Case Reports in Pulmonology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Pulmonary Nocardiosis in the Immunocompetent Host: Case Series Wed, 30 Sep 2015 13:49:32 +0000 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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. Night Sweats as a Prominent Symptom of a Patient Presenting with Pulmonary Embolism Mon, 11 May 2015 11:43:44 +0000 Pulmonary embolism is a common, potentially fatal disease. Making the correct diagnosis early can significantly reduce mortality and morbidity. We report the first case of drenching night sweats as one of the presenting symptoms of submassive pulmonary embolism. One week after undergoing laparotomic sigmoidectomy for diverticulitis, our patient started to experience drenching night sweats and pleuritic back pain. CT identified bilateral main stem pulmonary artery emboli, and treatment was initiated with subcutaneous enoxaparin injections. Imaging and laboratory workup failed to reveal any other explanation for the night sweats. Patient was discharged on rivaroxaban, and he reported complete resolution of symptoms upon the 3-month follow-up visit and 9-month follow-up call. Based on our case we propose night sweats to be a potential presenting symptom of pulmonary embolism. Our observation can help make an earlier diagnosis of pulmonary embolism. Attila Feher, Saif A. Muhsin, and Anna M. Maw Copyright © 2015 Attila Feher et al. All rights reserved. Pulmonary Nocardiosis in an Immunocompetent Patient with Cystic Fibrosis Wed, 15 Apr 2015 12:50:52 +0000 Nocardia spp. are bacteria of low virulence that cause infection classically in immunocompromised hosts with the lungs as the primary site of infection in the majority of cases. Patients with cystic fibrosis have pulmonary disease characterized by frequent and progressive bacterial infections. Reports of Nocardia spp. isolation in CF are rare in the literature and may represent colonization or active infection, the significance and optimal treatment of which are unknown. We report the second case to date of Nocardia transvalensis pulmonary infection in an immunocompetent patient with CF and the first in a child under the age of eighteen. Lucy Schoen, Jonathan D. Santoro, Carlos Milla, and Sumit Bhargava Copyright © 2015 Lucy Schoen et al. All rights reserved. Successful Treatment of Bronchial Fistula after Pulmonary Lobectomy by Endobronchial Embolization Using an Endobronchial Watanabe Spigot Wed, 15 Apr 2015 11:47:14 +0000 A bronchial fistula is one of the most serious complications that can occur following pulmonary lobectomy. We herein report a case of bronchial fistula that was successfully treated by endobronchial embolization using an Endobronchial Watanabe Spigot (EWS). A 72-year-old male underwent right lower lobectomy of the lung with nodal dissection for a pulmonary squamous cell carcinoma. A bronchial fistula developed 53 days after surgery. Tube drainage was performed, and air leakage was apparent. Under endoscopic observation, intrathoracic injection of indigo carmine revealed that a fistula existed at the peripheral site of the B2ai bronchus. After one EWS (small) was inserted into the B2a bronchus tightly using a bronchoscope, the air leakage was stopped. Pleurodesis was further carried out, the thoracostomy tube was subsequently removed, and the patient was discharged. Endobronchial embolization using an EWS is an option for the treatment of a bronchial fistula after pulmonary resection. Yuichiro Machida, Makoto Tanaka, Nozomu Motono, Sumiko Maeda, Katsuo Usuda, and Motoyasu Sagawa Copyright © 2015 Yuichiro Machida et al. All rights reserved. Cocaine Induced Pleural and Pericardial Effusion Syndrome Mon, 30 Mar 2015 14:01:37 +0000 A 42-year-old African American female with chronic cocaine use for 20 years, presented with two-day history of exertional shortness of breath and pleuritic chest pain. She was admitted three years back with acute kidney injury and skin rashes. At that time, skin biopsy was consistent with leukocytoclastic vasculitis and renal biopsy revealed proliferative glomerulonephritis. She responded to oral prednisone and mycophenolate with complete recovery of her kidney functions. Skin rash was waxing and waning over the last two years. On the second admission, patient was found to have large pleural effusion on computerized tomography scan and pericardial effusion on echocardiogram as shown in the figures. Pleural fluid analysis was exudative. Her serology was negative for ANA (antineutrophilic antibody) and anti-dsDNA (double stranded DNA). Complements levels were normal. She had positive low titers of ANCA levels. The patient was started on a course of prednisone for 6 months. Her pleural and pericardial effusion resolved completely on follow-up imaging with computerized tomography scan and echocardiogram. This case is unique since the pericardial