Lung cancer letter

Very interesting letter to the editor on lung cancer, that puts things into perspective and that is often overlooked. Written by someone who also has left many comments on this site, so check it out.

IPF treatment - worse than the "cure"

Here's another anecdote on a patient started on prednisone/azathioprine/NAC for IPF. He was started on this for a variety of reasons, but one was that the biopsy had a bit more inflammatory changes even though there was ample fibroblastic foci and heterogeneity, so I thought a 3-6 month trial would be reasonable. By the time his imuran was up to 75 mg, I saw him. A repeat spiro was unchanged (FVC 43% predicted) but his DLCO went from 35% to 45% so I continued the meds. However he had mouth pain and the tongue showed possible thrush so I kept the Imuran at 75, gave some nystatin swish and sent him out to be followed up in 2 months and repeat the HRCT with the sprio/DLCO. However, his mouth pain did not go away and worsened, and he started developing malaise and a fever. I saw him in clinic that day. He looked fairly sick but vitals ok. He had a soft palate lesion. I got derm to KOH it and there are some non-budding hyphae so he's to get clotrimazole . Then almost as an afterthought I added on amylase and lipase to the repeat LFT's and low and behold the lipase is 800.
Of note his WBC was 13 and now down to 6....
This side effect is likely going to be self-limiting as he stays off the imuran. As I tell him to go light on PO intake, I am adding a creatinine to make sure he is not volume depleted (he's an outpatient).

Precedex?

Redneck Crit Care (nice name) submitted this question:

One of our CT surgeons has been using Precedex for postop sedation for vent patients with good success.
www.ptjournal.com/ptjournal/fulltext/30/3/PTJ3003158.pdf

according to information in that article, it appears to be a very attractive option. It is a short-acting alfa2 agonist and you do not have to discontinue this before, during or after extubation because it does not cause respiratory depression. Are many intensivists already using this in medical ICU?

Tuberculosis

Interesting question submitted from Nasia:

18 year old man migrated from Thailand in 2005. Father in 2004-2205 had active pulmonary TB, treated for six months with standard regimen and responded. Patient does not recall whether he had PPD done then or not and was not treated for LTBI. Now is asymptomatic but CXR done for other reasons was abnormal.chest CT shows 5 very small (largest is 2.5 mm) scattered nodules. sputum AFBs are negative including cultures. current PPD negative and quantiferon test negative as well. Physical exam unrevealing. would you treat for latent TB given exposure?