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Background. Sarcoidosis is a multisystem granulomatous condition of uncertain aetiology that most frequently affects the lungs. Because of clinical and radiological similarities with tuberculosis, particularly in high-prevalence regions, sarcoidosis is frequently misdiagnosed as TB.Objective. To review the clinical features of sarcoidosis patients in an SApopulation, adding clinical information to the relatively few studies that have been conducted in SA patients with sarcoidosis. Methods. This was a retrospective study of 102 sarcoidosis patients conducted between 2002 and 2006 at the Charlotte Maxeke Johannesburg Academic Hospital.Results. Of 102 sarcoidosis patients, there were 69 (67.6%) females and 33 (32.4%) males. The majority (85.3%) were non-smokers. The mean age of the group was 44.6 years. One-third of patients had chronic comorbid diseases. Almost 17% had been treated initially for TB, prior to being diagnosed as having sarcoidosis. Two patients developed active TB while receiving corticosteroid treatment for sarcoidosis. The salient clinical manifestations were dry cough (the most common presenting symptom in 82.4%), dyspnoea in 53.9%, cutaneous lesions other than erythema nodosum in 33.3%, and on lung examination crackles were noted in 37.3% of patients. Raised angiotensin-converting enzyme (ACE) levels were found in 56.8% of patients. The majority (48%) of patients had stage II chest radiographic changes. Cutaneous (28.4%), mediastinal lymph node (25.5%) and transbronchial lung (25.5%) biopsies were the most frequent sites confirming granulomatous inflammation. Overall, 21.2% of patients had obstructive airway disease. Systemic corticosteroids were indicated in 87.3% of patients and the relapse rate was 60.7%. Conclusion. Sarcoidosis is often initially misdiagnosed as TB in SA. The most common biopsy sites for histological confirmation were the skin and mediastinal lymphnodes, and transbronchial lung biopsies were also frequently taken. Stage II chest radiographic changes were most common. Overall, systemic corticosteroids were administered in 87.3% of cases and the relapse rate was 60.7%.

Respiratory diseases such as pneumonia are one of the main concerns in the livestock industry. Economic losses owing to pneumonia are prevalent in small ruminants and pathogenic organisms such as Pasteurella and Mannheimia are the principal bacterial agents involved in pneumonic pasteurellosis. Two adult Alpine female goats with signs of respiratory involvement were referred. Clinical examinations of these animals showed fever, anorexia, dyspnea with head and neck strain and open mouth breathing, unilateral serous nasal discharge, abdominal breathing with harsh, and crackles lung sound upon auscultation. Radiography of the thoracic region was performed and severe generalized pulmonary involvement was detected in the goats. Due to the severity of the conflict, both cases were lost despite treatment. At necropsy, consistent findings included non-collapsing lungs with varying degrees of consolidation covered by fibrin and cranioventral consolidation with red-grey discoloration and firm, meaty consistency. Histopathologically, fibrinosuppurative bronchopneumonia was diagnosed in both cases. Finally, following microbiological findings, Pasteurella multocida was isolated from lung lesions of both animals, and pasteurellosis was confirmed. Overall, pasteurellosis is one of the most important pulmonary diseases in goats, and the best way to deal with it is to prevent the disease through vaccination and control stressful behaviors in the environment.

A man in his 60s was hospitalised for dyspnoea with minimal exertion and at rest. His medical history includes hypertension, non-ischaemic cardiomyopathy, left bundle branch block and congestive heart failure (HF). He had received a cardiac resynchronisation therapy implantable cardioverter-defibrillator (CRT-D) 2 years prior to the current admission, with initial improvement in symptoms, after which he was lost for follow-up. He is currently on a medical regimen that includes a β-blocker, a loop diuretic and an angiotensin receptor blocker. Physical exam reveals elevated jugular venous pressure, crackles at both bases and a third heart sound. The chest X-ray (CXR) is …

Background The clinical diagnosis of pneumonia is usually based on crackles at auscultation, but it is not yet clear what kind of crackles are the characteristic features of pneumonia in children. Lung sound monitoring can be used as a “longtime stethoscope”. Therefore, it was the aim of this pilot study to use a lung sound monitor system to detect crackles and to differentiate between fine and coarse crackles in children with acute pneumonia. The change of crackles during the course of the disease shall be investigated in a follow-up study. Patients and methods Crackles were recorded overnight from 22:00 to 06:00 h in 30 children with radiographically confirmed pneumonia. The data for a total of 28 800 recorded 30-s epochs were audiovisually analysed for fine and coarse crackles. Results Fine crackles and coarse crackles were recognised in every patient with pneumonia, but the number of epochs with and without crackles varied widely among the different patients: fine crackles were detected in 40±22% (mean±sd), coarse crackles in 76±20%. The predominant localisation of crackles as recorded during overnight monitoring was in accordance with the radiographic infiltrates and the classical auscultation in most patients. The distribution of crackles was fairly equal throughout the night. However, there were time periods without any crackle in the single patients so that the diagnosis of pneumonia might be missed at sporadic auscultation. Conclusion Nocturnal monitoring can be beneficial to reliably detect fine and coarse crackles in children with pneumonia., Lung sound monitoring can detect crackles in children with pneumonia and might improve diagnosis https://bit.ly/3CfaCl7

BACKGROUND Persistent tachypnea of infancy (PTI) is the most common interstitial lung disease in young children. As no standardized therapeutic guidelines exist, different pharmaceuticals are used to treat PTI; inhaled corticosteroids (ICS) and bronchodilators being mostly used. This observation assessed the effectiveness of bronchodilators and ICS in children with PTI enrolled in the children's interstitial lung diseases (chILD)-EU Register. METHODS Symptomatic children with PTI were observed according to a predetermined stepwise protocol including bronchodilators as the first choice treatment (6 weeks). In patients with incomplete response, additionally, ICS was given (12 weeks). Signs, symptoms, and pulmonary function were evaluated at three time points: at baseline, 6 (±1) weeks after initiation of bronchodilators, and 12 (±1) weeks after bronchodilators/ICS. RESULTS Thirty-one children (median age: 44 months, interquartile range [IQR]: 15-67) were included. The therapy was associated with a significant reduction of tachypnea (53.3% of patients, p = 0.02), exercise intolerance (52.2% of patients, p

OdzimekMartyna, Maj-Gnat Katarzyna. Disorders of the statics of the body and the temporomandibular joint. Journal of Education, Healthand Sport. 2021;11(8):369-380. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2021.11.08.041 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2021.11.08.041 https://zenodo.org/record/5303429 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2021; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 05.08.2021. Revised: 15.08.2021. Accepted: 28.08.2021. Disorders of the statics of the body and the temporomandibular joint Martyna Odzimek 2, Katarzyna Maj-Gnat 1 - Ph.D. student, Institute of Physiotherapy, Collegium Medicum, Jan Kochanowski University in Kielce, Poland; - student, Institute of Physiotherapy, Collegium Medicum, Jan Kochanowski University in Kielce, Poland. Address for correspondence: odzimek.martyna@onet.pl SUMMARY INTRODUCTION The temporomandibular joint is a synovial, complex (hinge-sliding) joint that connects the temporal bone with the mandible by means of an articular disc. Temporomandibular joint dysfunctions most often concern several disease entities and include various symptoms and ailments. One of the first symptoms of the disease is pain that stems from a muscle or joint. In addition, we can observe: limitations in the mobility and range of movement of the jaw, problems with chewing food, crackles in the joint, pain in pressure and touch of the muscles, earaches and noise or changes in the appearance of the face (the so-called "square face"). Any deviation from the correct body posture is called a posture defect. OBJECTIVE The main aim of the study is to present the significant relationship between disturbed statics of the body and the temporomandibular joint, thanks to which we can explain the importance of proper planning of diagnostics as well as conducting dental and physiotherapeutic therapy. THE WEIGHT OF THE BODCIES The materials used to write the article include scientific works from 1992-2021. The data was collected using the PubMed search engine and manual filtering. 80 publications were qualified for the analysis. SUMMARY According to the analyzed literature, we believe that there is a relationship between disturbances in the body statics and the stomatognathic system. The complexity of the issue shows that it is important to conduct multi-directional and interdisciplinary therapy. KEY WORDS:temporomandibular joint, dysfunctions of the temporomandibular joints, posture defects.

