RUL cavitary lesion.

HC from Michigan has this question: "This gentleman 4 months s/p kidney transplant complaints of shortness of breath. No sputum production. PPD negative pre-transplant. Unable to obtain induced sputums. He had a CT guided biopsy (ID service, before he got to us), of the abnormal finding on CT of the thorax which is negative for AFB and other organisms. Can you reliably rule-out tuberculosis on these grounds without a respiratory sample?; The classic thick vs thin cavity differential diagnosis, can be applied on this case? What is the next step?"

Follow up to Friday's chest xray

This is a classic example of collapsed segment of the left lower lobe. You can't usually tell which segment it is, because they will all collapse medially like that and look the same on CXR (because of the pulmonary ligament, it has to collapse that way). The lateral shows some haziness (red circle) and loss of left diaphragm (arrow), but no clear lines to indicate the collapsed lung edge. The PA view clearly shows the collapsed segment (arrows). The CT is shown for comparison.
The patient ended up having an endobronchial lesion at the proximal portion of the left lower lobe. It was squamous cell carcinoma.

Question about mometasone

We received this question by email. Any thoughts?

"I am a private practice pulmonologist and was just detailed re: mometasone DPI. The only dose is 220 ug, but it comes in 30, 60 and 120 dose units. The company is telling us that once the DPI is removed from the foil packaging the drug expires in 45 days. This seems to be a ploy to prevent 220 ug QD use with the 120 dose unit, which would be one of the most economical ICS. I searched the web looking data on mometasone stability, and it seems to be a stable molecule. Does anyone know any data? I smell a scam."

Friday Radiology - Chest Xray

What is the finding on the chest xray and what is thus the likely diagnosis of this patient? I'll post the chest CT on Monday. Have a good weekend all....



Read the comments and then find the answer Here

Follow-up to Wednesday CxR

Good pick-up by Mendez. The CxR has that L for a reason. This is a new patient with Kartagener's who is establishing local pulmonary care. She has chronic sinus disease but not much in the way of bronchiectasis.

COPD and NIPPV

Does anyone know the citation of a study showing an actual survival benefit to using BiPAP ventilation in a patient with a COPD exacerbation vs. conventional mechanical ventilation?
All of the studies listed in Bart Celli's consensus states show trends to survival benefit.

Follow-up to ABTx choice

I will wrap this one up so we can focus on JCH's and MLazar's postings.
This is mixed fungal and bacterial endocarditis. Though Candida is a concern and has a fairly high mortality, Aspergillus is the second most common cause of fungal endocarditis and has a very poor prognosis: mortality for treated Aspergillus endocarditis is usually ~80%. The cytology smears were typical of Aspergillus... We started therapy with Vanco (as suggested by JCH I think), gent and Rif (since he had a new prosthetic valve) as well as ampho B and Cancidas. I did not find good data on "double-coverage" for Aspergillu but it has such a dismall prognosis there are many case studies and small series review using Ampho and Voriconazole or Cancidas.
Despite aggressive support his hemodynamics continued to deteriorate for the first week. His family made him a DNR and he died one night of sudden VFib...

Wednesday CxR rounds

What is the diagnosis?



update: after reading the comments, see the answer here

Can we remove this trach

Here's a quick one: 78 y/o man presented to my clinic with the question: can we remove my trach? Actually, he doesn't speak English, and the entire history (or what I could get of one) was provided by his family.

Here's the story: He had a presyncopal episode several months ago and was admitted to another hospital. Developed respiratory distress that night, and was intubated. I have no idea why, but the family says he had been getting narcotics for pain related to the foley (which was placed because he was severely hyperglycemic-known diabetic). Anyway, he self extubated a day later, and required reintubation with 30 minutes. There was apparantly a question of airway edema. A trach was placed 1 week later (no other attempts to remove the tube), and he was discharged to a rehab facility (he was off of the vent).

There, his trach was downsized from an 8 -> 6 -> 4. With the #4, he developed respiratory distress (family things it was a mucous plug). The staff took out the #4, but were unable to get a larger trach in, so he was orally intubated again. A repeat trach was placed 2 days later, and he was in the ICU for 3 weeks (again, I get no history of a pneumonia or mechanical respiratory failure, but I'm told he was on the vent for most of that time) prior to transfer back to rehab.

He was in rehab for 2 months, and now home for 1 month. He's got an uncuffed 6-shiley and caps it without difficulty. He's got a Passey-Muir that he uses to speak with family.

Only other PMH is multi-infart dementia. The rest of the history and exam are unremarkable. Spirometry shows a fixed obstruction-classic-if anyone wants it for their teaching files, let me know.

Anyway, what do you tell them? Can we decannulate?

Dypnea with a pleural effusion

81 yo male with a past history of obstructive jaundice s/p ERCP and removal of a stone one week prior to readmission. He was discharged from the hospital shortly after this procedure at which he was returned to his care facility for two to three weeks. While at his NH, he started to have worsening shortness of breath which has worsened over the last 2 months but has become more profound in the last week. It is worse with exertion and he can currently only walk approximately 10 feet. He denies any complaints of chest pain, calf pain or calf swelling. He has no history of venous thromboembolic disease. The patient denies wheezing, cough or sputum production, hemoptysis, a runny nose, reflux symptoms or palpitations.