and pleural effusions developed without any other etiology in the setting of cocaine; hence, we describe this clinical syndrome as cocaine induced pleural and pericardial effusions syndrome (CIPP). Shehabaldin Alqalyoobi, Omkar Vaidya, Al-Ma’Mon Abu Ghanimah, Ahmed Elkhanany, and Ashraf Gohar Copyright © 2015 Shehabaldin Alqalyoobi et al. All rights reserved. Primary Antiphospholipid Syndrome Associated with Pneumonia: A Case Report of a 16-Year-Old Male Patient Sun, 22 Mar 2015 10:48:50 +0000 Antiphospholipid syndrome (APS) is an autoimmune disease characterised by arterial and/or venous thrombosis and/or recurrent pregnancy loss in the presence of antiphospholipid (APL) antibodies. It is evaluated as APS when it develops associated with other systemic autoimmune diseases or primary APS if there is no concomitant disorder. In this study, we present a case of a 16-year-old male patient with primary APS. The patient was admitted with presumptive diagnosis of pneumonia, but multiple pulmonary thromboembolism (PTE) was observed on computerized tomography (CT) pulmonary angiography. APL antibodies positivity and thrombocytopenia developed in our patient. The patient was evaluated as primary APS since another etiology that could explain PTE was not found. Primary APS is a rare disease in children along with adolescents, compared with APS associated with other systemic autoimmune diseases. We present here a young male patient with primary APS and PTE to contribute to the literature. The patient initially had pneumonia but later developed PTE and thrombocytopenia. Süreyya Yilmaz, Fusun Topcu, Hadice Selimoglu Sen, Yasar Yildirim, Zülfükar Yilmaz, Ali Veysel Kara, and Cihan Akgul Ozmen Copyright © 2015 Süreyya Yilmaz et al. All rights reserved. Lung Cancer with Skin and Breast Metastasis: A Case Report and Literature Review Mon, 16 Mar 2015 11:01:53 +0000 Lung cancer is one of the most common cancers in America. Frequent sites of metastasis include the Hilar lymph nodes, adrenal glands, liver, brain, and bone. The following case report is of a primary lung cancer with metastases to the breast and skin. Case. A 48-year-old African American male with a past medical history of poorly differentiated left breast cancer status after modified radical mastectomy (MRM), chronic obstructive pulmonary disease, and smoking (20 pack-years) presents to the ER with progressive shortness of breath on exertion, upper back pain, and weight loss for 2 months in duration. On physical examination he is found to have a MRM scar on his left breast and a left periumbilical cutaneous mass. Chest X-ray and chest CT reveal a right upper lobe mass and biopsies from the breast, lung, and the periumbilical mass indicate a poorly differentiated carcinoma of unclear etiology; all tumor markers are negative. The patient is male and a chronic smoker; therefore the diagnosis is made as lung carcinoma with metastases to the breast and skin. Conclusion. A high index of suspicion for cutaneous metastases should be cast when investigating cutaneous pathologies in patients at risk for primary lung malignancy. Bikash Bhattarai, Marie Frances Schmidt, Meenakshi Ghosh, Abhisekh Sinha Ray, Saveena Manhas, Vikram Oke, Chidozie Charles Agu, Md. Rawshan Basunia, Danilo Enriquez, Joseph Quist, Catherine Bianchi, Ravi Hans, and Saroj Kandel Copyright © 2015 Bikash Bhattarai et al. All rights reserved. Primary Pulmonary Malignant Fibrous Histiocytoma Sun, 08 Mar 2015 09:15:08 +0000 Malignant fibrous histiocytoma (MFH) is one of the most common adult soft tissue sarcomas. MFH is very aggressive and is most often found in the extremities and the retroperitoneum, but it can manifest at other sites. Though the lungs are the most common sites of metastasis, they rarely present there as a primary tumor. Our report describes a rare case of a primary MFH tumor in the lung. Careful diagnostic procedure should be followed to ensure the tumor does not have extrapulmonary origins. Though MFH is highly invasive and deadly, surgical excision of the tumor has been shown to be successful. Devin P. Patel, Yogesh S. Gandhi, Keith E. Sommers, Devanand Mangar, and Enrico M. Camporesi Copyright © 2015 Devin P. Patel et al. All rights reserved. A Rare Cause of Cavitary Lesion in the Lung: Richter’s Transformation Tue, 24 Feb 2015 14:36:58 +0000 Richter’s transformation (RT) refers to the development of aggressive lymphoma during the course of CLL. Clinically, patients with RT present with an aggressive disease course with rapidly enlarging lymph nodes, hepatosplenomegaly, and elevated serum lactate dehydrogenase levels. But rarely it presents with extra nodal organ involvement at the beginning. Common sites of extra nodal involvement are the gastrointestinal tract, eye, central nervous system, lung, and kidney. We are reporting this case that was presented with RT in the lung involvement