Case Reports in Pulmonology

Background. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first introduced in China in 2019, and it has rapidly spread all around the world. Cryptococcus neoformans is the leading cause of fungal meningitis in human immunodeficiency virus- (HIV-) infected patients. A variety of laboratory tests have been introduced for rapid diagnosis of meningitis. Methods. Here, we report a case of coinfection with COVID-19 and cryptococcal meningitis in a HIV-positive patient with abnormal laboratory findings. In this case, COVID-19 was positive by polymerase chain reaction (PCR) and computerized tomography (CT) scan diagnosis. Cryptococcal antigen testing of CSF was negative, whereas India ink staining and cerebrospinal fluid (CSF) culture confirmed the presence of C. neoformans. Results. Although the patient was in a critical stage of illness, serum and CSF levels of procalcitonin were abnormally low, within normal limits. On the other hand, although initial lumbar puncture had showed elevated protein level, the repeat CSFs presented remarkably reduced protein levels. Our findings indicate that despite COVID-19 infection, procalcitonin level may remain normal in HIV-associated cryptococcal meningitis, and findings of an apparently normal procalcitonin level should not exclude the possibility of infection. Also, antigen testing may present false-negative result, and it should not be the sole laboratory method for diagnosis of infectious meningitis. Consequently, CSF culture and staining is recommended, even when antigen testing of organism is negative and CSF profile is unremarkable. Conclusion. Laboratory information should be combined with a good understanding of clinical manifestations of patient to determine if meningitis is present and confirmed COVID-19 should not ignore possibility of other infections for consideration.

Cryoprobes inserted through a bronchoscope in the airways have frequently been used for the removal of foreign bodies and clots. We present a case of a 72-year-old man who presented with COVID-19 pneumonia and respiratory failure, requiring intubation and proning. During his stay, he developed pneumothoraces in the left hemithorax, which necessitated the placement of two large-bore chest tubes. However, the pneumothorax recurred. There was no air leak in either chest tube, and attempts to restore their patency through flushing or suctioning were unsuccessful. A disposable flexible bronchoscope was inserted into the chest tubes, allowing visualization of the source of occlusion and identification of a blood clot obstructing both tubes. These clots were successfully removed using a cryoprobe inserted through the working channel of the bronchoscope, leading to the restoration of chest tube patency and resolution of the pneumothorax.

Background. Sarcoidosis is a complex disease with nonspecific etiology and clinical presentation. Its diagnosis is often delayed due to the absence of a single specific investigation modality. A multidisciplinary approach is necessary for its diagnosis. Report. A 49-year-old male presented with recurrent dyspnea on exertion, easy fatigue, and chest pain after several visits to different health facilities over 5 months. A diagnosis of pulmonary sarcoidosis was made after a series of laboratory and imaging investigations were done revealing bilateral reticonodular opacifications, noncaseating granulomata, elevated serum ACE and calcium levels consistent with sarcoidosis. Conclusion. Sarcoidosis, although a rare presentation in our setting, may easily be overlooked or misdiagnosed if a holistic or multidisciplinary approach is not employed in its diagnosis. Nonspecificity of symptoms contributes to the delayed diagnosis.

A 68-year-old patient presented with persistent hemoptysis and weight loss. A CT scan showing diffuse bilateral ground-glass opacities and nodules was followed by bronchoscopy. While diffuse alveolar hemorrhage (DAH) could be seen, specimens obtained during bronchoscopy did not provide conclusive histological findings. The decision was made to conduct video-assisted wedge resection, after which histological examinations revealed the diagnosis of bifocal nodular manifestation of an epithelioid angiosarcoma in the lung. Being a rare entity even among sarcomas, these kinds of tumors can be primary lung tissue angiosarcomas or metastatic lesions with primaries in places like the skin, breast, and heart. Treatment usually includes chemotherapy, but prognosis remains grim. This case highlights that in DAH, uncommon causes should be considered, and sufficient probe gathering is the key to early diagnosis and treatment.

Hydralazine is a vasodilator used for the management of hypertension, heart failure, and hypertensive emergencies in pregnancy. It has been implicated in the causation of drug-induced lupus erythematosus (DLE) and rarely with ANCA-associated vasculitis (AAV), which may present as a pulmonary-renal syndrome and be rapidly fatal. Herein, we describe a case of hydralazine-associated AAV presenting as acute kidney injury with the use of early bronchoalveolar lavage (BAL) with serial aliquots to aid with diagnosis. Our case highlights how, in the correct clinical setting, BAL can act as a rapid diagnostic test to help guide quicker treatment to allow for better patient outcomes.

Pulmonary arteriovenous malformations are abnormal, direct communications between the branches of the pulmonary artery and pulmonary veins, but without pulmonary capillaries between them. During pregnancy, PAVMs can enlarge and become symptomatic, causing even serious complications like haematothorax. To recognize the PAVM that becomes symptomatic in pregnancy, one must be able to distinguish the patient’s symptoms caused by developing complications of PAVM, as in the case we present, from physiological changes accompanying a healthy pregnancy, including their degree in relation to the stage of pregnancy. The modified early obstetric warning score charts are a very helpful tool in the assessment of (ab)normal signs and symptoms in pregnant women, especially for physicians who rarely manage pregnant women.