A young man in his 20s presented to the emergency department with a 2-week history of dyspnoea and fever. His medical history was remarkable for recurrent episodes of fever with arthralgia in childhood f. Clinical examination revealed pedal oedema, bounding pulses and a holodiastolic murmur. Additionally, chest auscultation revealed bibasilar crackles. The ECG showed sinus tachycardia with features of left ventricular volume overload. Two-dimensional transthoracic echocardiography was performed and …

Bronchiectasis (BE) is a common but neglected chronic lung disease. Most epidemiological data are limited to cohorts from Europe and the USA, with few data from low income and middle income countries “Bronchiectasis” is a chronic debilitating respiratory condition, natural history of Bronchiectasis is variable, some patients have only a few chest infections per year with no disease progression overtime, while others have more frequent prolonged infective episodes and progress more quickly to respiratory failure with an associated increase in risk of death.A vicious cycle of infection and inflammation exists in damaged airways with patient suffering from persistent cough, purulent sputum production, recurrent chest infections and general malaise, associated with increased morbidity and reduced quality of life and socioeconomic, cost of long term management is significant.162 CT confirmed adult patients≥ 18 years were included in the study, data of patients were retrieved demography, clinical features, causative factors, spirometry and imaging reports were studied and analysed.162 adult patients were included in the study. Males (54%) and more than 50 years age group population [64%] was predominantly affected. 58% were non-smokers.Chronic cough (100%) with sputum production (86%) and fatigue (78%) were the most common symptoms, digital clubbing and crackles were the most common examination findings. Dominant cause of BE was post infection (46%) followed by COPD (20%), ABPA (10%) and miscellaneous causes. Obstructive abnormality (42%) was the most common spirometric pattern observed. Higher incidence of cystic BE (57%) was found in our study.Patients > 50 years and males were predominantly affected. Most of the study population had never smoked. Most common symptom found was chronic productive cough and fatigue. Etiology of BE is heterogeneous. Post Tuberculosis BE variety was common. BE in COPD patients was not less common. Central Bronchiectasis was not uncommon.

Unilateral proximal interruption of pulmonary artery with ipsilateral occurrence of lung fibrosis is a very rare entity. This case report is about a 27 year old male who had complaints of progressive dysponea since 1 year. He had past history of recurrent lower respiratory tract infections. On auscultation, velcro crackles are heard on right side. Pulmonary function test showed restrictive pattern. Chest Radiography, High Resolution Computed Tomography and CT Pulmonary angiography were performed.

1. Sneha Butala, MD* 2. Lauren Pronman, DO*,† 3. Michelle Baechtold, MD‡ 4. Timmie R. Sharma, MD‡ 5. Rebecca Fish, MD§ 6. Qin Yao, MD§ 1. *Department of Pediatrics and 2. §Division of Neonatology and Perinatal Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH 3. †Department of Genetics and Genomics and 4. ‡Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH A 24-year-old gravida 2 para 1 woman presents at 32 weeks’ gestation with vaginal bleeding concerning for placental abruption. The prenatal history is unclear because the mother obtained most of her prenatal care in Mexico. She precipitously gives birth to a female infant via breech vaginal delivery. On delivery, the infant is intubated and given 1 dose of surfactant due to respiratory failure. Apgar scores are 2 and 3 at 1 and 5 minutes, respectively. The birthweight is 1,900 g. A chest radiograph demonstrates diffuse severe alveolar opacity in bilateral lung fields consistent with severe respiratory distress syndrome. The infant is transported to a tertiary center and develops worsening hypoxia requiring 100% oxygen. The blood gas on admission reveals severe mixed respiratory and metabolic acidosis. The infant receives additional doses of surfactant and a prolonged period of respiratory support. The severity of the infant’s respiratory distress syndrome is disproportionate to the degree of prematurity. Pertinent physical examination findings include mottling of the skin with thick white scale. The scale is symmetrical, involving the scalp, shoulders, and extremities (Figs 1 and 2). External ear canals are not visible; they may be absent or occluded by the scale, which is also found around the nares. Thin erosions in rectangular shapes on her abdomen are noted where cardiac leads have been placed. Erosions are also found on the right side of the face near the endotracheal tube securement device and on the bilateral dorsum of feet. Auscultation of the lungs reveals coarse breath sounds and diffuse crackles bilaterally, without increased work of breathing, retractions, or nasal flaring. There is no collodion membrane, ectropion (outturning of the eyelids), or eclabium (outturning of the lips) present. Figure 1. Thick adherent scales and erosions on day 1. Figure 2. Thick adherent scales and erosions at 4 weeks. The complete blood …

Background: Worldwide community-acquired pneumonia (CAP) is the major cause of high mortality among under five children in India. After introduction of Pneumococcal and H. influenzae vaccination there is paucity of data regarding etiological profile of pneumonia. Aims and Objective: To evaluate the Clinico- epidemiological profile and etiology of community acquired pneumonia in children. Materials and Methods: We enrolled children aged 3-59 months with CAP (based on WHO criteria of tachypnea with cough or breathing difficulty) over 18 months and recorded presenting symptoms, clinical signs and chest radiography. We performed blood and nasopharyngeal swab (NPS) bacterial culture simultaneously to detect etiological agent of community acquired pneumonia in children. Results: Out of 150 cases of CAP, 90 % of caeses had cough and fever and nearly 80-90% cases had tachypnea and crackles on examination. Radiological findings suggestive of pneumonia was seen in 86% cases . Most common organism isolated was S aureus in both NPS culture (18.7 %) and blood culture (14.7 %). Other common organisms detected in NPS culture were S pneumoniae (6%), E Coli (4.7%), Klebsiella (4.7%), CONS (3.3%), and Pseudomonas (2.7%). In blood culture the common organism detected after S aureus was E coli (5.3%), S pneumoniae (3.3%), Klebsiella (3.3%), CONS( 3.8%), and Pseudomonas (2.5%). Conclusions: We observed that S aureus was the predominant etiological organism isolated in both blood and nasopharyngeal swab bacterial culture in patients suffering from community-acquired pneumonia.

A 2-month-old male Holstein calf was presented for evaluation of a continuous systolic murmur. A grade V/VI left basilar continuous murmur and a grade IV/VI right basilar continuous murmur was auscultated upon evaluation with increased respiratory effort, wheezes, and crackles. Multimodality diagnostics were performed on this patient for further workup and included transthoracic and transesophageal echocardiography, fluoroscopy guided angiography, and gross necropsy with histopathology. An aortopulmonary window with continuous left-to-right shunting was identified at the level of the left aortic sinus of Valsalva with a severely dilated left coronary artery and left-sided congestive heart failure. This case report outlines the diagnostic workup of a rare congenital heart defect and secondary cardiac abnormalities not previously identified in veterinary literature.

Background: Previous reports have documented ground-glass opacities (GGOs), followed by appearance of the crazy pavement pattern and consolidation as the typical findings on chest computed tomography (CT) in patients with Coronavirus Disease-2019 (COVID-19) Case: A 69-year-old man with chronic renal failure and diabetes mellitus presented with a 2-day history of fever and fatigue, without cough or sputum production Chest auscultation revealed coarse crackles at the right base Laboratory findings included a normal leukocyte count, normal serum procalcitonin level, and a slightly elevated serum C-reactive protein level Chest CT performed on day 2 after symptom onset revealed consolidation in the right lower lobe with an air bronchogram The patient was tentatively diagnosed as having bacterial pneumonia, however, antibiotic treatment with ampicillin/sulbactam yielded no improvement of the symptoms, respiratory status, or laboratory findings A repeat chest CT revealed changes in the findings of the right lower lobe from areas of focal consolidation to GGOs GGOs and areas of consolidation were also detected in the other lung lobes A polymerase chain reaction test for Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) returned a positive result Discussion: Focal areas of lung consolidation is an atypical radiological presentation of coronavirus pneumonia It is possible that the initial findings of CT represented those of bacterial pneumonia which responded to the antibiotic therapy, and that the GGOs that developed subsequently reflected new-onset SARS-CoV-2 pneumonia However, the symptom of fatigue without cough or sputum, a normal leukocyte count, and a poor response to antibiotics are not typical findings of bacterial pneumonia Our experience suggests that it is important to consider other or concomitant diseases when the initial treatment is followed by a deteriorating clinical course in patients with pneumonia Moreover, it is essential to prevent the spread of hospital-acquired infection, especially if epidemic diseases need to be included in the initial differential diagnosis

A 50-year-old woman was referred to our hospital for further examination of severe constricting pain at the right-side dominant anterior chest. She had medical history of outgrown childhood asthma and allergies to several animals. Chest auscultation revealed no wheezes, rhonchi and other crackles. Laboratory findings showed an eosinophilia and an elevation of total immunoglobulin E. The results of an electrocardiogram, a chest X-ray and a chest CT were unremarkable. A fractional exhaled nitric oxide value remarkably elevated, but the abnormalities in pulmonary function test were modest. Her chest pain was ameliorated after inhaling procaterol. Based on these findings, a diagnosis of chest tightness variant asthma was formulated, and we started treatment with inhaled corticosteroid / long acting β2 agonist. At two-weeks after treatment, her symptom markedly improved and a fractional exhaled nitric oxide value decreased, which led to a definitive diagnosis of chest tightness variant asthma. A fractional exhaled nitric oxide value further decreased to the normal range in consistent with symptom disappearance at 10-months after treatment, indicating the usefulness of fractional exhaled nitric oxide as a promising marker for the diagnosis and clinical improvement of chest tightness variant asthma. J. Med. Invest. 68 : 389-392, August, 2021.

