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Background Bulla is a common cause of primary spontaneous pneumothorax. Video-assisted thoracoscopic surgery (VATS) through the lateral chest wall is a common surgical approach and an effective treatment for this condition, but postoperative incision scars affect the aesthetic outcome. VATS via axillary approach can hide the scar in the axilla, and the wound in its natural state is invisible; this greatly improves the cosmetic appearance. To our knowledge, this is the first report of VATS-based bullectomy via the axillary approach in a patient with spontaneous pneumothorax. Case presentation A 20-year-old female patient was admitted to the hospital with a 2-day history of chest tightness and chest pain. Plain chest computed tomography showed right spontaneous pneumothorax, lung compression of 75%, and right pulmonary bulla. After complete preoperative examination, VATS bullectomy via right axillary approach was performed. During the operation, a bulla measuring about 4 × 4 cm was found at the apex of the right lung and resected. The incision healed well, and the patient was discharged after surgery. Conclusions VATS bullectomy via axillary approach is safe and feasible, with the incision hidden in the axilla and not visible in the natural state. This method leaves no scar on the chest wall and has good cosmetic outcome.

Background The skin of neonates and infants undergoes a maturation process from birth and is susceptible to barrier disruption. The current algorithm follows a US-based consensus paper on skincare approaches using gentle cleansers and moisturizers in neonatal and healthy infant skin. This summary provides clinical information for pediatric dermatologists, dermatologists, and pediatric healthcare providers treating neonates and infants. Methods The project used a modified Delphi process comprising virtual discussions followed by an online follow-up replacing the use of a questionnaire. During the virtual meeting, the systematic literature review results and a draft algorithm addressing over-the-counter skincare for neonates and infants with healthy skin were discussed and adopted using evidence coupled with the expert opinion and experience of the panel. Results The algorithm addresses three clinical signs: xerosis, erythema, and erosion/bulla. A growing body of evidence recognizes the benefits of ongoing daily use of non-alkaline cleansers and ceramides containing moisturizers to reduce inflammation and maintain a healthy skin barrier function. Diaper rash is common in infants presenting as erythema or, in more severe cases, skin erosion. Skin protection with a barrier cream and frequent diaper changes using disposable diapers resolves most cases; however, if the rash continuous despite appropriate care, rule out a candida infection. Conclusion The current algorithm focuses on neonatal and infant healthy skin that can benefit from skincare. When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids help maintain the protective skin barrier. J Drugs Dermatol. 2021;20(11):1195-1205. doi:10.36849/JDD.6219.

Giant lung bullae are usually seen in patients with severe chronic obstructive pulmonary disease. Over time, air trapping leads to severe dyspnea and CO2 accumulation. In severe cases, overinflation and rupture of the bulla can cause secondary life-threatening tension pneumothorax. Since positive pressure ventilation exerts deleterious effects on the bulla, general anesthesia is always challenging in patients with giant bullae. We encountered remarkable intraoperative hypercapnia and decreased tidal volume in a 58-year-old male patient with bilateral bullae who underwent right upper bullectomy, due to overinflation of a bulla located in the upper lobe of the ventilated side. Through this experience, to avoid further overinflation, we devised an original, unique and simple airway management strategy using a standard double lumen tube (DLT), which only requires slightly deeper advancement of the DLT to achieve selective lobar blockade during one lung ventilation (OLV). Following the first case, we used this strategy in a 48-year-old male patient who underwent left giant bullectomy, resulting in successful airway management without overinflation during OLV. We recommend our strategy as an option for successful intraoperative airway management during OLV in select bullectomy patients with bilateral giant bullae.

The recent outbreak of the novel coronavirus 2019 (Covid-19) spread rapidly throughout several countries around the worldand has posed enormous health challenges. Symptom of Covid-19 are non-specific and the disease presentation can range from no symptoms (asymptomatic) to severe pneumonia and death. The most commonly reported oral manifestations in the literature are ulcer, erosion, bulla, vesicle, pustule, fissured or depapillated tongue, macule, papule, plaque, pigmentation, halitosis, among others. The professionals must be prepared to recognize theoral manifestations of the disease to promote the most adequate treatment. This study presents 5 cases of oral manifestations in patients diagnosed with Covid-19. The patients presented ulcerations, vesiculopapular lesions, papillary lesions, lingual erythesa, keratose-like lesions and white plaque. Lips, tongue, labial mucosa, palate and gum were affected. If this hypothesis is proven, when health professionals observe these oral manifestations, they could refer these patients to be tested and perform the appropriate treatment.

