Pneumosiderosis

What causes Pneumosiderosis? Try doing a search on that you won't find anything.
It is a 64 year old patient presenting with some weight loss and a bit of a dry cough. CT showed bilateral reticulonodular opacities and no lymphadenopathy. We sent him for a bronch to assess for things like MAC. The TBBx came back as Pneumosiderosis (iron in the lung). The micro was negative. He was a welder as an occupation. The metal was steel.

intermittent oxygen in hydropneumothorax with Bronchopleural fistula(BPF)?

Here is an interesting question submitted by "zolt"

OK we all know that oxygen accelerates the rate of absorption of pneumothorax by about 4 times and so is of value in patients with pneumothorax being managed conservatively. Now in patients with hydropneumothorax with collapse with BPF with tube thoracostomy, is there any role of intermittent oxygen? how will be the diffusion mechanics in such patients or will all the oxygen come out through BPF?

Follow-up to pulmonary infiltrates

This is the case below with worsening infiltrates. She had diffuse alveolar hemorrhage and we checked an ANCA that was + at 1:640. She was started on steroids and Cytoxan but has developed hematuria and worsening renal failure. Her pulmonary hemorrhage is much improved but her kidneys continue to worsen.

D-dimer testing to determine the duration of anticoagulant therapy

What do you all think about using the d-dimer test in the decision to stop or continue anticoagulation in patients with a first idiopathic thrombotic event?
Here is the abstract from Current Opinion in Pulmonary Medicine. 13(5):393-397, September 2007.

Abstract

Purpose of review: The optimal duration of oral anticoagulation after a first idiopathic venous thromboembolism is uncertain. Recent prospective observational studies show that D-dimer levels have a predictive value for the risk of recurrence. D-dimer testing may help in assessing the individual need for prolonged anticoagulation.

Recent findings: The recently published Prolong study investigated 608 patients with a first unprovoked venous thromboembolism who had received oral anticoagulation for at least 3 months. D-dimer testing was performed 1 month after anticoagulation withdrawal. Patients with normal D-dimer (n = 385) did not resume anticoagulation. Patients with abnormal D-dimer were randomized to resume (n = 103) or not resume (n = 120) anticoagulation. All patients were followed for an average of 1.4 years. Study outcomes occurred in 6.2% of patients with normal D-dimer, and in 15.0% and 2.9% of those with abnormal D-dimer who were allocated to stop or to resume anticoagulation, respectively.

Summary: Patients with an abnormal D-dimer measured 1 month from anticoagulation withdrawal have a significant incidence of recurrent venous thromboembolism which is reduced by resumption of anticoagulation. The risk of recurrence in patients with normal D-dimer is significantly lower. D-dimer testing can be used to regulate the duration of anticoagulation.

Pulmonary infiltrates

This is a 77-year-old woman who presented with significant cough, dyspnea and hypoxemia and was found to have pulmonary infiltrates. She has been started on aggressive good antibiotic therapy, but continued to have an elevated white blood cell count, dyspnea and cough so we were consulted. No previous label of COPD; never smoked; no heart disease; no odd exposures.

She had not been able to produce significant amounts of sputum. She was also found to be hyponatremic with significant fluctuation of her sodium during her initial hospital stay. Urine and serum Osms were consistent with some SIADH and she improved with fluid restriction. Unremarkable U/A and normal renal function.

She then developed some respiratory distress, mild hemoptysis, worsening hypoxemia and had to be intubated and had the changes seen on the second CxR. (Some cuts from the CT from that day are included).

What would you want to know/do next?

Abnormal CxR

This is a follow-up to the case below of the 64 y/o man with dense pulmonary infiltrates.
Cultures were all negative. His ANCA was positive with an atypical pattern. A mediastinoscopy revealed large benign nodes with sinus histiocytosis with no diagnostic evidence of metastatic carcinoma, granulomata, or lymphoma.
His VATS lung Bx revealed necrotizing vasculitis and fibrosis most consistent with Wegener's granulomatosis (the Bx slides were sent out for a second opinion and were reviewed by Dr. Katzenstein).
How would you treat him?

More data on "Abnormal CxR"

This is the 64-year-old man with progressive, worsening dyspnea described below.
Initial blood cultures and sputum culture were non-revealing. His ESR was 75 with a positive ANA screen but essentially negative titers (<1:40); U/A was unimpressive, renal function was normal, initial CBC had mild anemia (Hgb 12.6) but normal WBC (7.6 with 90% PMNs) and normal platelets.
What other tests/info would you like next?

