Case Reports in Pulmonology http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Mucous Membrane Pemphigoid with Tracheal Involvement Wed, 03 Feb 2016 12:03:34 +0000 http://www.hindawi.com/journals/cripu/2016/5749784/ 34-year-old African American female with history of pemphigoid presented with hemoptysis. Patient was found to have mucous membrane pemphigoid involving the oropharynx and extending to trachea, till just above main stem carina. Four other cases described mucosal pemphigoid involving the trachea. We hereby present a brief review of current consensus on management of mucous membrane pemphigoid with airway involvement. Arash Minaie and Salim R. Surani Copyright © 2016 Arash Minaie and Salim R. Surani. All rights reserved. Humoral Immunity in Bronchiectasis: Finding Good’s Syndrome Tue, 29 Dec 2015 14:07:51 +0000 http://www.hindawi.com/journals/cripu/2015/531731/ We present a case of a 37-year-old man with a past history of a surgically removed thymoma, who presented with recurrent pulmonary infections and bronchiectasis. On further testing, he was found to have low total immunoglobulin levels, a constellation of findings known as Good’s syndrome. He responded well to immunoglobulin replacement, in addition to the usual treatments for bronchiectasis. We present this case to emphasize the association of bronchiectasis, low immunoglobulins, and thymomas and the role of immunoglobulin replacement as a treatment option. C. Pu, S. Sukhal, and S. Fakhran Copyright © 2015 C. Pu et al. All rights reserved. Endobronchial Enigma: A Clinically Rare Presentation of Nocardia beijingensis in an Immunocompetent Patient Thu, 24 Dec 2015 08:19:42 +0000 http://www.hindawi.com/journals/cripu/2015/970548/ Nocardiosis is an opportunistic infection caused by the Gram-positive weakly acid-fast, filamentous aerobic Actinomycetes. The lungs are the primary site of infection mainly affecting immunocompromised patients. In rare circumstances even immunocompetent hosts may also develop infection. Diagnosis of pulmonary nocardiosis is usually delayed due to nonspecific clinical and radiological presentations which mimic fungal, tuberculous, or neoplastic processes. The present report describes a rare bronchoscopic presentation of an endobronchial nocardial mass in a 55-year-old immunocompetent woman without underlying lung disease. The patient exhibited signs and symptoms of unresolving community-acquired pneumonia with a computed tomography (CT) scan that showed a space-occupying lesion and enlarged paratracheal lymph node. This patient represents the unusual presentation of pulmonary Nocardia beijingensis as an endobronchial mass. Pathology obtained during bronchoscopy demonstrated polymerase chain reaction (PCR) confirmation of nocardiosis. Symptoms and clinical findings improved with antibiotic treatment. This patient emphasizes the challenge in making the diagnosis of pulmonary nocardiosis, especially in a low risk host. A literature review presents the difficulties and pitfalls in the clinical assessment of such an individual. Nader Abdel-Rahman, Shimon Izhakain, Walter G. Wasser, Oren Fruchter, and Mordechai R. Kramer Copyright © 2015 Nader Abdel-Rahman et al. All rights reserved. Interstitial Lung Disease in Werner Syndrome: A Case Report of a 55-Year-Old Male Patient Wed, 16 Dec 2015 12:41:54 +0000 http://www.hindawi.com/journals/cripu/2015/361694/ Werner syndrome (WS) is a progeroid or premature aging syndrome characterized by early onset of age-related pathologies and cancer. The average life expectancy of affected people is 52.8 years and tends to increase. The major causes of death are malignancy and myocardial infarction. Increased telomere attrition and decay are thought to play a causative role in the clinical and pathological manifestations of the disease. Although telomere length, with or without germline mutation, is known to be associated with interstitial lung disease, the latter is not associated with WS. To the best of our knowledge, we report the first case describing a WS patient with fatal ILD. This case suggests that older patients with WS could develop ILD. Clinical outcome of WS patients may thus be improved by counselling them regarding smoking cessation or other exposure and by proposing antifibrotic therapy. Tiphaine Goletto, Flora Crockett, Selim Aractingi, Cecile Toper, Patricia Senet, Jacques Cadranel, and Jean-Marc Naccache Copyright © 2015 Tiphaine Goletto et al. All rights reserved. Pulmonary Vein Stenosis Mimicking Nonspecific Interstitial Pneumonia Tue, 08 Dec 2015 08:31:13 +0000 http://www.hindawi.com/journals/cripu/2015/290391/ Pulmonary vein stenosis (PVS) is a known complication after catheter ablation of arrhythmias. Surprisingly, little information is available on its manifestations in the lung. We describe the case of a 39-year-old woman who presented from an outside hospital with worsening shortness of breath after catheter ablation of pulmonary veins for atrial fibrillation. After an initial diagnosis of pneumonia and its nonimprovement with antibiotics, a surgical lung biopsy was done and interpreted as nonspecific interstitial pneumonia (NSIP) with vascular changes consistent with pulmonary arterial hypertension. Later, she was admitted to our institution where a transthoracic echocardiogram (TTE) and subsequent computed tomography (CT) angiogram of the heart showed severe stenosis of all four pulmonary veins. The previous lung biopsy was rereviewed and reinterpreted as severe parenchymal congestion mimicking NSIP. Our case demonstrates that PVS is an underrecognized complication of catheter ablation, and increased awareness among both clinicians and pathologists is necessary to avoid misdiagnosis. Karthika R. Linga, Andras Khoor, Jonathan A. Phelan, and Isabel Mira-Avendano Copyright © 2015 Karthika R. Linga et al. All rights reserved. Silicone Breast Implants: A Rare Cause of Pleural Effusion Thu, 26 Nov 2015 13:45:55 +0000 http://www.hindawi.com/journals/cripu/2015/652918/ Pleural effusions are one of the rarest complications reported in patients with silicone gel filled breast implants. The silicone implants have potential to provoke chronic inflammation of pleura and subsequent pulmonary complications such as pleural effusion. Herein, we report a 44-year-old female who presented with left sided pleural effusion, six weeks after a silicone breast implantation surgery. The most common infectious, inflammatory, and malignant causes of pleural effusion were excluded with pleural fluid cytology and cultures. With recurrent effusion in the setting of recent surgery, the chemical reaction to silicone breast implants was sought and exploration was performed which revealed foreign body reaction (FBR) to silicone material. The symptoms dramatically improved after the explantation. Imam H. Shaik, Bindu Gandrapu, Fernando Gonzalez-Ibarra, David Flores, Jyoti Matta, and Amer K. Syed Copyright © 2015 Imam H. Shaik et al. All rights reserved. Untreated Active Tuberculosis in Pregnancy with Intraocular Dissemination: A Case Report and Review of the Literature Thu, 26 Nov 2015 12:09:39 +0000 http://www.hindawi.com/journals/cripu/2015/370462/ Background. Tuberculosis (TB) is a disease that affects hundreds of millions of people across the world. However, the incidence in developed countries has decreased over the past decades causing physicians to become unfamiliar with its unspecific symptoms. Pregnant individuals are especially difficult because many symptoms of active TB can mimic normal physiological changes of pregnancy. We present a case report of a 26-year-old multiparous woman, G4P3003, at 38-week gestation with a history of positive PPD who emigrated from Ghana 6 years ago. She came to the hospital with an initial complaint of suprapubic pain, pressure, and possible leakage of amniotic fluid for the past week. Patient also complained of a productive cough for the past 3 to 4 months with a decrease in vision occurring with the start of pregnancy. Visual acuity was worse than 20/200 in both eyes. Definitive diagnosis of active TB was delayed due to patient refusal of chest X-ray. Fortunately, delay in diagnosis was minimized since patient delivered within 24 hours of admission. Active TB was confirmed with intraocular dissemination. Patient had optic atrophy OS (left eye) and papillitis, choroiditis, and uveitis OD (right eye) due to TB infiltration. Fetus was asymptomatic and anti-TB therapy was started for both patients. Shadi Rezai, Stephen LoBue, Daniel Adams, Yewande Oladipo, Ramses Posso, Tiffany Mapp, Crystal Santiago, Manisha Jain, William D. Marino, and Cassandra E. Henderson Copyright © 2015 Shadi Rezai et al. All rights reserved. A Large Pleural Effusion following Abdominal Aortic Surgery Mon, 09 Nov 2015 13:02:13 +0000 http://www.hindawi.com/journals/cripu/2015/254010/ Chylous ascites and coexistent chylothorax is a rare but important complication following retroperitoneal abdominal surgery. We report a 70-year-old male who developed gradual abdominal distension, chest tightness, and dyspnea five months after having an uncomplicated aortobifemoral bypass performed. Physical examination was consistent with a large right sided effusion and ascites which were confirmed by computed tomography. Thoracentesis