologic specimens are very high.