Abnormal CxR

This is a very pleasant, 64-year-old man with progressive worseningdyspnea over the past couple of months. He states that up until maybe six months ago he had been in his usual state of health and had no persistentdyspnea. For the past 3-4 months he has had insidious onset of dyspnea on exertion, which has been worsening. He has had no associated cough, no chest pain, no fever, no chills and no night sweats. He denies any significant paroxysmal nocturnal dyspnea, though he does have some component of orthopnea. He has never had hemoptysis. His weight has been stable. He actually has gained some weight in the past couple of years. He has had no previous label of severe chronic lung disease.

PAST MEDICAL HISTORY: Significant for some hypertension.He had been diagnosed with mediastinal and hilar adenopathy some 15 yearsago, according to the patient. He actually underwent a bronchoscopy atthat time, but was not found to have any significant evidence ofmalignancy. He has never had a sleep study. The films and reports on his adenopathy are in a Mississippi and not available...
SOCIAL HISTORY: He used to smoke, but quit about 15 years ago when he was diagnosed with the mediastinal and hilar adenopathy. He worked in freight mostly at docks and driving transport. No alcohol abuse, no illicit drug use. He used to live in Mississippi (now here in TN). He has no exposure to sick contacts. He lives with his wife and they have no pets. No alcohol abuse, no illicit drug use.
FAMILY HISTORY: Is remarkable for his sister having pulmonary fibrosis, but we are not sure as to what type. She apparently is on oxygen 24/7.
REVIEW OF SYSTEMS is otherwise fairly unremarkable.
PHYSICAL EXAMINATION: Afebrile. Only pertinent positives are some faint right basilar crackles which actually cleared withcough. He has slightly diminished breath sounds at the bases. I could not appreciate any wheezing. He has no edema, no clubbing and no cyanosis.
CxR and CT as below. What do you think and how would you work him up?

Hemoptyis and bilateral infiltrated UPDATE

The case below was posted last week. Since that time I obtained a high res CT and autoimmune panel. The ANCA and ANA were normal. The BAL (clear non-bloody) was negative for any infection. The cell count of about 500 was predominantly macrophages. He is still short of breath (mostly on exertion but to a lesser extent at rest). He has no fevers or other constitutional symptoms. No more hemoptysis.

CT (no hilar adenopathy, by the way):


63 year old man with one week of hemoptysis. The hemoptysis is described as streaks of blood with the underlying sputum being slighltly light green or white. No malaise. Just some shortness of breath. No fevers or night sweats. No anorexia or weight loss. He feels pretty well except for the mild increase in SOB.
He is a 48 pack year smoker now quit. No significant exposure or travel history. For what its worth (if anything), he was cleaning out his gutters about a week before the symptoms. Lots of decayed leaves etc.

On exam he is WNWD and NAD. Vitals and pulsox are normal. No LAD and the lungs are clear to auscultation.

His WBC is 14 and in June it was 7.
His xray from 3 years ago:




The xray from today is seen here:



He has persistent dyspnea despite a course of azithro for presumed mycoplasma. The BAL was negative for virus or fungi.
His new cxr is here:


What is your differential dx?

TB pericarditis

Submitted by IS:

What are your opinions regarding the use of adjuvant steroids for presumed TB pericarditis? Do you think a pericardial biopsy is a must if we have a positive PPD, negative cytology of fluid, low glucose on fluid studies, and good clinical history? Thanks.

Steroid responsive adenopathy?

65-year-old woman presented initially for evaluation of shortness of breath. A CT thorax revealed some patchy airspace opacification RUL (see below) . She underwent bronchoscopic evaluation and it demonstrated some interstitial inflammation with hyperplastic type 2 pneumoctyes. No granulomas seen. No fungal or AFB elements on BAL. A cell count was not sent.
She was begun on a course of steroids 40mg and felt her breathing improved significantly while on them, but once she stopped them, her shortness of breath recurred. Her cough has also recurred, though it's mostly non-productive. A CT was repeated 5 monts later and is shown below.



Question: What ILD had adenopathy and is steroid responsive? The only 2 I can think of are sarcoid and berrylliosis, but the interstial inflammation would be inconsistent with that. Any thoughts out there?

A man with weakness and a some minor CT abnormalities

From Doug:

53 yo man with an 80 pack yr smoking hx and history of Etoh abuse was admitted
with a 5 week hx of progressive ataxia, diplopia, dysarthria,
and dysphagia. Initially w/u revealed unremarkable MRI brain, and a CT
C/A/P showing prevascular lymph nodes with some calcifications and left hilar borderline enlarged lymph nodes, and a renal cyst not further characterized on that study.