Objective: SARS-CoV-2 (originally named COVID-2019) pneumonia is currently prevalent worldwide. The number of cases has increased rapidly but the auscultatory characteristics of affected patients and how to use it to predict who is most likely to survive or die are not available. This study aims to describe the auscultatory characteristics and its clinical relativity of SARS-CoV-2 pneumonia by using a wireless stethoscope. Material and methods: A cross-sectional, observational, single-center case series of 30 consecutive hospitalized patients with confirmed SARS-CoV-2 pneumonia at Leishenshan Hospital in Wuhan, China, were enrolled from March 9 to April 5, 2020. Clinical, laboratory, radiological, treatment data and lung auscultation were collected and analyzed. Lung auscultation was acquired by a wireless electronic stethoscope. Auscultatory characteristics of the moderate, severe, and critically ill patients were compared. Results: Kinds of crackles including fine crackles and wheezing were heard and recorded in these patients. Velcro crackles were heard in most critically ill patients (6/10). Besides, patients with Velcro crackles were all dead (6/6). There was no positive lung auscultatory finding in the moderate group and little positive lung auscultatory findings (4/10) in the severe group. Conclusion: Velcro crackles can be auscultated by this newly designed electronic wireless stethoscope in most critically ill patients infected by SARS-CoV-2 and predicts a poor prognosis. Moderate and severe patients without positive auscultatory findings may have a better prognosis.

A 25-year-old man presented to the emergency department with acute-onset chest pain and shortness of breath. A physical examination revealed coarse crackles in the both lower lungs. Consolidation and ground-glass opacities suggesting viral infection were detected in the right lower lobe on chest computed tomography. Laboratory findings revealed elevated troponin, leukocytosis, and lymphopenia. Electrocardiography revealed ST segment elevation with PR depression in leads I, aVL, V5, and V6, and ST depression and PR elevation in aVR. Echocardiography revealed diffuse cardiac hypokinesia and a decreased left ventricular ejection fraction. Suspecting coronavirus disease 2019 (COVID-19)–related myopericarditis, the patient was hospitalized. After one week of empirical antibiotics, antivirals, and supportive therapy, his condition improved. Antibody testing for COVID-19 was positive on hospitalization day 8. The presentation of myopericarditis can be vague and mislead physicians during the COVID-19 pandemic. Myopericarditis should be included as a differential diagnosis for patients with suspected COVID-19.

Pneumocystis pneumonia (PCP) and pulmonary tuberculosis infection (PTB) are important opportunistic infections in HIV-infected patients. The diagnosis remains challenging since Pneumocystis jirovecii cannot be cultured, and expectorated-sputum is frequently difficult to obtain. The monoclonal-antibody detection for P. jirovecii from induced sputum is promising in diagnosing PCP. This study determined the percentage of PCP in HIV-infected patients with pulmonary infiltrates at three government hospitals in Jakarta. The concurrent infection of PTB was carefully documented as well. This cross-sectional study was carried out by documenting the clinical symptoms, laboratory findings, chest X-ray, while clinical outcomes were evaluated during hospitalization. The sputum induction was conducted for P. jirovecii with monoclonal antibody detection at the laboratory of Parasitology Department, Faculty of Medicine Universitas Indonesia, as well as Ziehl-Nielsen staining for PTB. The results indicated that of 55 HIV-infected patients with pulmonary infiltrates, the positive monoclonal antibody for P. jirovecii was detected in eight patients (14.6%). Weight loss, fever, shortness of breath, and crackles were found in all PCP patients; while dry cough in five patients. Moreover, PTB cases with positive acid-fast bacilli (AFB) was detected in five patients (9.1%), the PTB cases with negative AFB was 43.6% (24 out of 55 patients), and the rest 26 patients (47.3%) were not proven to have PTB. The concurrent infections of PCP and PTB were documented in three out of five positive AFB patients. The clinical outcome of eight PCP patients showed improvement in five patients, but the other three patients died. Laboratory findings play an important role in the diagnosis of PCP and PTB, along with clinical characteristics and radiological features. Low CD4+ cell count was considered a possible risk factor for PCP and poor clinical outcomes.

Case Presentation A 50-year-old woman presented with 3 months of cough, dyspnea, and fatigue. She also reported new fevers, night sweats, and a rash on her face and torso. On presentation she was tachycardic and tachypneic, with oxygen saturation of 81% on 2 L/min of oxygen. She was in mild respiratory distress. Results of the physical examination were remarkable for tender left cervical and axillary adenopathy and bibasilar pulmonary crackles. She had an acneiform rash on her face, chest, and back, consisting of multiple nonblanching erythematous or violaceous macules and papules ( Fig 1 ) and had conjunctival edema. Admission laboratory test results were significant for a WBC count of 56,000, of which 79.5% were lymphocytes. Hemoglobin and platelet levels were normal. She was admitted for further management.

Summary Background B-lines have been associated with adverse clinical outcomes in patients with heart failure (HF) when found at hospital discharge or during outpatient visits. Whether lung ultrasound (LUS) assessed B-lines may predict in-hospital mortality in patients with acute HF is still undetermined. Aim To evaluate the association between B-lines on admission and in-hospital mortality among patients admitted with acute HF. Methods Hand-held LUS was used to examine patients with acute HF. LUS was performed in eight chest zones with a pocket ultrasound device and analyzed offline. The association between B-lines and in-hospital mortality was assessed using Cox regression models. Results We included 62 patients with median age 56 years, 69.4% men, and median left ventricle ejection fraction 25%. The sum of B-lines ranged from 0 to 53 (median 6.5). An optimal receiver operating characteristic-determined cut-off of ≥19 B-lines demonstrated a sensitivity of 57% and a specificity of 86% (area under the curve 0.788) for in-hospital mortality. The incremental prognostic value of LUS when compared with lung crackles or peripheral edema by integrated discrimination improvement was 12.96% (95% CI: 7.0–18.8, P = 0.02). Patients with ≥19 B-lines had a 4-fold higher risk of in-hospital mortality (HR 4.38; 95% CI: 1.37–13.95, P Conclusion In patients admitted with acute HF, point-of-care LUS measurements of pulmonary congestion (B-lines) are associated with in-hospital mortality.

A 60-year-old woman was admitted to our hospital due to coronavirus disease 2019 (COVID-19) pneumonia with a chief complaint of persistent low-grade fever and dry cough for two weeks. Thoracic computed tomography demonstrated a crazy paving pattern in the bilateral lower lobes. In a COVID-19 ward, we used a novel wireless stethoscope with a telemedicine system and successfully recorded and shared the lung sounds in real-time between the red and green zones. The fine crackles at the posterior right lower lung fields changed from mid-to-late (day 1) to late inspiratory crackles (day 3), which disappeared at day 5 along with an improvement in both the clinical symptoms and thoracic CT findings.

Case Answer A 49-year-old woman was admitted with 2 weeks of progressive dyspnea, edema, and hypertension. Medical history is significant for ESKD attributed to hypertensive nephrosclerosis. She underwent a deceased-donor kidney transplant 2 months before admission. The post-transplant serum creatinine concentration reached a nadir of 2.0 mg/dl. An allograft biopsy performed 2.5 weeks before admission revealed acute cellular rejection (Banff borderline). She was treated with steroids. Physical examination on admission was notable for tachypnea at 24 breaths/min, BP of 180/95 mm Hg, pulse of 91/min, with oxygen saturation of 98% on 5 L of oxygen. Pertinent findings included bilateral 3+ pitting edema, crackles, and wheezing. Laboratory evaluation revealed serum sodium of 134 mmol/L, potassium of 4.6 mmol/L, bicarbonate of 16 mmol/L, BUN of 94 mg/dl, and serum …

Fatigue, a non-specific symptom, is often dismissed as trivial or functional, however, an underlying malignant, endocrine, or metabolic disorder may be the cause of fatigue. We present the case of an elderly lady who presented with tiredness, anorexia, and vomiting for a month. Physical examination revealed pallor, facial puffiness, and coarse crackles in the left mammary area. Investigations revealed hyponatremia and hypokalemia. The patient denied a history of amenorrhea and lactation failure, but further questioning revealed that she had severe post-partum hemorrhage necessitating a hysterectomy. Investigations revealed normal TSH, low normal fT4, inappropriately low FSH, and LH. The patient was treated with thyroid and adrenal hormone replacement. We present this case to emphasize the importance of detailed history taking for a medical diagnosis, especially in conditions like Sheehan’s syndrome with relatively non-specific presenting complaints.

Background The characterization and clinical profiling of people affected by Idiopathic Pulmonary Fibrosis (IPF), based on clinical events occurring prior to the diagnosis of the fibrotic disease, may facilitate the understanding of events and comorbidities that occur before the diagnosis of IPF and aid in identifying patients at an earlier stage of the disease. Methods In this observational study, a cohort of 96 patients, obtained from a community-based pulmonary clinic, were studied retrospectively. These patients were diagnosed with IPF between January 2008 and November 2016, based on findings on lung biopsy and/or high-resolution CT. Using clinical data obtained within the five years before diagnosis and the two-step method of cluster analysis, patients were assigned to one of four groups. The distribution of clinical characteristics and comorbidities present prior to diagnosis was analyzed among the clusters. Results Cluster 1 is composed of male patients, smokers, with ischemic heart disease. Cluster 2 is composed of male patients, smokers with dyspnea at rest, dry cough and prevalent emphysema. Cluster 3 is composed of male patients without other significant comorbidities, half of whom had dyspnea at exertion. Cluster 4 includes female patients only, most of whom never-smokers and the largest portion of patients with hypothyroidism. The majority of patients had basal end-inspiratory crackles at time of diagnosis, equally distributed among clusters. Conclusion Different clinical phenotypes of IPF emerge years before time of diagnosis and if confirmed in larger cohorts may help in forming diagnostic algorithms that would allow earlier diagnosis of IPF.