yielded an opaque milky fluid with analysis consistent with a chylothorax with a paracentesis revealing fluid that was similar in both appearance and biochemistry. The patient failed initial conservative management so a chest tube was placed followed by chemical pleurodesis. We review the literature of the pathophysiology and treatment approach to such a pleural effusion. Vinoo K. Ramsaran, Vandana K. Seeram, James Cury, and Adil Shujaat Copyright © 2015 Vinoo K. Ramsaran et al. All rights reserved. Severe Respiratory Distress in a Child with Pulmonary Idiopathic Hemosiderosis Initially Presenting with Iron-Deficiency Anemia Sun, 08 Nov 2015 11:57:54 +0000 http://www.hindawi.com/journals/cripu/2015/876904/ Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of alveolar hemorrhage in children but should be considered in children with anemia of unknown origin who develop respiratory complications. It is commonly characterized by the triad of recurrent hemoptysis, diffuse parenchymal infiltrates, and iron-deficiency anemia. Pathogenesis is unclear and diagnosis may be difficult along with a variable clinical course. A 6-year-old boy was admitted to the hospital with a severe iron-deficiency anemia, but he later developed severe acute respiratory failure and hemoptysis requiring intubation and mechanical ventilation. The suspicion of IPH led to the use of immunosuppressive therapy with high dose of corticosteroids with rapid improvement in clinical condition and discharge from hospital. A. Potalivo, L. Finessi, F. Facondini, A. Lupo, C. Andreoni, G. Giuliani, and C. Cavicchi Copyright © 2015 A. Potalivo et al. All rights reserved. Community-Acquired Pneumonia and Empyema Caused by Citrobacter koseri in an Immunocompetent Patient Sun, 08 Nov 2015 09:48:34 +0000 http://www.hindawi.com/journals/cripu/2015/670373/ Citrobacter species, belonging to the family Enterobacteriaceae, are environmental organisms commonly found in soil, water, and the intestinal tracts of animals and humans. Citrobacter koseri is known to be an uncommon but serious cause of both sporadic and epidemic septicemia and meningitis in neonates and young infants. Most cases reported have occurred in immunocompromised hosts. The infections caused by Citrobacter are difficult to treat with usual broad spectrum antibiotics owing to rapid generation of mutants and have been associated with high death rates in the past. We believe this is the first case described in the literature of a community-acquired pneumonia and empyema caused by Citrobacter koseri in an immunocompetent adult patient. Miguel Angel Ariza-Prota, Ana Pando-Sandoval, Marta García-Clemente, Ramón Fernández, and Pere Casan Copyright © 2015 Miguel Angel Ariza-Prota et al. All rights reserved. Pulmonary Peripheral Carcinoids after Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia and Tumorlets: Report of 3 Cases Tue, 03 Nov 2015 09:29:07 +0000 http://www.hindawi.com/journals/cripu/2015/851046/ Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and tumorlets are neuroendocrine cells proliferations smaller than 5 mm. The former confines to bronchial/bronchiolar wall, while the latter broke through epithelial basement membrane. The authors present 3 cases of DIPNECH and tumorlets associated with a typical peripheral carcinoid tumor without underlying lung disease. The patients presented with nonspecific pulmonary symptoms: 3 females, 60, 72, and 84 years old, whose CT-scans showed well-defined pulmonary nodules, 2.2, 1.6, and 1.4 cm, respectively; first patient was submitted to lobectomy and the others underwent surgical biopsy. Whitish/brownish lobulated tumors corresponded to typical carcinoids (less than 2 mitoses/2 mm2 and without necrosis); polygonal/elongated cells under lobular pattern expressed CD56, chromogranin A, synaptophysin, and CK7; Ki-67 positivity was between 1 and 3%. Bronchial/bronchiolar wall neuroendocrine cell hyperplasia and several neuroendocrine nodules under 5 mm, with identical morphologic and immunoexpression, were observed, without lung disease. Typical carcinoid associated with DIPNECH and tumorlets without other pulmonary diseases is rare. Sporadic cases may recall embryonal neuroendocrine differentiation potentiality to develop peripheral hyperplasia, most commonly in underoxygenated parenchyma. The described cases are elucidative of peripheral spectrum of neuroendocrine cell tumour evolution, reinforcing higher female incidence as in central carcinoids, still without a clear preneoplastic lesion. Carlos Abrantes, Rui Caetano Oliveira, Joana Saraiva, João Bernardo, and Lina Carvalho Copyright © 2015 Carlos Abrantes et al. All