Conjunctival neoplasia is one of the most frequent tumors in the eye. Actinic keratosis (AK) or solar keratosis is a precancerous lesion that is included with other epithelial tumors. This alteration does not break the basal membrane. There is enough evidence of successful outcomes to consider interferon alfa-2b (IFN alfa-2b) as the first choice of treatment for this type of tumors. In addition, side effects are mild and uncommon. We report a case in an 83-year-old woman who was referred to evaluate a leukoplakia in the tarsal conjunctiva of the lower left eyelid that measured 1 cm in diameter. Pathological study revealed AK. After the INF alfa-2b treatment, we observed conjunctival hyperemia, noninfiltrated upper nasal de-epithelization, and inferior nasal bulla. AK with presentation in conjunctiva is rarely described and in tarsal conjunctiva is exceptional. It is the first case published with only tarsal conjunctiva affectation.

Background Spontaneous pneumothorax is a common problem globally. Bullas and blebs have been implicated in this problem, but the etiology of their formation is unknown. We aim to show the relation between a novel clinical finding, the pulmonary delayed inflation (PDI) sign, and the etiology of bulla and bleb formation in young patients. Methods We retrospectively analyzed data from 111 patients with pneumothorax and a control group of 27 patients. We evaluated the relation between the PDI sign and other clinical factors. Results The PDI sign was observed in 78 patients. Of these, 75 exhibited the PDI sign in only the upper lobe. Regardless of smoking status, patients 34 years of age or younger had a significantly higher incidence of the PDI sign than, patients 55 years of age or older and control patients. The inflation time in patients 34 years of age or younger, regardless of smoking status, was significantly longer than in patients 55 years of age or older and patients in the control group. There was no significant association between inflation time and the presence of asthma. Conclusions The novel PDI sign is seen in patients 34 years of age or younger. Because this sign may indicate a peripheral bronchial abnormality and may be related to the formation of blebs and bullae in young patients with spontaneous pneumothorax, it is possible that it can be used to develop effective treatments for pneumothorax in young patients.

Introduction: Vesiculobullous diseases are a group of disorders in which primary lesion is a vesicle or a bulla on the skin or mucous membrane or both. Though some of the veisculobullous lesions are characteristics in their appearance and distribution, clinically many a times a definitive diagnosis cannot be made by physical examination alone. Then the dermatologists are forced to resort to histopathology for a definite diagnosis and classification. In the present scenario, even though histopathological study is sufficient in most of the cases, it is often accompanied by immunofluorescence antibody tests for confirmation of the diagnosis and monitoring of the disease. Direct immunofluorescence antibody test is a gold standard to confirm the disease and the indirect test helps to monitor the disease. Objectives: This study was carried out to find out clinical and histopathological correlation in diagnosing the disease. Materials and Methods: In the present study, histopathological evaluated vesiculobullous lesions over the period of 2 years. A total number of 35 cases were encountered. Staining procedures done are haematoxylin – eosin staining, leishmann staining and direct immunofluorescence stain. Results: A total number of 35 cases were encountered which constituted 0.70% of overall biopsy specimen and 12.32% of skin biopsy specimen. The pemphigus vulgaris formed commonest disease encountered accounting for 34.30% of all skin lesions. Bullous pemphigoid formed the second most common disease observed (31.34%) affecting both sexes equally. Conclusions: All though the ‘primary’ vesiculobullous lesions of skin are seen in a small group of people, they have been associated with significant a morbidity and mortality. It is important to distinguish each of these entities and separate them appropriate for management and treatment. Even though clinical examination has its own importance, both histopathological and DIF testing is must, as it confirms the diagnosis and

Fixed drug eruption (FDE) is one of the common types of cutaneous adverse drug reaction. This study was conducted to study the common types of drugs causing FDE and to find the management pattern of FDE in a tertiary care teaching hospital. In this study we found that orindazole (24%) and co-trimoxazole (20%) had higher incidence of FDE. Sixty eight percent of patients developed post inflammatory pigmentation. The most common clinical presentations was black patch in 44%, followed by bulla with erythematous patch in 20% of pigmented patches. Topical steroids, antihistaminic and oral corticosteroids were the common drugs used in the management of fixed drugs eruptions. The most common affected site was lip in 33.3% followed by trunk in 21%. The most common age group was 11-20 year followed by 21-30 year, fifty-one cases were seen in male. Keywords: Fixed drug eruption, Cutaneous Adverse drug reaction, Pigmentation.