Introduction Coronavirus disease 19 (COVID-19), due to severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2), comprises a broad spectrum of clinical presentation ranging from flu-like syndrome to organ failure. The risk of coinfections is high and responsible for a worse prognosis, mainly in the case of bacterial involvement and in the presence of particular comorbidity. We present the clinical, laboratory, radiologic characteristic along with therapeutic management of a patient with COVID-19 and Staphylococcus aureus coinfection. Case presentation A 55-year-old Caucasian woman was admitted to our hospital due to a two-day history of fever and acute dyspnea with severe respiratory failure worsened after the administration of atezolizumab and nab-paclitaxel. Her medical history comprehended a triple negative, BRCA1-related, PD-L1 positive right breast cancer with multiple bone metastasis, causing bone marrow infiltration-related severe pancytopenia. Her physical examination revealed scattered wheezes, rales, and bilateral dry crackles in the middle and lower lung fields and lower limb paresis. The body mass index was 30 kg/m2 and arterial blood gas evaluation revealed a stage III acute respiratory distress syndrome. Microbiological specimens revealed a Staphylococcus aureus positivity from endotracheal aspirate. The chest computed tomography (CT) scan showed the presence of large areas of parenchymal consolidation and aerial bronchogram, bilateral "ground glass" areas reaching the highest extension on the upper and middle zones. The high clinical and radiological suspicion of COVID-19 along with the negative result of nasopharyngeal specimen make necessary an endotracheal aspirate resulting positive for SARS-CoV2. Patient started an antimicrobial treatment and lopinavir-ritonavir plus hydroxychloroquine but, unfortunately, died five days after hospital admission. Conclusion The high risk of mortality of our patient was due to viral-bacterial coinfection, advanced cancer status with active immunotherapy. This case highlights the need for a prompt clinical, laboratory, and radiological evaluation to allow a correct diagnosis and start a specific therapy.

You are consulted to evaluate a 56-year-old woman with known Raynaud's phenomenon, finger swelling of several; months' duration, and new hypertension with a blood pressure of 160/100 mm/Hg. She also reports progressive shortness of breath. Physical examination reveals telangiectasias, sclerodactyly, and proximal skin sclerosis (thick shiny skin on the chest and upper arms), and bibasilar crackles are found on chest examination. Laboratory tests reveal evidence of microangiopathic hemolytic anemia, thrombocytopenia, and elevation of the serum creatinine level (previously normal), and chest computed tomography shows evidence of ground-glass opacification in both lower lung fields.

BACKGROUND: Interstitial lung disease (ILD) results in high morbidity and health-care utilization. Diagnostic delays remain common and often occur in nonpulmonology settings. Screening for ILD in these settings has the potential to reduce diagnostic delays and improve patient outcomes. RESEARCH QUESTION: This study sought to determine whether a pulmonary function test (PFT)-derived diagnostic prediction tool (ILD-Screen) could accurately identify incident ILD cases in patients undergoing PFT in nonpulmonology settings. STUDY DESIGN AND METHODS: Clinical and physiologic PFT variables predictive of ILD were identified by using iterative multivariable logistic regression models. ILD status was determined by using a multi-reader approach. An ILD-Screen score was generated by using final regression model coefficients, with a score ≥ 8 considered positive. ILD-Screen test performance was validated in an independent external cohort and applied prospectively to PFTs over 1 year to identify incident ILD cases at our institution. RESULTS: Variables comprising the ILD-Screen were age, height, total lung capacity, FEV(1), diffusion capacity, and PFT indication. The ILD-Screen showed consistent test performance across cohorts, with a sensitivity of 0.79 and a specificity of 0.83 when applied prospectively. A positive ILD-Screen strongly predicted ILD (OR, 18.6; 95% CI, 9.4-36.9) and outperformed common ILD clinical features, including cough, dyspnea, lung crackles, and restrictive lung physiology. Prospective ILD-Screen application resulted in a higher proportion of patients undergoing chest CT imaging compared with a historical control cohort (74% vs 56%, respectively; P = .003), with a significantly shorter median time to chest CT imaging (5.6 vs 21.1 months; P < .001). INTERPRETATION: The ILD-Screen showed good test performance in predicting ILD across diverse geographic settings and when applied prospectively. Systematic ILD-Screen application has the potential to reduce diagnostic delays and facilitate earlier intervention in patients with ILD.

Recently, cases of coronavirus disease 2019 (COVID-19) with unknown routes of transmission are being reported from various parts of Japan When close contacts of infected patients present with symptoms, the index of suspicion for COVID-19 is high, and consultations and examinations are implemented with sufficient infection control measures in place On the other hand, the possibility of COVID-19 is often difficult to consider initially in cases from the community presenting with upper respiratory tract symptoms, such as sore throat and cough, and/or fever The initial upper respiratory tract symptoms are similar to those of common cold It is only much later, usually about one week after the appearance of symptoms, that COVID-19 is suspected and the test for SARS-CovV-2 is performed Until then, the patients may have consulted their family doctor and been tested for influenza, and may have been prescribed a cold medicine or antitussive We encountered 10 cases of COVID-19 pneumonia that developed in the community and tested positive for SARS-CoV-2 by PCR The presenting symptoms were a fever of over 38°C in 9 cases, nasal discharge in 1 case, sore throat in 4 cases, cough in 8 cases, sputum in 5 cases, shortness of breath in 6 cases, malaise in 7 cases, and gastrointestinal symptoms in 3 cases Five cases also showed poor health and fever in the family All cases needed 1-3 consultations to be finally diagnosed, and the interval from the appearance of symptoms to diagnosis was 5-12 days Coarse crackles could be auscultated in only one case, and the SpO2 was more than 95% in 8 cases, and 80% in 2 cases No increase of the peripheral white blood cell count was observed in any of the cases, and the blood lymphocyte count was less than 1,000/μL in 6 cases The serum CRP showed only a slight increase to up to 5 mg/dL in 7 cases, and a slight increase in the d-dimer level was observed in 5 cases In some cases, while it was difficult to detect abnormalities on the chest X-ray, chest computed tomography showed multiple bilateral ground-glass opacities, predominantly in the peripheral/subpleural regions, in all cases Nine of the 10 patients also showed lesions in the lower right lobe We describe the clinical characteristics of COVID-19 pneumonia among cases of infectious diseases encountered in the community Based on the above, we suggest that in cases from the community presenting with fever and upper respiratory symptoms, one clue to suspecting COVID-19 is the presence of persons among family members who are also unwell

Background Pulmonary Alveolar Microlithiasis (PAM) is an uncommon, gradually progressive and eventually fatal hereditary disease that affects young population. Familial cases account for up to 50% of reported cases. There are few described cases of extrapulmonary manifestations of PAM and rare reports of cardiac involvement. Case report A 45-year-old male patient presented to our center with progressive shortness of breath and dry cough. On physical examination, he was tachypneic and chest examination revealed diminished breath sounds with bilateral early inspiratory crackles. Further workup revealed the diagnosis of PAM. Echocardiography revealed calcifications covering the tricuspid valve with elevated right ventricular systolic pressure. He reported having two sisters with similar illnesses and chest radiographic abnormalities, one died at the age of 38 years from respiratory failure and the other is 42-year-old and still alive and was diagnosed with PAM. Another 35 member of his family were diagnosed with PAM. Unfortunately, few days after discharge, he arrested at home. Conclusions Recently, type-II sodium/phosphate co-transporter has been identified in a human aortic valve. Studies have suggested penetrance of mutations of SLC34A2 gene might explain such variability of pulmonary and extrapulmonary involvement. Our case reports a familial cluster of PAM, and the first case of concomitant tricuspid calcification. This finding might be a useful in the investigation for a future genetic targeted therapy., Highlights • PAM is a fatal hereditary disease that affects young population. • There are few described cases of extrapulmonary manifestations of PAM. • Mutations of SLC34A2 gene might explain variability of extrapulmonary involvement.