PAST MEDICAL HISTORY: Obstructive jaundice secondary to gallstones; COPD per his PCP's records.

SOCIAL HISTORY: Smoking history: 20 pack years; he quit 15 years ago.
Alcohol use: The patient admits to 6 to 7 beers per week for approximately 60 years.
He denies IV or street drug use. He was exposed to asbestos for approximately 7 months as he was working in a factory in which the asbestos was being removed. No travel.

PE: Vitals: Heart rate 76, resps 18. BP 136/76. Saturation: 96% on Room Air. Neck: No JVD. Heart: Normal. Lungs: clear throughout all fields, however, decreased BS in all fields. Extremities: Fingernails positive for clubbing. Pitting edema noted in the lower extremities.

Labs: Sodium 142, potassium 4.3, chloride 110, bicarb 23, BUN 6, creatinine 1.0, glucose 98, calcium 8.2, phosphorus 2.7, albumin 2.3, total protein 5.0, alk phos 151, AST 26, ALT 38, total bili 3.5, direct bili 1.8.
white blood cells 8.6, H and H 9.4, and 29.7 platelets 771.

RADIOGRAPHS:



How would you proceed? What tests would you want next?

New ICS

Has anybody used or had any experience with the new mometasone inhaler (Asmanex)?
It comes in an auto-haler similar to Pulmicort but it has a counter which is a nice improvement over Pulmicort.

QQ

Just a quick question while we are all mulling over Carlos' post; if a patient had resection of some RUL aspergilloma and he is going to get a renal transplant (thus immunosuppressed), do you give that patient prophylactic itraconazole after the kidney transplant?

Choices of ABTx

We were consulted to see this is 72-year-old man following emergent aortic valve replacement. He had had a CABG in 2000 and ha done extremely well until approximately two to three weeks PTA when he began experiencing increasing shortness of breath and dyspnea on exertionre. He was seen by cardiology and a 2-D-ECHO revealed aortic insufficiency and possible signs of Valsalva to left atrial fistula. He had an emergent valve replacement and we were consulted because the valve appeared grossly infected and intra-op swabs revealed GPCs in chains and yeast on smears.
He was intubated and on pressors post-op. What would you like to know and what ABTx would you recommend?

Follow-up to hypercalcemia

This is the 61 y/o man with a pulmonary mass and the bony lesions that Jennings astutely thought looked like a plasmacytoma. I was also impressed by the combination of lung mass and hypercalcemia. There were no other thoracic lesions.
We started standard hyperCa++ treatment, his MS improved and his creatinine came down from 2.0 to o.8 with normalization of his Ca++.
We set him up for a CT-guided Bx of his lung mass: he developed massive hemoptysis, almost coded; we emergently intubated him and I used the bronchoscope to advance the ETT towards a selective L intubation...
He recovered and prior to re-Bx'ing we repeated a CT scan and the nodule was gone!
He went home to recover from his respiratory failure and we finished his w/up as an outpatient: no more lung masses but his bone lesions and BM Bx led to a diagnosis of multiple myeloma.

Monday morning radiology

Here's a smoker with COPD. Match the abnormality seen on both CXR and CT.

DVT and ambulation

Here's another interesting question we received:

"Hello. Great blog. We have a patient with an extensive DVT. He is being heparinised. He asked if he should walk on it. Is there a risk of embolization events if you walk on a leg with DVT? If so, what is the time frame in which it becomes safe to do so? On the other hand, is it better or worse to keep the leg up and stay in bed? This would seem counterintuitive to virchow's triad which warns agains immobilisation."

Airborn

A 3rd year resident had an interesting question. He wanted to see what others thought. He asks, "we are all taught that bacterial pneumonia is not 'catching'. You can put a patient with community-acquired pneumonia, i.e. strep pneumonia, in the same room as someone else and their roommate will not catch pneumonia. Why then is TB contagious, when this is ALSO a bacteria? Or to put it another way, why is TB the only type of bacterial pneumonia that is contagious?"

Hypercalcemia and lung mass

This is a 61 y/o man with a significant Hx of smoking. He presented to our ER with a 3-week history of polyuria, weakness, fatigue, confusion and abdominal pain. Using my keen diagnostic skills I asked the ER to check a calcium level which was 15.2. He was admitted and treated for the hypercalcemia.
His Cxr showed some hyperinflation and a RLL pulmonary nodule better characterized on the CT scan below (check out the vertebral bodies).
What would you do next? What is your differential?

Answer/follow-up to this case on http://pulmonaryroundtable.blogspot.com/2005/08/follow-up-to-hypercalcemia.html

CT followup?

This question is from a doc in Ohio:

A f/u CT was done on a patient 1 and 1/2 months after RUL community-aquired pneumonia.
The reading was: "Small focal pneumonic process in the anterior subsegment of the right upper lobe. The 2 tiny nodules in the right lower lobe likely represent
noncalcified granulomas or intrapulmonary lymph nodes."

Does this patient need any more f/u CT's based on thsi interpretation?

CT for back pain

Here's an interesting case of a 42 y/o with minimal PmHx. She has a history of htn and bronchitis. She had some back pain so they ordered a CT.