DDx included subacute cerebellar degeneration and progressive supranuclear palsy.
Multiple CSF and serum labs were pending at time of discharge

He was readmitted a week later for progressive dysphagia for liquids in addition to solids, worsening gait s/p falls, and continued dysarthria and diplopia. IV IgG was given empirically without improvement. Repeat LP and additional infectious
serologies were negative. A dedicated renal CT was done to further characterize the indeterminate lesion on the previous CT, showing only a
simple cyst.

What would you do next? <<<>>>





Addendum added after case presented:
These are the EBUS images from the bronch including and the core biopsy from the TBNA. The answer was that these little lymph nodes were small cell carcinoma. The special stain is a cytokeratin stain of the malignant cells.

Shortness of breath with phrenic nerve paralysis

Submission
60 year old woman with sarcoidosis by mediastinal biopsy 1978 doing well, never requiring steroids. 2 mos prior developed SOB - smothering type of feeling even at rest but also on exertion. A CXR during a routine physical showed a left paralyzed hemidiaphragm.

Pmhx
sarcoid as above
NQWMI 1991 Echo on f/u showed torn chordae and LV "contractile abnormality" on a thallium test.


Three fluorouscopies revealed unilateral paralysis. Scheduled for EMG studies

Patient also adds:
"I am 60 y/o and live a quiet life but my legs are now getting weak and I am unable to bend down in a sitting position and get up. I failed to mention that I had a lumbar puncture which was normal. MRI showed cervical problems but nothing serious I guess. The pons area of my brain showed vascular changes due to aging. I also had strabismus during all of this and had a prism put in my glasses because of a convergence problem with my eyes. Could this all be connected? Myasthenia gravis I guess has been ruled out and they are calling this idiopathic phrenic nerve paralysis. Should I pursue this any further?I have about 40% function of my left lung."

Note: please consider adding a comment to help keep this blog going!

Shortness of breath

Submission from outside reader:

Hi I have been looking at this blog for since 2005 on a weekly basis and wonder if you take questions from patients. Your site is informative it is a pity you are not getting the hits.

I am a 38yo M and I have a chronic symptoms now for many years with NO DIAGNOSIS despite pressing for one.

I have a hacking cough with some sputum in the morning, I also have nearly constant SOB with an inability to get a deep breath. A feeling of stiffness in my lungs. I feel constantly like my breathing is not good. This has been with me since 2003. Excercise tolerance is ok i.e. I could run a mile in 10min but I struggle to breathe throughout.

Pleurisy type pain on and off weekly, specifically located in same location at upper left back. Lower rib pain on left.

Asthma as a child, allergic rhinitis as a teenager and young adult, smoked in college (10 a day) and socially (30 at weekend) till I was 33. On and off asthma meds since 1994. Tried Singulair, Symbicort, Spiriva etc. Tried also extensive courses of Zoton, Nasocort etc.

Have been evaluated many times over the years by 3 pulmos spent '000$ and the best they can give me as a diagnosis is " a chronic inflammation similar to chronic bronchitis with little or no asthma but we are reluctant to give it a title "

Here is the dilemma, all tests normal my FEV1 is 4.45…101%, FVC 5.8…104%, FEV/FVC 76. DLCO Normal. FEF25-75 83% Lung Vols Normal


Here is the question:

Why do I have symptoms if all tests are normal. What do you guys think.. have you seen this before, normal tests but chronic symptoms with dyspnea.

Chest xray x 4 Normal
2 x HRCT (1 year between) Normal, Body Ples Normal. Methacholine Normal
ECG Stress Test Normal
Echo Cardio Normal
Bloods Normal, 2 x HRCT (1 year between) Normal, Body Ples Normal. Methacoline Normal

MRI ordered by Rheumo .. Normal

Not in my brain either!! I have loads of other stuff to worry about like kids, my stressful job as a broker, mortgages etc

Pulmicort discontinued?

Has anyone else heard that Astra Zeneca will be discontinuing pulmicort? Were they not making a profit on this? Anecdotally, I see a lot of patients on Pulmicort.

This is from The FDA site:

NDA 20-441, PULMICORT TURBUHALER 200 mcg (budesonide inhalation powder) will no longer be available at AstraZeneca.

The introduction of PULMICORT FLEXHALER (budesonide inhalation powder, 90 & 180 mcg), NDA 21-949, will be accompanied by the phasing out of PULMICORT TURBUHALER so as to minimize confusion in the marketplace.

AstraZeneca has no further plans to manufacture NDA 20-441, PULMICORT TURBUHALER 200 mcg (budesonide inhalation powder).