rights reserved. Giant Right Intrathoracic Myxoid Fusocellular Lipoma Mon, 05 Oct 2015 11:53:28 +0000 http://www.hindawi.com/journals/cripu/2015/302189/ Intrathoracic lipomas are rare benign tumors; their behavior is not completely clear and their surgical removal may be challenging. We report a case of a giant right intrathoracic myxoid fusocellular lipoma compressing the lung, tracheobronchial tree, and esophagus which was removed through a posterolateral thoracotomy. Complete removal resulted in resolution of the chest pain and improvement of the dyspnea, with no recurrence at 4-year follow-up. Petre V. H. Botianu, Anda Mihaela Cerghizan, and Alexandru M. Botianu Copyright © 2015 Petre V. H. Botianu et al. All rights reserved. Pulmonary Nocardiosis in the Immunocompetent Host: Case Series Wed, 30 Sep 2015 13:49:32 +0000 http://www.hindawi.com/journals/cripu/2015/314831/ Pulmonary nocardiosis is commonly recognized as an opportunistic infection in patients with predisposing immunosuppressive conditions. However, reports of pulmonary nocardiosis in the immunocompetent host are rare. Here, we report a case series of four patients with pulmonary nocardiosis without a predisposing condition. Inderjit Singh, Frances Mae West, Abraham Sanders, Barry Hartman, and Dana Zappetti Copyright © 2015 Inderjit Singh et al. All rights reserved. The Rapid Initiation, Titration, and Transition from Intravenous to Oral Treprostinil in a Patient with Severe Pulmonary Arterial Hypertension Thu, 17 Sep 2015 11:57:37 +0000 http://www.hindawi.com/journals/cripu/2015/498981/ In patients who require urgent initiation of pulmonary arterial hypertension medications due to disease progression, it is customary to start intravenous prostacyclin therapy, typically during a hospital admission. If there are complicating factors or relative contraindications to intravenous and subcutaneous prostanoids, oral treprostinil provides another pathway to prostanoid therapy, but this usually requires a prolonged titration. We describe the case of a thirty-six-year-old male with severe pulmonary arterial hypertension and contraindication to intravenous and subcutaneous prostanoid therapy due to congenital deafness and the risk of not hearing the intravenous pump alarms. Intravenous treprostinil was initiated, titrated to high dose, and then rapidly transitioned to oral treprostinil. A rapid initiation, titration, and transition from intravenous to oral treprostinil can be safely performed under watchful supervision in order to achieve higher and more efficacious doses of oral treprostinil in a timely manner. James Benjamin Gleason, Justin Dolan, Pirouz Piran, and Franck Farzad Rahaghi Copyright © 2015 James Benjamin Gleason et al. All rights reserved. A Cause of Bilateral Chylothorax: A Case of Mesothelioma without Pleural Involvement during Initial Diagnosis Wed, 16 Sep 2015 14:21:32 +0000 http://www.hindawi.com/journals/cripu/2015/962504/ Chylothorax is characterized by fluid accumulation in the pleural cavity containing chylomicrons due to disruption of lymphatic drainage in the thoracic ductus and development of chylothorax. A 60-year-old male patient presented to our clinic with shortness of breath and displayed bilateral pleural effusion and diffuse mediastinal lymph nodes in his computed chest tomography images. There were no thickening and nodular formation on the pleural surfaces. PET-CT showed no pathological FDG uptake. Thoracentesis showed a chylous effusion. Drainage reduced during monitoring could not be stopped; therefore, surgical intervention was considered. The patient underwent right thoracotomy. There were no pathological findings in the parietal and visceral pleura during the surgery. Initially lymphoma was considered. Perioperative samples were collected from the mediastinal lymph node. The pathology analysis reported metastasis of malignant mesothelioma. Evaluation of a repeated chest computed tomography showed nodular formations on the pleural surfaces. Mediastinal lymph nodes compressed the ductus thoracicus, resulting with chylothorax. The present case, with malignant mesothelioma, bilateral chylothorax, and mediastinal lymph node without any pleural involvement during initial diagnosis, is rare and will hence contribute to the literature. Ercan Kurtipek, Meryem İlkay Eren Karanis, Nuri Düzgün, Hıdır Esme, and Mustafa Çaycı Copyright © 2015 Ercan Kurtipek et al. All rights reserved. Legionella micdadei: A Forgotten Etiology of Growing Cavitary Nodules: A Case Report and Literature Review Tue, 15 Sep 2015 10:45:41 +0000 http://www.hindawi.com/journals/cripu/2015/535012/ Background. Legionella