Objective This paper is aimed at investigating the clinical characteristics of primary Sjogren’s syndrome (pSS) with lymphocytic interstitial pneumonia (LIP). Methods The demographic data, clinical manifestations, laboratory and radiological findings, treatment, and prognosis from 15 cases of pSS-LIP patients were retrospectively analyzed. The data were compared with t test, χ2 test, and Pearson/Spearman correlation analysis. Results (1) Fifteen cases of patients with pSS-LIP are all females (100%). Compared with pSS with interstitial lung disease(pSS-ILD) patients, the incidence of dry cough, dental caries is higher in pSS-LIP patients. The incidence of shortness of breath, weight loss, and crackles is lower in pSS-LIP patients than that of pSS-ILD patients. (2) Compared with pSS-ILD patients, pSS-LIP patients had higher percentage of patients with ANA, anti-SSA52KD antibody, anti-SSA60KD antibody, and anti-SSB antibody, and the higher concentration of serum globulin. (3) Compared with pSS-ILD patients, the frequency of obstructive ventilation dysfunction is significantly higher and the frequency of diffusion dysfunction is significantly lower in pSS-LIP patients. (4) The most frequent HRCT findings in patients with pSS-LIP is cysts (100%), followed by ground-glass opacities (73.3%), nodular shadow (73.3%) among the pSS-LIP patients. Compared with PSS-ILD patients, the incidence of pulmonary nodule shadow is significantly higher in PSS-LIP patients, while that of grid shadow was significantly lower. (5) Compared with the baseline, the sum of the number, maximum diameter, and diameter of cysts in three levels of pSS-LIP patients showed an increasing trend after treatment. (6) Correlation analysis: The changes of ground-glass opacities were positively correlated with using GC or not, and those were negatively correlated with the dose of GC treatment. Besides, there is a positive correlation between the annual change rate of the maximum diameter of cysts (△Ømax1/t) and the use of CTX; there is a positive correlation between the annual change rate of the total diameter of cysts (△Øsum1/t) and the use of CTX. Conclusion To the patients of pSS-LIP, female were more common than male, and the onset of LIP was usually more insidious. Hyperglobulinemia and anti-SSA antibody were more prominent in patients with pSS-LIP. Pulmonary function showed the higher rate of obstructive ventilation dysfunction and the lower rate of diffusion dysfunction. The appearance of ground-glass opacities in pSS-LIP patients suggests that the infiltration of inflammatory cells increases, which may cause airway compression, the expansion of terminal bronchioles, and the formation of cysts. The more ground-glass opacities appear earlier, and the more appearance of new cysts later. Therapy with glucocorticoid may be effective on the ground-glass opacity during acute stage, and therapy with cyclophosphamide may be effective on the cysts during chronic stage. The heavier ground-glass opacity is at baseline, the more likely it will recur during maintenance treatment. So follow-up closely is needed.Key Points• It is the first clinical study with more cases of patients with pSS-LIP.• Female and hyperglobulinemia and anti-SSA antibody were more prominent in patients with pSS-LIP.• Pulmonary function showed the higher rate of obstructive ventilation dysfunction and the lower rate of diffusion dysfunction.• Therapy with glucocorticoid may be effective on the ground-glass opacity during acute stage, and therapy with cyclophosphamide may be effective on the cysts during chronic stage.

Hypersensitivity pneumonitis (HP), also called extrinsic allergic alveolitis, is a respiratory syndrome involving the lung parenchyma specifically the alveoli, terminal bronchioles and alveolar interstitium. HP is caused by delayed allergic reaction to variety of antigens like microbes, animal proteins, and low-molecularweight chemicals. Bagassosis is one such HP caused by repetitive inhalation of bagasse. Though use of bagasse as cause of HP is known, use of bagasse in brickkiln factory as fuel and its association with HP has not been well documented. We report a case of HP in a brick-kiln worker where bagasse was used as fuel. A twenty-five years old man, working in a brick kiln for five years, presented with complaints of dry cough, low grade fever and weight loss for one month. He had bilateral lower lobe crackles on auscultation. The history of bagasse, clay and coal dust exposure, clinical presentation and imaging were suggestive of HP. However, being endemic in India, pulmonary tuberculosis was ruled out by negative Mantoux test, sputum for acid fast bacilli and Cartridge Based Nucleic Acid Amplification Test. He was managed with corticosteroids and symptomatic treatment with good response and resolution of clinical signs and radiological changes., {"references":["Coultas DB, Zumwalt RE, Black WC, Sobonya RE. The epidemiology of interstitial lung diseases. Am J Respir Crit Care Med. 1994;150:967-72. doi: 10.1164/ajrccm.150.4.7921471.","Lacasse Y, Cormier Y. Hypersensitivity pneumonitis. Orphanet J Rare Dis. 2006;1:25. doi: 10.1186/1750-1172-1-25.","Fernández Pérez ER, Kong AM, Raimundo K, Koelsch TL, Kulkarni R, Cole AL. Epidemiology of Hypersensitivity Pneumonitis among an Insured Population in the United States: A Claims-based Cohort Analysis. Ann Am Thorac Soc. 2018;15(4):460‐9. doi: 10.1513/AnnalsATS.201704-288OC.","Gruchow HW, Hoffmann RG, Marx JJ Jr, Emanuel DA, Rimm AA. Precipitating antibodies to farmer's lung antigens in a Wisconsin farming population. Am Rev Respir Dis. 1981;124(4):411-5. doi: 10.1164/arrd.1981.124.4.411.","Singh S, Collins BF, Sharma BB, Joshi JM, Talwar D, Katiyar S, et al. Hypersensitivity pneumonitis: Clinical manifestations – Prospective data from the interstitial lung disease-India registry. Lung India. 2019;36(6):476-82 doi: 10.4103/lungindia.lungindia_263_19.","Hearn CE. Bagassosis: an epidemiological, environmental, and clinical survey. Br J Ind Med. 1968;25(4):267-82. doi: 10.1136/oem.25.4.267.","Singh AB, Singh A, Pandit T. Respiratory diseases among agricultural industry workers in India: a cross-sectional epidemiological study. Ann Agric Environ Med. 1999;6(2):115‐26.","Fink JN, Ortega HG, Reynolds HY, Cormier YF, Fan LL, Franks TJ, et al. Needs and opportunities for research in hypersensitivity pneumonitis. Am J Respir Crit Care Med. 2005;171(7):792-8. doi: 10.1164/rccm.200409-1205WS.","Selman M, Pardo A, King TE Jr. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Am J Respir Crit Care Med. 2012;186(4):314-24. 10.1164/rccm.201203-0513CI.","Johannson KA, Elicker BM, Vittinghoff E, Assayag D, de Boer K, Golden JA, et al. A diagnostic model for chronic hypersensitivity pneumonitis. Thorax. 2016;71(10):951-4. doi: 10.1136/thoraxjnl-2016-208286.","Lynch DA, Rose CS, Way D, King TE Jr. Hypersensitivity pneumonitis: sensitivity of high-resolution CT in a population-based study. AJR Am J Roentgenol. 1992;159(3):469-72. doi: 10.2214/ajr.159.3.1503007.","Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest. 2012;142:208-17. doi: 10.1378/chest.11-2479.","Reich JM. Chirping rales in bird-fancier's lung. Chest 1993;104(1):326-7. doi: 10.1378/chest.104.1.326b.","Kokkarinen JI, Tukiainen HO, Terho EO. Effect of corticosteroid treatment on the recovery of pulmonary function in farmer's lung. Am Rev Respir Dis. 1992;145(1):3-5. doi: 10.1164/ajrccm/145.1.3.","Morisset J, Johannson KA, Vittinghoff E, Aravena C, Elicker BM, Jones KD, et al. Use of mycophenolate mofetil or azathioprine for the management of chronic hypersensitivity pneumonitis. Chest 2017; 151(3):619-25. doi: 10.1016/j.chest.2016.10.029."]}

Background Lung function testing in small children is cumbersome. However, reduced variability of tidal breathing recorded using impedance pneumography (IP) during sleep was recently found to be a potential objective marker of wheeze in children aged 1‐5 years. We aimed to investigate how an acute bronchial obstruction (BO) and its severity, and recovery thereof reflect in expiratory variability index (EVI). Methods EVI was measured using a wearable IP system (Ventica®) during sleep in 40 healthy controls (aged 1.5‐5.9 years) and 30 patients hospitalized due to acute BO (aged 1.3‐5.3 years). In healthy controls, EVI was measured for 1‐3 nights at their homes. Patients were measured for several nights during hospitalization, as practically feasible, and at home 2 and 4 weeks post‐discharge. Results We received 79 EVI results from 39 controls and 139 from 30 patients. 90% had previous BO episodes, 30% used asthma controller medication before and 100% after hospitalization. Compared to controls, EVI was significantly lower during hospitalization (P

Objective Lower respiratory tract infections (LRTI) are one of the most important causes of morbidity and mortality in childhood. Hypoxemia, pulmonary hypertension (PH) due to pulmonary vasoconstriction, and heart failure due to various causes are the most important risk factors for mortality in LRTI. The aim of this study was to investigate characteristics of the patients with LRTI and the frequency of PH that developed secondary to LRTI. Materials and Methods The study included 70 patients who were diagnosed as having LRTI clinically and radiologically between January 2012 and March 2013 at Department of Pediatrics, Konya Training and Research Hospital. Age, sex, risk factors for LRTI, symptoms and physical examination findings, laboratory tests, and Doppler echocardiography findings of the patients were retrospectively reviewed. Results Of the patients, 44 (62.9%) were male and 26 (37.1%) were female. Thirty-seven (52.9%) patients were younger than 1 year, and the mean age was 2.5 ± 3.11 years. The most common symptoms of the patients were cough and fever. Rhonchus, retraction, and crackles were found to be the most common findings in physical examinations. Heart failure was found in 10% of patients and PH was detected in 8.6% through Doppler echocardiography. Development of heart failure and the presence of bilateral patch infiltration on posteroanterior chest X-rays were significantly more frequent in patients with PH. Some 42.9% of patients had at least one viral agent in their nasopharyngeal swabs. The most common viral agents were respiratory syncytial virus and rhinoviruses. Conclusion PH may develop during the course of LRTI in children. Given that the development of PH can cause life-threatening complications such as heart failure, affected patients should be kept under close follow-up. It should be remembered that PH is more likely to develop in patients with bilateral patch infiltration on chest X-ray.