Introduction Vanishing lung syndrome, also known as giant bullous emphysema is a condition usually reported in young male thin smokers. There are numerous case reports that have added to the body of evidence. There are also case reports of the giant bulla being misinterpreted for a pneumothorax. Case report A 61 year old male with severe chronic obstructive lung disease presented to Accident and Emergency with progressive breathlessness. A chest radiograph showed a giant right sided bulla that was initially misinterpreted as a tension pneumothorax. Further review of his imaging and lung function pointed to him having vanishing lung syndrome. He was referred for a cardiothoracic opinion but was eventually managed conservatively. Discussion Vanishing lung syndrome is characterised by a slowly enlarging upper lobe bulla that compresses normal lung parenchyma and causes mediastinal shift, with the patients experiencing increasing dyspnoea and reduced exercise tolerance. Smoking cessation is the mainstay of treatment. If they are relatively asymptomatic, patients are managed conservatively. Otherwise a variety of lung volume reduction techniques can be considered. A large bulla can look the same as a pneumothorax but the former does not have a lung edge and has a more rounded appearance. A CT scan is very useful in differentiating between the two pathologies. Bullae are predominantly caused by smoking. Bullae will cause high total lung volumes and residual volumes, but low alveolar volumes. Bullae can be observed or treated by surgical techniques, African relevance • The relevance of the differential diagnosis of pneumothorax is important within the African context (tuberculosis, etc.). • Obstructive and bullous lung disease is often a challenging diagnosis.

Tracheobronchomegaly is a rare disease with congenital abnormal change in respiratory tract; its image features are also very special. In this case, we described a 57-year-old male with cough, expectoration, chest pain, and dyspnea. In our institution, the result of chest CT scan is highly extraordinary, which showed obvious dilation of the trachea and main bronchi, emphysema, and a number of pulmonary bullae, and there was a big bulla with air-fluid level on the lower lobe of the right lung. Fortunately, after wedge resection for the big bulla on the lower lobe of right lung under video-assisted thoracoscopic surgery, this patient’s symptoms were significantly relieved. The clinical manifestations of tracheobronchomegaly lack specificity; this disease has freakish image features. At present, there are no effective treatments for tracheobronchomegaly, which just was an accidental discovery in this patient; we just mainly take surgical measures to treat the big bulla for relieving symptoms.

Introduction: Angina bullosa hemorrhagica is a disease without a concomitant hematological or vesiculobullous disorder characterized by painless hemorrhagic bullae in the oral mucosa; it is rarely seen and has a good course. Case presentation: A 45-year-old female patient was admitted to the emergency department with a painless hemorrhagic bulla that suddenly appeared on the soft palate. A blister, 2 cm in diameter and dark red in color, was seen extending from the hard palate’s posterior to the soft palate. Nasolaryngoscopic evaluation was performed, and no additional hemorrhagic bulla was detected. She was discharged with the recommendation of oral mouthwash. Discussion: Solitary hemorrhagic bulla, suddenly occurring on the soft palate, is diagnostic for angina bullosa hemorrhagica. Some authors have reported that blisters in the posterior pharynx may progress to acute upper airway obstruction. Conclusion: Early nasolaryngoscopic evaluation in angina bullosa hemorrhagica is an excellent option to be considered by the emergency physician to prevent life-threatening situations.

Objective Some cases of peripheral facial paralysis are resistant to treatment, thus, a non-recovery model of facial paralysis is needed to develop new treatment strategies for this condition. The purpose of the current study was to develop an animal model of which facial palsy was severe and prolonged. Methods Ten 8-week-old female Hartley guinea pigs weighing between 400 and 500 g were used for the animal model. The vertical segment of the facial canal was accessed via the otic bulla, without removing the bony wall of the facial canal. The canal was then frozen for 5 s using freeze spray. Facial movements, electroneurography (ENoG), histology, and changes in temperature were evaluated. Results All animals exhibited complete facial paralysis immediately after the procedure and recovered gradually, however, not all of them had recovered completely 15 weeks after freezing. The ENoG values one week after freezing for all animals (10/10) were 0%. Histological examination one week after freezing revealed that most of the vertically placed myelinated nerve fibers which had been frozen were remarkably affected and denatured. The number of vertically placed myelinated nerve fibers increased 15 weeks after freezing, but the nerve fibers were smaller than normal nerve fibers and were distorted in shape. Conclusion Complete facial paralysis was induced in Hartley guinea pigs by freezing the facial canal. The behavioral, ENoG, and histopathological data suggest that the facial paralysis was severe and prolonged. This model may assist in developing novel treatment for severe facial palsy and facilitate basic research on facial nerve regeneration.