micdadei is a Gram negative bacterium that can stain weakly acid fast. It was first described in 1979 after immunosuppressed patients developed pneumonia at a Pittsburgh VA, initially given the name Pittsburgh Pneumonia Agent. It is the second most common Legionella species causing infection after pneumophila, and typically infects immunocompromised hosts. It is not easy to be cultured which makes diagnosing difficult. Case Presentation. A 31-year-old female with ulcerative colitis, primary sclerosing cholangitis, and cirrhosis presented with fever, chills, shortness of breath, dry cough, and chest pain for five days after being started on immunosuppression for autoimmune hepatitis two months earlier. The first chest CT showed small bilateral cavitary nodules. The nodules continued to grow on subsequent imaging despite what was thought to be appropriate therapy. A transthoracic biopsy was performed which grew Legionella micdadei and the patient improved after being treated with levofloxacin. Conclusion. Legionella micdadei is an atypical pathogen known to cause pneumonia in immunosuppressed patients. This case highlights a typical presentation of an atypical infection not commonly thought about and should be considered when nodules are growing despite being on broad antimicrobial therapy. Daniel Lachant and Paritosh Prasad Copyright © 2015 Daniel Lachant and Paritosh Prasad. All rights reserved. Recurrent Pleural Effusions Occurring in Association with Primary Pulmonary Amyloidosis Wed, 02 Sep 2015 12:03:09 +0000 http://www.hindawi.com/journals/cripu/2015/421201/ Recurrent pleural effusions occurring in association with immunoglobulin light chain amyloidosis and not associated with amyloid cardiomyopathy are rare. These portend an overall poor prognosis with mean survival time of approximately 1.8 months. We hereby report a case of a 59-year-old Caucasian female with recurrent pleural effusions and an ultimate diagnosis of pulmonary amyloidosis in association with plasma cell myeloma. The optimal treatment for recurrent pleural effusions in amyloidosis has not been determined; however, our patient responded to therapy with Cyclophosphamide-Bortezomib- (Velcade-) Dexamethasone (CyBorD) and had no repeat hospitalizations or recurrence of pleural effusion at four-month follow-up after initiation of therapy. Lauren Tada, Humayun Anjum, W. Kenneth Linville, and Salim Surani Copyright © 2015 Lauren Tada et al. All rights reserved. Right Heart Transvalvular Embolus with High Risk Pulmonary Embolism in a Recently Hospitalized Patient: A Case Report of a Therapeutic Challenge Mon, 31 Aug 2015 12:23:37 +0000 http://www.hindawi.com/journals/cripu/2015/481357/ Thrombus-in-transit is not uncommon in pulmonary embolism but Right Heart Transvalvular Embolus (RHTVE) complicating this is rare. A 54-year-old obese male with recent hospitalization presented with severe dyspnea and collapse. Initial investigations revealed elevated d-dimer and troponin. CTA showed saddle pulmonary embolus and bedside echocardiogram revealed right ventricular (RV) pressure overload and dilatation (RV > 41 mm), McConnell’s sign, and mobile echodensity attached to tricuspid valve. Patient was immediately resuscitated and promptly transferred for surgical embolectomy under cardiopulmonary bypass. A long segment of embolus traversing through the tricuspid valve and extensive bilateral pulmonary artery embolus were removed. IVC filter was placed for a persistent right lower extremity DVT. Hypercoagulable work-up was negative. Patient continued to do well after discharge on Coumadin. Open embolectomy offers great promises where there is no consensus in optimal management approach in such patients. Bedside echocardiogram is vital in risk stratification and deciding choice of advanced PE treatment. Gyanendra Kumar Acharya, Ajibola Monsur Adedayo, Hejmadi Prabhu, Derek R. Brinster, and Parvez Mir Copyright © 2015 Gyanendra Kumar Acharya et al. All rights reserved. Pleuroparenchymal Fibroelastosis: A New Entity within the Spectrum of Rare Idiopathic Interstitial Pneumonias Wed, 26 Aug 2015 09:00:53 +0000 http://www.hindawi.com/journals/cripu/2015/810515/ Pleuroparenchymal fibroelastosis (PPFE) is a rare entity that has been recently included in the official American Thoracic Society/European Respiratory Society (ATS/ERS) statement in 2013 as a group of rare idiopathic interstitial pneumonias (IIPs). PPFE is characterized by pleural and subpleural parenchymal thickening due to elastic fiber proliferation, mainly in the upper lobes. The etiology of the disease is unclear, although some cases have been associated as a complication