Background: Effective auscultations are often hard to implement in isolation wards. To date, little is known about the characteristics of pulmonary auscultation in novel coronavirus (COVID-19) pneumonia. Objectives: The aim of this study was to explore the features and clinical significance of pulmonary auscultation in COVID-19 pneumonia using an electronic stethoscope in isolation wards. Methods: This cross-sectional, observational study was conducted among patients with laboratory-confirmed COVID-19 at Wuhan Red-Cross Hospital during the period from January 27, 2020, to February 12, 2020. Standard auscultation with an electronic stethoscope was performed and electronic recordings of breath sounds were analyzed. Results: Fifty-seven patients with average age of 60.6 years were enrolled. The most common symptoms were cough (73.7%) during auscultation. Most cases had bilateral lesions (96.4%) such as multiple ground-glass opacities (69.1%) and fibrous stripes (21.8%). High-quality auscultation recordings (98.8%) were obtained, and coarse breath sounds, wheezes, coarse crackles, fine crackles, and Velcro crackles were identified. Most cases had normal breath sounds in upper lungs, but the proportions of abnormal breath sounds increased in the basal fields where Velcro crackles were more commonly identified at the posterior chest. The presence of fine and coarse crackles detected 33/39 patients with ground-glass opacities (sensitivity 84.6% and specificity 12.5%) and 8/9 patients with consolidation (sensitivity 88.9% and specificity 15.2%), while the presence of Velcro crackles identified 16/39 patients with ground-glass opacities (sensitivity 41% and specificity 81.3%). Conclusions: The abnormal breath sounds in COVID-19 pneumonia had some consistent distributive characteristics and to some extent correlated with the radiologic features. Such evidence suggests that electronic auscultation is useful to aid diagnosis and timely management of the disease. Further studies are indicated to validate the accuracy and potential clinical benefit of auscultation in detecting pulmonary abnormalities in COVID-19 infection.

An 83-year-old man was taken to the emergency room (ER) because of fever, shortness of breath, swelling of the legs, weakness, confusion, and nausea. He had several comorbidities, including chronic kidney disease and a left fibrothorax with internal fluid collection caused by previous tuberculous pleurisy. The patient was found with acute respiratory failure, and auscultation revealed reduction of breath sounds in the left lower field, crackles in the right middle and basal fields, and widespread rales. Chest radiography showed large opacity in the left middle and lower areas and opacity in the right middle zone. Blood tests showed leukocytosis, marked increase in inflammation indices and volume overload, renal failure, hyperglycemia, and electrolyte imbalance. The patient received oxygen supplement, a loop diuretic, and broad-spectrum antibiotics, with dose adjustment for renal impairment. Urine output was 100 mL/24 hr, but the patient refused hemodialysis, thus peritoneal dialysis was initiated. The patient showed clinical improvement, the fever disappeared, oxygen saturation became sufficient without administration of oxygen, and the white blood cell count and inflammatory indices normalized. The diagnostic workup for active tuberculosis was negative. No invasive pleural procedures were needed. Chest imaging showed that the pulmonary opacities in the middle right and lower left areas had disappeared. Pulmonary opacity caused by the known left calcific fibrothorax was still clearly evident. This chapter deals with the causes, mechanisms, and imaging of fibrothorax. Strategies to prevent it and surgical treatment options are also addressed.

­An 83-year-old woman with a history of hypertension, diabetes and paroxysmal atrial fibrillation anticoagulated with acenocoumarol was brought to the emergency department due to dyspnoea. At admission, the patient reported a 1-week history of malaise, shortness of breath and non-productive cough. She denied fever but reported pain on the left flank. On examination, auscultation showed arrhythmic tones and crackles in the left lower lung field. Laboratory findings showed leucocytosis of 15.32×103/μL, and the C reactive protein was 177 mg/L. The activated partial thromboplastin time was 54.8 s, and the international normalised ratio was 7.09. A chest X-ray showed left lower lobe consolidation with pleural effusion. Point-of-care ultrasound was performed using a low-frequency curved transducer (2–5 MHz). The probe was placed in the left posterior axillary showing a pulmonary consolidation, but also a hypoechoic lesion in the spleen was found (figure 1).Figure 1Ultrasound image of the spleen in longitudinal section demonstrating a large, hypoechoic, wedge-shaped lesion.QuestionWhat is the most likely diagnosis?Splenic abscessSubcapsular splenic haematomaSplenic infarctionSplenic hydatid cystFor answer see page 2

P4 Table 1Characteristics of the subjectsCharacteristics Subjects with ILAs on LDCT (n = 39) Age, yr, mean (± SD) 68.8 (± 4.3) Gender, n (%) Female 15 (38.5) Male 24 (61.5) Smoking status, n (%) Current 7 (17.9) Ex 32 (82.1) Respiratory symptoms, n (%) None 19 (48.7) Cough 3 (7.7) Dyspnoea 9 (23.1) Cough & dyspnoea 6 (15.4) N/A 2 (5.1) Physical examination findings, n (%) None 5 (12.8) Crackles 17 (43.6) N/A 17 (43.6) Baseline lung function,%pred, median (range) FEV1,% pred 91 (58 – 130) FVC,% pred 94.8 (65 – 143) TLco,% pred 57.6 (28.4 – 98.8) Kco,% pred 79.5 (36.4 – 94) MDT Diagnosis ILAs, n (%) 8 (20.5) ILD, n (%) IPF 14 (35.9) Smoking-related ILD 6 (15.4) Hypersensitivity pneumonitis 4 (10.3) PPFE 3 (7.7) Sarcoidosis 1 (2.6) Post-COVID ILD 1 (2.6) Vasculitis 1 (2.6) Unclassifiable 1 (2.6) Treatment, n (%) Smoking cessation advice 6 (15.4) Antifibrotic 7 (17.9) Immunomodulatory treatment 2 (5.1) None 23 (59) ResultsILAs of >5% extent on LDCT were identified in 39/1853 (2.1%) subjects screened between August 2018 and April 2021 (table 1). Respiratory symptoms were present in 18/39 (46.1%) and crackles were auscultated in 17 of 22 subjects (77.3%) undergoing physical examination. Past exposure to potential environmental triggers was noted in 21/39 (53.8%). Diagnostic bronchoalveolar lavage was performed in 7/39 (17.9%) and one patient underwent transbronchial lung cryobiopsy. After MDT discussion, ILD was concluded in 31/39 (79.5%) cases, of which 14/31 (45.2%) were diagnosed with IPF. In the IPF subgroup, antifibrotics were initiated in 7/14 (50%) of cases. In those diagnosed with other ILDs, immunomodulatory treatment was initiated in 2/25 (8%) subjects.ConclusionA large proportion of individuals with newly identified ILAs have an abnormal clinical examination and respiratory symptoms, consistent with the widely held suspicion that ILD is underdiagnosed in the community. Lung cancer screening in this demographic provides a unique opportunity to address this unmet health metric. Earlier identification of ILD, specifically IPF, allows institution of antifibrotic therapies proven to modify the natural history of the disease by preserving lung function and extending life. The cost-effectiveness of this approach for ILD screening warrants detailed evaluation.