diagnosed while researching cavitary lesion etiology. Fatma Yıldırım, İskender Kara, Sedat Yıldız, Nalan Akyürek, Kadir Acar, Melda Türkoglu, and Gülbin Aygencel Copyright © 2015 Fatma Yıldırım et al. All rights reserved. Pleural Mycobacterium Avium Complex Infection in an Immunocompetent Female with No Risk Factors Sun, 22 Feb 2015 11:31:54 +0000 Mycobacterium avium complex (MAC) infections rarely affect the pleura, accounting for 5–15% of pulmonary MAC. We report a case of MAC pleural effusion in an otherwise immunocompetent young patient. A 37-year-old healthy female with no past medical history was admitted to the hospital with two weeks of right sided pleuritic chest pain, productive cough, and fever. She was febrile, tachycardic, and tachypneic with signs of right sided pleural effusion which were confirmed by chest X-ray and chest CT. Thoracentesis revealed lymphocytic predominant exudative fluid. The patient underwent pleural biopsy, bronchoscopy with bronchoalveolar lavage, and video assisted thoracoscopic surgery (VATS), all of which failed to identify the causative organism. Six weeks later, MAC was identified in the pleural fluid and pleural biopsy by DNA hybridization and culture. The patient was started on clarithromycin, ethambutol, and rifampin. After six months of treatment, she was asymptomatic with complete radiological resolution of the effusion. The presence of lymphocytic effusion should raise the suspicion for both tuberculous and nontuberculous mycobacterial disease. Pleural biopsy must be considered to make the diagnosis. Clinicians must maintain a high index of suspicion of MAC infection in an otherwise immunocompetent patient presenting with a unilateral lymphocytic exudative effusion. Ravi P. Manglani, Misbahuddin Khaja, Karen Hennessey, and Omonuwa Kennedy Copyright © 2015 Ravi P. Manglani et al. All rights reserved. Tracheal Papilloma Treated with Cryotherapy and Interferon-α: A Case Report and Review of the Literature Wed, 18 Feb 2015 13:29:47 +0000 Tracheal papilloma (TP) is characterized by papillomatous growth of the bronchial epithelium that involves the trachea as a response to Human Papilloma Virus (HPV) infection. A 40-year-old male, with 3-month history of progressive dyspnea was admitted to our hospital, and there were no any other respiratory symptoms. Physical examination was unremarkable. Chest computed tomography (CT) showed that there was a papillomatous mass at the distal trachea. The lesion occupied 80% of tracheal lumen. This patient received cryotherapy and mechanical debridement under general anesthesia and postoperative pathology showed endotracheal papillomatosis. Patient was treated with interferon-α (IFN-α) and he showed no recurrence at the 8th month of his therapy. Fatma Yıldırım, Murat Türk, Sedat Demircan, Nalan Akyürek, and Ahmet Selim Yurdakul Copyright © 2015 Fatma Yıldırım et al. All rights reserved. Hypoxia: An Unusual Cause with Specific Treatment Wed, 04 Feb 2015 09:31:20 +0000 Hypoxia is a well-recognized consequence of venous admixture resulting from right to left intracardiac shunting. Right to left shunting is usually associated with high pulmonary artery pressure or alteration in the direction of blood flow due to an anatomical abnormality of the thorax. Surgical or percutaneous closure remains controversial; however it is performed frequently for patients presenting with clinical sequela presumed to be resulting from paradoxical embolization secondary to right to left shunting. We report two patients with hypoxia and dyspnea due to right to left shunting through a patent foramen ovale (PFO) and venous admixture in the absence of elevated pulmonary artery pressures or other predisposing conditions like pneumonectomy or diaphragmatic weakness. Percutaneous closures of the PFOs with the self-centering Amplatzer device resulted in resolution of hypoxia and symptoms related to it. John P. Berger, Ganesh Raveendran, David H. Ingbar, and Maneesh Bhargava Copyright © 2015 John P. Berger et al. All rights reserved. Organizing Pneumonia Associated with Pegylated Interferon α and Ribavirin Therapy Thu, 29 Jan 2015 09:16:35 +0000 Hepatitis C virus infection is the leading cause of chronic liver disease in the United States of America. Pegylated interferon α and ribavirin combination is the mainstay of treatment. Severe pulmonary toxicities are rarely reported. We report here a case of severe form of organizing pneumonia secondary to pegylated interferon α therapy presenting as acute respiratory failure. Patient has near complete recovery with withdrawal of pegylated interferon α and steroid therapy. We report this case to raise the awareness of this rare but potentially life-threatening pulmonary complication of pegylated interferon α therapy. Amit Chopra, Creticus Marak, Narendrakumar Alappan, and Chang Shim Copyright © 2015 Amit Chopra et al. All rights reserved.