after bone marrow transplantation, lung transplantation (LT), chemotherapy, and recurrent respiratory infections. The patients usually report progressive dyspnea and dry cough and are predisposed to develop spontaneous or iatrogenic pneumothoraces after surgical lung biopsy (SLB) for its diagnosis. That is why better awareness with the clinical and radiologic features can help optimal management by the multidisciplinary team. Novel invasive techniques such as cryobiopsy may become useful tools in these patients as it could spare SLB. We present the first reported cases in Spain. Karina Portillo, Ignasi Guasch, Caroline Becker, Felipe Andreo, Maria Teresa Fernández-Figueras, José Ramirez Ruz, Carlos Martinez-Barenys, Samuel García-Reina, Pedro Lopez de Castro, Irene Sansano, Ana Villar, and Juan Ruiz-Manzano Copyright © 2015 Karina Portillo et al. All rights reserved. Metastatic Squamous Cell Carcinoma Component from an Adenosquamous Carcinoma of the Lung with Identical Epidermal Growth Factor Receptor Mutations Sun, 23 Aug 2015 08:12:08 +0000 http://www.hindawi.com/journals/cripu/2015/283875/ The case reported is a young “light” ex-smoker who initially had a localized adenosquamous carcinoma bearing an epidermal growth factor receptor (EGFR) sensitizing mutation. He first recurred six months after initial treatment within the brain with a pure squamous histology and the same EGFR mutation. Surgical resection and radiation rendered him disease-free. Subsequent isolated recurrence within the lung eighteen months later was a pure adenocarcinoma, again with the same identified EGFR mutation. These histologic changes (from adenosquamous to pure squamous to pure adenocarcinoma) have been described but not before in the absence of any selection pressure with EGFR tyrosine kinase inhibitors. This case points out the histologic “flexibility” of EGFR mutant lung cancers and the importance for appropriate molecular testing in nonsmokers with lung cancer of any histologic type. Jarred Burkart, Konstantin Shilo, Weiqiang Zhao, Efe Ozkan, Amna Ajam, and Gregory A. Otterson Copyright © 2015 Jarred Burkart et al. All rights reserved. Successful Treatment of Bulla with Endobronchial Valves Wed, 12 Aug 2015 06:43:45 +0000 http://www.hindawi.com/journals/cripu/2015/947403/ Emphysematous bullae are a complication of end-stage COPD. Patients with large bullae and poor respiratory function have limited treatment options. Surgical resection is a recognized treatment, but functional improvement after bullectomy is not satisfactory in patients with forced expiratory volume in 1 s (FEV1) < 35% predicted. When this 59-year-old male end-stage COPD patient was assessed, he was cachectic and lung function tests showed a FEV1 of 0.56 L (19% predicted) and a RV of 7 L (314% predicted), while 6MWT was 315 m and MRC dyspnea score was 4. Chest X-ray revealed a massive bulla of 10 cm in diameter in the right middle lobe. A fibrobronchoscopy was performed under local anesthesia and 2 Zephyr 4.0 valves were placed in the right middle lobe. Chest X-ray and CT scan performed 36 days later showed the complete resolution of the bulla. Seven months later, the patient demonstrated an improvement in FEV1 (+30%) and a decrease in RV from 314 to 262% predicted. This case report shows that the Zephyr valves may be successfully used to treat a large bulla in the right middle lobe in a patient with diffuse emphysema and severely impaired lung function. Erdoğan Çetinkaya, Mehmet Akif Özgül, Şule Gül, Hilal Boyacı, Ertan Cam, Emine Kamiloglu, and Mustafa Çörtük Copyright © 2015 Erdoğan Çetinkaya et al. All rights reserved. Pulmonary Hyalinizing Granuloma Mimicking Metastatic Lung Cancer Wed, 05 Aug 2015 14:52:38 +0000 http://www.hindawi.com/journals/cripu/2015/610417/ Pulmonary hyalinizing granuloma is a very rare benign condition, which usually manifests as solitary and sometimes as multiple pulmonary nodules. Deposition of immune complexes in the lung parenchyma due to hypersensitivity reactions is implicated in the etiology of pulmonary hyalinizing granuloma. A 59-year-old female patient who presented to our clinic with complaints of chest pain and cough had bilateral, multiple, and rounded lesions with regular margins suggesting metastatic lung disease. A transthoracic needle biopsy of the nodule was performed in the left pulmonary anterior segment. Biopsy showed no malignancy. Since no diagnosis was made by the biopsy, the patient underwent a video-assisted thoracic surgery. The wedge biopsy reported pulmonary hyalinizing granuloma. We aimed to present the diagnosis and treatment stages of our patient who was diagnosed