What you need to know Bronchiolitis is a viral lower respiratory tract infection occurring mainly in the winter months, most commonly caused by respiratory syncytial virus (RSV). It is seen primarily in infancy but occurs up to 2 years of age and is the most common indication for hospitalisation in this age group. Ninety percent of children are infected with RSV in their first 2 years, and up to 40% will experience bronchiolitis during the initial infection.1 Bronchiolitis usually begins with a viral upper respiratory tract prodrome (rhinorrhoea and cough) followed by increasing respiratory effort (tachypnoea and/or accessory muscle use) with wheezing and/or crackles heard on chest auscultation. Diagnosis and assessment of disease severity is based on history and physical examination findings and does not require any confirmatory testing (box 1).1 Box 1 ### Guidance on optimal assessment of infants with bronchiolitis12RETURN TO TEXT

ObjectiveAssess characteristics of clinical pneumonia after introduction of pneumococcal conjugate vaccine (PCV), by HIV exposure status, in children hospitalized in a governmental hospital in Malawi.Methods and findingsWe evaluated 1,139 children ≤5 years old hospitalised with clinical pneumonia: 101 HIV-exposed uninfected (HEU) and 1038 HIV-unexposed, uninfected (HUU). Median age was 11 months (IQR 6-20), 59% were male, median mid-upper arm circumference (MUAC) was 14 cm (IQR 13-15) and mean weight-for-height z score was -0.7 (±2.5). The highest Respiratory Index of Severity in Children (RISC) scores were allocated to 10.4% of the overall cohort, respectively. Only 45.7% had fever, and 37.2% had at least one danger sign at presentation. The most common clinical features were crackles (54.7%), nasal flaring (53.5%), and lower chest wall indrawing (53.2%). Compared to HUU, HEU children were significantly younger (9 months v. 11 months), with lower mean birth weight (2.8 kg v. 3.0 kg) and MUAC (13.6 cm v. 14.0 cm), had higher prevalence of vomiting (32.7% v. 22.0%), tachypnoea (68.4% v. 49.8%), and highest RISC scores (20.0% v. 9.4%). Five children died (0.4%). However, clinical outcomes were similar for both groups.ConclusionsIn this post-PCV setting where prevalence of HIV and malnutrition is high, children hospitalised fulfilling the WHO Integrated Management of Childhood Illness criteria for clinical pneumonia present with heterogeneous features. These vary by HIV exposure status but this does not influence either the frequency of danger signs or mortality. The poor performance of available severity scores in this population and the absence of more specific diagnostics hinder appropriate antimicrobial stewardship and the rational application of other interventions.Strengths and limitations of the studyWe evaluated over 1,100 children hospitalized with pneumonia in a low-income country setting after introduction of PCV.This observational cohort was nested within a prospective hospital-based study of PCV13 effectivenessWe assessed the demographic and clinical characteristics of clinical pneumonia patients and compared HEU vs. HUU children, and computed RISC scores for severe pneumonia

BackgroundLower respiratory tract (LRT) involvement, observed in about 20% of patients suffering from coronavirus disease 2019 (COVID-19) is associated with a more severe clinical course, adverse outcomes and long-term sequelae. Early identification of LRT involvement could facilitated targeted and timely interventions that could alter the short- and long-term disease outcomes. The LungPass is an automated lung sound analysis platform developed using neural network technology and previously trained. We hypothesised that the LungPass could be used as a screening tool for LRT involvement in patients with COVID-19.MethodsIn a prospective observational study involving 282 individuals with presenting in the emergency department with a strong clinical suspicion of COVID-19 and imaging findings consistent with COVID-19 LRT involvement (25.5% had concomitant hypoxia), and 32 healthy controls, we assessed the sensitivity and specificity of the LungPass in identifying LRT involvement in COVID-19. We also compared the auscultatory findings of the LungPass compared to a chest physician using a traditional, high-quality stethoscope.ResultsAmong individuals with COVID-19 LRT involvement, the LungPass identified crackles in at least one auscultation site in 93.6% and in two or more points in 84%. Moreover, the LungPass identified any abnormal lung sound (crackles or wheeze) in at least one auscultation site in 98.6% and in at least two points in 94% of the participants. The respective percentages for the respiratory physicians were lower.Considering the presence of any added abnormal sound (crackles or wheeze) in at least two auscultation points as evidence of LRT involvement, LungPass demonstrated a sensitivity of 98.6% (95% confidence intervals [CI]: 96.4%-99.6%) and a specificity of 96.9% (95% CI: 83.8%-99.9%) in identifying COVID-19 LRT involvement.ConclusionThis exploratory study suggests the LungPass is a sensitive and specific platform for identifying LRT involvement due to COVID-19, even before the development of hypoxia.

An 86-year-old female with a past medical history of hypertension, vertebral fractures with chronic lumbar pain, hip fracture, osteoporosis, deafness, and microcytic anemia underwent hospital admission for emergency medical management of her respiratory distress. The (overall) diagnostic workup confirmed COVID-19, the patient presented with 50% SPO2 (oxygen saturation), sinus tachycardia, diffuse bilateral pulmonary crackles, mild jugular venous distention (JVD), minimal bilateral pitting edema, elevated cardiac enzymes, bilateral pulmonary opacities, and ST-segment elevation. The cardiovascular assessment indicated stress-induced cardiomyopathy/Takotsubo cardiomyopathy (TCM) determined by 35%-40% LVEF (left ventricular ejection fraction), mid to apical left ventricular (LV) akinesia with preserved function in the proximal segment, aortic valve sclerosis, reduced excursion of Trileaflet valve (without stenosis), and mild-to-moderate tricuspid regurgitation with moderate pulmonary artery systolic pressure (PASP). The treatment protocol relied on 81 mg aspirin, 75 mg plavix, 20 mg lipitor, remdesivir, dexamethasone, ceftriaxone, azithromycin, red blood cells transfusion (pRBCs), endotracheal intubation for respiratory support, and systemic hemodynamic support. The patient's condition did not improve despite all treatment, and she passed away after seven days following her hospital admission.

Conventional lung auscultation is essential in the management of respiratory diseases. However, detecting adventitious sounds outside medical facilities remains challenging. We assessed the feasibility of lung auscultation using the smartphone built-in microphone in real-world clinical practice. We recruited 134 patients (median[interquartile range] 16[11–22.25]y, 54% male, 31% cystic fibrosis, 29% other respiratory diseases, 28% asthma, 12% no respiratory diseases) at the Pediatrics and Pulmonology departments of a tertiary hospital. First, clinicians performed conventional auscultation with analog stethoscopes at 4 locations (trachea, right anterior chest, right and left lung bases), and documented any adventitious sounds. Then, smartphone auscultation was recorded twice in the same four locations. The recordings (n = 1060) were classified by two annotators. Seventy-three percent of recordings had quality (obtained in 92% of the participants), with the quality proportion being higher at the trachea (82%) and in the children’s group (75%). Adventitious sounds were present in only 35% of the participants and 14% of the recordings, which may have contributed to the fair agreement between conventional and smartphone auscultation (85%, k = 0.35(95% CI 0.26–0.44)). Our results show that smartphone auscultation was feasible, but further investigation is required to improve its agreement with conventional auscultation.

Monitoring pathological mechano-acoustic signals emanating from the lungs is critical for timely and cost-effective healthcare delivery. Adventitious lung sounds including crackles, wheezes, rhonchi, bronchial breath sounds, stridor or pleural rub and abnormal breathing patterns function as essential clinical biomarkers for the early identification, accurate diagnosis and monitoring of pulmonary disorders. Here, we present a wearable sensor module comprising of a hermetically encapsulated, high precision accelerometer contact microphone (ACM) which enables both episodic and longitudinal assessment of lung sounds, breathing patterns and respiratory rates using a single integrated sensor. This enhanced ACM sensor leverages a nano-gap transduction mechanism to achieve high sensitivity to weak high frequency vibrations occurring on the surface of the skin due to underlying lung pathologies. The performance of the ACM sensor was compared to recordings from a state-of-art digital stethoscope, and the efficacy of the developed system is demonstrated by conducting an exploratory research study aimed at recording pathological mechano-acoustic signals from hospitalized patients with a chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, and acute decompensated heart failure. This unobtrusive wearable system can enable both episodic and longitudinal evaluation of lung sounds that allow for the early detection and/or ongoing monitoring of pulmonary disease.

Background Differential diagnosis of interstitial lung diseases (ILDs) during the COVID-19 pandemic is difficult, due to similarities in clinical and radiological presentation between COVID-19 and other ILDs on the one hand, and frequent false-negative swab results on the other. We describe a rare form of interstitial and organizing pneumonia resembling COVID-19, emphasizing some key aspects to focus on to get the right diagnosis and treat the patient properly. Case presentation A 76-year-old man presented with short breath and dry cough in the midst of the COVID-19 outbreak. He showed bilateral crackles and interstitial-alveolar opacities on X-ray, corresponding on computed tomography (CT) to extensive consolidations with air bronchograms, surrounded by ground glass opacities (GGO). Although his throat-and-nasopharyngeal swab tested negative, the picture was overall compatible with COVID-19. On the other hand, he showed subacute, rather than hyperacute, clinical onset; few and stable parenchymal consolidations, rather than patchy and rapidly evolving GGO; pleural and pericardial thickening, pleural effusion, and lymph node enlargement, usually absent in COVID-19; and peripheral eosinophilia, rather than lymphopenia, suggestive of hypersensitivity. In the past year, he had been taking amiodarone for a history of ventricular ectopic beats. CT scans, in fact, highlighted hyperattenuation areas suggestive of amiodarone pulmonary accumulation and toxicity. Bronchoalveolar lavage fluid (BALF) investigation confirmed the absence of coronavirus genome in the lower respiratory tract; conversely, high numbers of foamy macrophages, eosinophils, and cytotoxic T lymphocytes with low CD4/CD8 T-cell ratio were detected, confirming the hypothesis of amiodarone-induced cryptogenic organizing pneumonia. Timely discontinuation of amiodarone and initiation of steroid therapy led to resolution of respiratory symptoms, systemic inflammation, and radiographic opacities. Conclusions A comprehensive analysis of medical and pharmacological history, clinical onset, radiologic details, and peripheral and BALF cellularity, is required for a correct differential diagnosis and management of ILDs in the COVID-19 era.