Worsening dyspnea in a patient with IPF

71 year olf woman with idiopathic pulmonary fibrosis diagnosed by open lung 2004 (UIP on biopsy). Since that time she has been stable with good exercise tolerance, and able to get around with little difficulty. PFT's also stable during that time frame with FVC in low 80% since 2004. Over the last 2 months she reports increased dyspnea on exertion and fatigue. Her ambulation has decreased over the last 3 or 4 months because of pain of her left hip, which for the last 6 months she had been getting injections for. She is due to get left total hip replacement. She has difficulty getting out of the chair because of pain in her hip. She does still try to get around, but her ambulation she does admit has decreased over the last 3 months because of this pain. She denies any nocturnal shortness of breath or orthopnea. She has no chest pain. There is no fevers, chills, night sweats. No appreciable weight gain subjectively. No anorexia. No cough.

Her physical exam is a pleasant woman sitting in a chair, in no acute distress. Blood pressure 123/59, pulse is 77, respiration is 20, O2 sat is 97% on room air, her weight is 228 pounds. Her weight in March 21st on another scale at another clinic was 221 pounds and her weight on our scale in January 2007 was 231 pounds. HEENT: Trachea midline, no lymphadenopathy. The JVP seems to be about 4 to 5 cm. The lungs have crackles basilarly and laterally about the third of the way up. Heart is regular rate and rhythm with a positive S3, no murmurs or rubs. Abdomen: Benign. There is trace pitting edema bilaterally at the ankles.

Spirometry shows the ratio of 84%. FEV1 of 1.87 (83% of predicted), FVC of 2.21 (74% of predicted). DLCO 65% of predicted. In May 2006 FVC was 80% of predicted and DLCO 74% of predicted.
CXR this visit:


CXR from 2 years ago:


What are your thoughts and/or what would you do next?

Acute on chronic Blogemia

Sorry there have been no new posts. Baleeiro and I are essentially the last surviving members of the blog (functionally, not literally - the others are not dead; they just lost interest) and our motivation for daily posts has somewhat diminished given lack of participation from outside readers, previous contributors and anyone else who might come across this blog. I will most likely leave a post or two a week and we will see where this goes. We have been steadily building a database over 2 years of pulmonary cases (with discussion) and all categorized, so it is a bit of a shame that it goes this way. Hopefully we can wean the blog off of the proverbial vent and not proceed to comfort care measures....

-JJ

low DLCO in runner

Submission from Hal :


15 y/o WF distance runner on track team c/o SOB. No improvement in the past year as perceived inability to breathe. She is is 5 7 tall, 115 pounds. All State, All American runner in 1600M and 800M.

PFTs showed DLCO 71% pred (18.9 with ref 26.6), DL Adj 80% (18.9 with 23.5 ref).
VA 5.09 L

FVC 106%, FEV1 100%, FEF25-75 96%.

Chest xray showed...ordered but not done yet.

Normal CBC

Any thoughts on etiology and suggestions for further work-up?

Cavitary mass

86 year old man with history of dementia brought by his caretaker for mental status changes and lethargy. He lives in an assisted living facility, but has no TB risk factors otherwise (He has his own apartment-like structure, but I beleive there is a common area).

His CT:



There was no hilar or mediastinal adenopathy.
The thickest wall area on that lesion was 4-5 mm.

Someone placed a PPD and it was 11 mm. It was reportedly negative 6 months ago.
He is not productive of sputum, so 3 gastric lavages were done and they were all negative. What would you do next? Are you worried about active tb? Here are my thoughts
1. How sensitive is gastric lavage for afb?
2. location of the cavitary mass is not where tb should be.
3. is he a ppd converter, or was he anergic or are we seeing a booster effect
4. His family does not want an aggressive w/u for cancer, but on the other hand one would not want to send someone home to hospice with active tb....

Dose of T-PA - Part Deux

I didn't get much feedback or interest on the post below on T-PA and empyemas so I contacted our T-PA rep and we got some references on the matter.
The dose varies widely and it seems you just can't go wrong...
In the Chest abstract I had listed in the original post the authors used 10 mg per instillation.
In a brief review/case report in Hospital Pharmacy in 2003 (vol 38 (11); pp: 1024-29) the authors used 16mg/100ml NSS infused daily. They derived the dose by extrapolating the ratio of Streptokinase usually used in empyemas to the dose for MI's.
In another Chest abstract, the initial dose was 10mg for complicated hemothoraces and that was increased to 25mg, still with good tolerability.
The pediatric literature was a bit more consistent and usually 0.1mg/kg was used in various trials.
Any other suggestions?