with pulmonary hyalinizing granuloma in the light of literature review. Nuri Düzgün, Ercan Kurtipek, Hıdır Esme, Meryem İlkay Eren Karanis, and İsmet Tolu Copyright © 2015 Nuri Düzgün et al. All rights reserved. Immunoadjuvant Therapy and Noninvasive Ventilation for Acute Respiratory Failure in Lung Tuberculosis: A Case Study Mon, 27 Jul 2015 09:26:09 +0000 http://www.hindawi.com/journals/cripu/2015/283867/ Acute respiratory failure caused by pulmonary tuberculosis is a rare event but with a high mortality even while receiving mechanical ventilatory support. We report the case of a young man with severe pulmonary tuberculosis refractory to conventional therapy who successfully overcame the critical period of his condition using noninvasive ventilation and immunoadjuvant therapy that included three doses of etanercept 25 mg subcutaneously. We conclude that the use of etanercept along with antituberculosis treatment appears to be safe and effective in patients with pulmonary tuberculosis presenting with acute respiratory failure. René Agustín Flores-Franco, Dahyr Alberto Olivas-Medina, Cesar Francisco Pacheco-Tena, and Jorge Duque-Rodríguez Copyright © 2015 René Agustín Flores-Franco et al. All rights reserved. Congenital Pulmonary Airway Malformation in an Adult Male: A Case Report with Literature Review Wed, 08 Jul 2015 10:31:21 +0000 http://www.hindawi.com/journals/cripu/2015/743452/ Congenital pulmonary airway malformation (CPAM) is a rare cystic lung lesion formed as a result of anomalous development of airways in fetal life. Majority of the cases are recognized in neonates and infants with respiratory distress with very few presenting later in adult life. A 24-year-old male with history of three separate episodes of pneumonia in the last 6 months presented with left sided pleuritic chest pain for 4 days. He was tachycardic and tachypneic at presentation. White blood count was 14 × 109/L. Chest X-ray showed left lower lobe opacity. CT angiogram of thorax showed a well-defined area of low attenuation in the left lower lobe with dedicated pulmonary arterial and venous drainage and resolving infection, suggesting CPAM. He underwent left lower lobe lobectomy. Histopathology confirmed type 2 CPAM. CPAM is a rare congenital anatomic abnormality that can present with recurrent infections in adults. As a number of cases remain asymptomatic and symptomatic cases are often missed, prevalence of CPAM might be higher than currently reported. Dipti Baral, Bindu Adhikari, Daniel Zaccarini, Raj Man Dongol, and Birendra Sah Copyright © 2015 Dipti Baral et al. All rights reserved. Combined Intrathoracic and Subcutaneous Splenosis Discovered 51 Years after Abdominal Trauma Wed, 08 Jul 2015 09:52:53 +0000 http://www.hindawi.com/journals/cripu/2015/969067/ Splenosis is a rare condition that results from the autotransplantation of splenic parenchyma into unexpected locations such as the abdomen or subcutaneous tissue. In the presence of coexisting injury to the diaphragm intrathoracic transplantation can occur emerging as single or multiple pleural-based masses. This occurs after traumatic rupture of the spleen and is usually asymptomatic, only to be discovered incidentally on routine thoracic or abdominal imaging. To our knowledge this is the third documented case of combined intrathoracic and subcutaneous splenosis found in English literature. This occurred in a 71-year-old male involved in a motor vehicle accident at age 19 requiring urgent splenectomy. He has a significant cigarette smoking history and was referred to our hospital for further evaluation of an abnormality seen on shoulder X-ray. James Benjamin Gleason, Anas Hadeh, Maria Julia Diacovo, and Jonathan Ryan Schroeder Copyright © 2015 James Benjamin Gleason et al. All rights reserved. Perioperative Identification of an Accessory Fissure of the Right Lung Mon, 22 Jun 2015 10:00:02 +0000 http://www.hindawi.com/journals/cripu/2015/954769/ Anatomical variations of lungs are common in clinical practice; however, they are sometimes overlooked in routine imaging. Surgical anatomy of the lung is complex and many variations are known to occur. A defective pulmonary development gives rise to variations in lobes and fissures. Morphological presentation is of clinical importance and profound knowledge of the organogenesis and functional anatomy is imperative for the interpretation and evaluation of lung pathophysiology and subsequent surgical intervention. However, appreciating them on radiographs and CT scans is difficult and they are therefore often either not identified or completely misinterpreted. As presented in this case report, an