What you need to know A previously healthy and fully vaccinated (including 13-valent pneumococcal conjugate vaccine) 22 month old boy is brought to the emergency department because of a 12 hour history of high fever (up to 40°C). He had had low grade fever, runny nose, cough, and decreased oral intake for the past two days. On examination, he did not look severely ill but was febrile (38.3°C). His respiratory rate was 45 breaths/minute (normal range 25-40 breaths/min at 18-24 months old), heart rate was 140 beats/minute (normal range 98-135 beats/min at 18-24 months), and blood oxygen level was 95%. Although breath sounds were not decreased, some bibasilar crackles were noted on chest auscultation. A chest x ray was interpreted as having bilateral peribronchial infiltrates and haziness in the right lower lobe. To aide their decision whether to initiate antibiotic therapy, clinicians requested blood tests, which revealed a white blood cell count of 22.5×109/L (60.0% neutrophils), a CRP of 30 mg/L (normal

Background. Infective endocarditis caused by the dimorphic fungus Histoplasma capsulatum is extremely rare, occurring predominantly in individuals with prosthetic heart valves and HIV infection. To our knowledge, no case of H. capsulatum native valve endocarditis has been reported in Asia. Methodology. A descriptive study was carried out at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, in 2020. Results. A previously healthy 34-year-old man developed fever, umbilicated skin lesions, oral ulcers, hoarseness of voice, severe weight loss, and progressive dyspnea over the course of one week. Facial umbilicated papules, nodular ulcers in his tongue and palate, a diastolic rumbling murmur at the mitral valve, diffuse fine crackles in both lungs, and engorged neck veins were detected during the examination. Skin scraping of the facial lesion revealed both extracellular and intracellular yeasts with buddings, 2–4 μm in size on Wright’s stain. Transthoracic echocardiography demonstrated a left ventricular ejection fraction of 54 percent, severe rheumatic mitral stenosis, and multiple oscillating masses in the anterior mitral valve leaflet ranging in dimension from 1.5 to 2.4 cm. The HIV antibody test was negative. H. capsulatum endocarditis was diagnosed, and liposomal amphotericin B was administered. Due to cardiogenic shock, emergency open-heart surgery was conducted one day after admission. However, he died of multiorgan failure four days after the operation. The skin and vegetation cultures finally grew H. capsulatum after 1 week of incubation. Conclusions. To date, there has been handful of cases of H. capsulatum native valve endocarditis in non-HIV-infected patients. We report herein the first case in Thailand. Umbilicated skin lesions, especially combined with oral mucosal lesions, are a clinical clue that leads to the correct diagnosis of the causative organism.

Amyloidosis was initially described by Nicolaes Fonteyn in 1639. It is caused by the deposition of soluble immunoglobulin light chains as insoluble fibrils and can affect any organ including the heart, nervous system, dermis and subcutaneous tissue, kidneys and liver. This is a rare case of cardiac amyloidosis occurring with multiple myeloma and pleural effusion. A 65-year-old Arab woman, nonsmoker, nonalcoholic, known to have hypothyroidism and multiple myeloma, presented to the hospital with dyspnea and basilar crackles. Workup was done to exclude leukemia. Cardiac echography showed features of amyloidosis. Cardiac amyloidosis occurring with multiple myeloma and pleural effusion is rare. However, it is stated that 10–15% of amyloidosis patients might develop multiple myeloma (MM).

Knowledge and understanding about novel COVID-19 infection and its complications is of paramount importance in decreasing mortality on ongoing pandemic. A 40-year-old male with no past medical history arrived to the emergency clinic complaining of progressive shortness of breath and non-productive cough in the past week. He also reported worsening general malaise, headaches and fever despite recently completed antibiotic treatment with azithromycin for community acquired pneumonia. Physical examination was remarkable for tachycardia, tachypnea and bilateral respiratory crackles. Laboratory results were concerning for severe hypoxemia and lymphopenia. Bilateral pneumonic infiltrates were identified on imaging. The patient presented rapid clinical deterioration with signs of acute respiratory failure for which rapid sequence intubation protocol was followed. Inflammatory markers including ferritin levels were elevated raising suspicion for severe SARS-CoV-2, which was confirm by positive COVID-19 PCR test. After initial 48 hours with hydroxychloroquine, no clinical improvement was recorded. In view of continued clinical deterioration, the patient was enrolled in a convalescent plasma clinical trial with successful negative PCR test result after 48 hours of infusion. Results also correlated with slight clinical improvement including mechanical ventilation parameters, yet multiple attempts to wean off mechanical support were unsuccessful. Hospitalization was complicated with spontaneous bilateral pneumothorax. Multiple chest tubes were placed with minimal improvement of pneumothorax size. Exploratory bronchoscopy was performed and multiple bilateral sites of air-leak were encountered, explaining the non-resolving pneumothorax. The patient underwent exploratory thoracotomy, during which right lung fistula was corrected. Left lung pleurodesis with doxycycline was performed but unfortunately, pneumothorax persisted. Patient continued on ventilatory support for 5 months and remained with poor prognosis when this article was written. This case exposes the difficulty and complexity of caring for severe SARS-CoV-2 patients. To our knowledge there are only a handful of reported cases worldwide of COVID-19 infected patients complicated with bilateral non-resolving pneumothorax. As a novel disease, there aren't general practice guidelines to direct medical management. We describe this case in order to provide a point of reference for medical care workers treating similar patients. Many questions regarding SARS-CoV-2 infection are still unanswer, in particularly if early establishment of aggressive management would decrease incidence of this type of catastrophic lung complication.

Introduction:Patients with chronic lung disease are at risk of developing severe COVID 19 infection, and are likely to have poor outcomes. There is, however, little data available on the progression of interstitial lung disease (ILD) after severe COVID 19 infection. Here, we present the case of a patient with known ILD (chronic hypersensitivity pneumonitis, in this case), which progressively worsened after COVID 19 infection.Case Report:A 65 year old male presented to our clinic for management of chronic hypersensitivity pneumonitis in December 2018. In 2017, he had a video assisted thoracoscopic surgery performed, when it was diagnosed that the changes in his lungs were due to chronic hypersensitivity pneumonitis. On evaluation in our clinic, the patient reported dyspnea on exertion. He had mild crackles bilaterally and was saturating 94% on room air. A prior CT scan showed mild fibrosis. The patient was asked to come for a follow-up, but he was unable to do so due to the COVID 19 pandemic.In May 2020, the patient was diagnosed with severe COVID 19 pneumonia, and was admitted into the hospital, where he required supplementary oxygen. He was treated with Remdesivir and steroids, and was later discharged home on oxygen. When the patient was examined one month after discharge, he continued reporting worsening dyspnea and cough. At this time, a repeat CT scan of the chest showed worsening pulmonary fibrosis.Today, even though the patient has recovered from COVID-19, he remains dependent on supplementary oxygen.The patient has never been a smoker;he is an immigrant from Central America, having moved to the US in 2016. Back in Central America, he reported having a pet parrot in his home.Discussion:We suspect that continued exposure to the parrot may have been a cause of chronic hypersensitivity pneumonitis in our patient. Further, our case report indicates that COVID 19 may cause progression of ILD even after COVID 19 itself has been cured.Since the prevalence of ILD in general (and hypersensitivity pneumonitis in specific) is low, limited research has been carried out on the correlation of this disease with COVID 19. While a recent study did indicate that adults with preexisting ILD were at an increased risk of severe COVID 19, limited data is available on the long term consequences of COVID 19 infection for ILD patients.

A 75-year-old female with no history of lung disease developed severe pulmonary fibrosis within 1 month of acute severe COVID-19 pneumonia. She developed dry basal crackles, hypoxia needing home oxygen, and computed tomography changes which dramatically evolved from acute ground-glass opacities to honeycombing and traction bronchiectasis. Interestingly, these changes occurred despite her being on steroids through most of her hospital stay. She is being commenced on pirfenidone and her responses are carefully monitored, but the role of antifibrotic drugs are unclear and will only be established from large clinical trials.

Allergic bronchopulmonary aspergillosis (ABPA) is recognized as a rare, progressive, allergic disorder in patients with cystic fibrosis (CF) and asthma. Treatment of ABPA mainly includes systemic corticosteroids (CSs) and antifungal agents. Here, we report posaconazole treatment in a 9-year-old male child with ABPA and also review the literature on antifungal management of ABPA. The child with CF was admitted to the emergency room with complaints of fever, productive cough, and acute dyspnea. Auscultation of the lungs revealed obvious bilateral fine crackles and bilateral rhonchus. He was started with intravenous meropenem and amikacin for acute exacerbation. The patient was diagnosed with ABPA because of his failure to respond to antibiotherapy, elevated serum immunoglobulin (Ig) E, specific IgE, to Aspergillus fumigatus levels and sputum growth of A. fumigatus. He was successfully treated with posaconazole with marked clinical and laboratory improvement and no adverse effects. CSs and antifungal agents are the mainstay of therapy in patients with ABPA based on observational studies in children. Posaconazole is a useful treatment option for patients with ABPA.