accessory fissure separating the superior segment of the right lower lobe from its native lobe was seen perioperatively and could only retrospectively be defined on X-rays and CT scan. It is imperative to keep in mind that accessory fissures can be missed on imaging studies and thus can make the surgical procedure more challenging. Yannick Taverne, Gert-Jan Kleinrensink, and Peter de Rooij Copyright © 2015 Yannick Taverne et al. All rights reserved. Mineral Oil Aspiration Related Juvenile Idiopathic Arthritis Wed, 10 Jun 2015 08:26:04 +0000 http://www.hindawi.com/journals/cripu/2015/403109/ We describe the development of rheumatoid factor-positive migratory polyarthritis in a 5-year-old male who had been administered bidaily oral mineral oil as a laxative since birth. Minor respiratory symptoms, radiographic and bronchoscopic findings were consistent with chronic lipoid pneumonia. We speculate that immune sensitization to mineral oil promoted the clinical syndrome of juvenile idiopathic arthritis. Andrew D. Nelson, Philip R. Fischer, Ann M. Reed, and Mark E. Wylam Copyright © 2015 Andrew D. Nelson et al. All rights reserved. Interstitial Lung Disease of the UIP Variant as the Only Presenting Symptom of Rheumatoid Arthritis Sun, 07 Jun 2015 08:20:52 +0000 http://www.hindawi.com/journals/cripu/2015/205175/ Rheumatoid arthritis is a chronic inflammatory disease primarily manifesting with symptoms of joint pain. It also involves multiple organ systems in the body, including the lungs. Interstitial lung disease (ILD) is the most common form of pulmonary involvement in rheumatoid arthritis (RA). Without the typical symptoms such as chronic joint pain, establishing the diagnosis of RA could be quite challenging and a high index of suspicion is thereby required to diagnose ILD in patients with RA, thereby delaying treatment and increasing morbidity and mortality. We report a case of a 67-year-old Hispanic male with no previous history of rheumatoid arthritis or symptoms of typical joint pain who comes to the hospital only with the chief complaints of progressive worsening of shortness of breath for a duration of 6 months and was eventually diagnosed with ILD of the usual interstitial pneumonia variant with serologies positive for rheumatoid arthritis. Abhinav Agrawal, Braghadheeswar Thyagarajan, Sidney Ceniza, and Syed Hasan Yusuf Copyright © 2015 Abhinav Agrawal et al. All rights reserved. A Case of Disseminated Cryptococcal Infection and Concurrent Lung Tuberculosis in a Patient under Steroid Therapy for Interstitial Pneumonia Mon, 01 Jun 2015 08:07:56 +0000 http://www.hindawi.com/journals/cripu/2015/358926/ Both disseminated cryptococcal infection and tuberculosis occur in hosts with impaired cell-mediated immunity, but there have been few reports about the concurrent infections in patients without human immunodeficiency virus infection. A 64-year-old man, who had been taking corticosteroids for interstitial pneumonia, was diagnosed with disseminated cryptococcal infection. While the patient was receiving anticryptococcal therapy, pulmonary tuberculosis also emerged. The patient developed acute exacerbation of interstitial pneumonia and passed away. Based on the patient’s clinical course, serial computed tomography images, and autopsy results, we believe that the preceding several months of corticosteroid treatment might have contributed to these coinfections in the lungs already vulnerable due to underlying fibrosis. Aoi Kuroda, Sadatomo Tasaka, Kazuma Yagi, Takao Mochimaru, Tetsuo Tani, Ho Namkoong, Kyuto Tanaka, Yusuke Suzuki, Mami Hatano, Naoki Hasegawa, Yasunori Okada, and Tomoko Betsuyaku Copyright © 2015 Aoi Kuroda et al. All rights reserved. A Rare Cause of Persistent Pulmonary Hypertension Resistant to Therapy in The Newborn: Short-Rib Polydactyly Syndrome Wed, 20 May 2015 14:04:38 +0000 http://www.hindawi.com/journals/cripu/2015/274639/ Short-rib polydactyly syndrome is an autosomal recessively inherited lethal skeletal dysplasia. The syndrome is characterized by marked narrow fetal thorax, short extremities, micromelia, cleft palate/lip, polydactyly, cardiac and renal abnormalities, and genital malformations. In cases with pulmonary hypoplasia, persistent pulmonary hypertension of the newborn can develop. In this paper, we present a term newborn with persistent pulmonary hypertension of the newborn, which has developed secondary to short-rib polydactyly syndrome and was resistant to therapy with inhaled nitric oxide and oral sildenafil. Nihat Demir, Erdal Peker, İbrahim Ece, Sultan Kaba, Kemal Ağengin, and Oğuz Tuncer Copyright © 2015 Nihat Demir et al. All rights reserved.