We report a rare case of Wells syndrome in which a 61-year-old Caucasian male presented with three distinct skin lesions including a cutaneous bulla, an erythematous plaque, and a linear streak located on the patient's left anterior thigh, left dorsal wrist, and left anterior forearm, respectively. Histologic examination revealed diffuse and interstitial eosinophilic infiltrate admixed with lymphocytes and macrophages that predominantly involve the dermis. Nodular aggregates of eosinophils surrounding dermal collagen fibers suggestive of 'flame figures' were identified. Luna histochemical stain was used and highlighted the deposition of eosinophilic granules over the collagen bundles confirming the presence of flame figures. Laboratory workup revealed peripheral eosinophilia, but a comprehensive clinical evaluation failed to reveal a systemic disease and ultimately the diagnosis of eosinophilic cellulitis 'Wells Syndrome' was rendered. After a short course of immunosuppressive therapy, the patient experienced a complete resolution of the skin lesions on his last follow-up visit several weeks from the initial diagnosis. This case highlights the various clinical forms that Wells syndrome may present with and may serve as a good example for the use of Luna stain as a simple and cost-effective diagnostic tool that can help to arrive at the accurate diagnosis and inform therapy.

Spontaneous pneumothorax presents a unique diagnostic and therapeutic challenge in veterinary medicine, specifically with regard to accurate identification of bullous lesions. Positioning of dogs with spontaneous pneumothorax during CT has not previously been evaluated. This retrospective, diagnostic accuracy study was performed to evaluate the sensitivity, positive predictive value (PPV), and interobserver variability for detection of pulmonary bullae with dogs positioned in multiple recumbencies. Dogs underwent CT in sternal and dorsal recumbency followed by thoracic exploration via median sternotomy. Three American College of Veterinary Radiology-certified veterinary radiologists blinded to surgical findings reviewed dorsal and sternal images simultaneously. Severity of pneumothorax, degree of atelectasis, lesion location and size, and view in which lesions were most confidently identified were compared to surgical and histologic findings. Sensitivities and PPVs for bulla detection ranged from 57.7% to 69.2% and 62.1% to 78.9%, respectively. For two of the 3 radiologists, the location of bullae in the thorax was significantly associated with the recumbency in which the lesion was best identified. Degree of atelectasis was found to be associated with the ability to identify lesions (P ≤ .02). The interobserver variability for identification was good (κ = 0.670). The sensitivity of CT when performed in both sternal and dorsal recumbency is similar to that previously reported. Because the distribution of bullae is unknown prior to advanced imaging and bulla location affects which recumbency is most useful for identification, acquisition of CT images in both sternal and dorsal recumbency may improve detection of bullous lesions and aid surgical planning.

Background Patients with Marfan syndrome (MFS) often develop pneumothorax, but the features of pneumothorax in the context of MFS have not been well described in the literature. We clarified the clinical and histopathological characteristics of this condition in these patients. Methods Patients with MFS were selected from among all patients who underwent surgery for pneumothorax, between December 1991 and January 2015, in our hospital. We studied the histopathological characteristics of the resected lungs as well as the clinical features of the selected patients, including surgical findings and postoperative recurrence status. Results There were 966 operations underwent pneumothorax-related surgeries in our hospital. A total of 16 operations (1.66%) were performed on patients with MFS in 11 cases. In this study, 9 patients (6 men, 3 women) were included. Clinically, 7 patients (77.8%) had bilateral pneumothoraces and 4 (44.4%) exhibited postoperative recurrent pneumothoraces. Pathologically, the resected pulmonary bullae exhibited blood vessel cystic medial degeneration (55.6% of cases), calcification (55.6% of cases), and demonstrated elastic fiber fragmentation and degeneration (all cases). Conclusions As in few previous reports, many patients with MFS develop bilateral or postoperative recurrent pneumothoraces. In many patients, characteristic changes in the pulmonary bullae, possibly caused by degenerated elastic fibers, were observed.

Background: The vesiculobullous reaction pattern is characterized by the presence of vesicles or bullae within the epidermis or at the dermoepidermal junction. Despite some having characteristic presentations, it’s difficult to make a definite diagnosis clinically. Hence, cytological evaluation is required for reliable and early diagnosis. Objectives of the study are to determine the incidence of various vesiculobullous lesions and evaluate cytology as a tool for early diagnosis of vesiculobullous lesions. Methods: For Tzanck smears fresh vesicle or bulla was selected and incised with scalpel, reflecting the roof of bulla. Base of the blister scraped gently and material spread on a glass slide. These smears were stained with MGG (air dried), Pap and H&E stains (fixed).Skin punch biopsies from the bullae were subjected to routine fixation, processing, sectioning and staining. Results: A total of 62 Tzanck smears were done for vesiculobullous lesions of skin of which 29 had histopathological correlation. Herpes constituted the most common vesiculobullous disorder (42%) followed by bullous pemphigoid (27.4%) and pemphigus vulgaris (19.3%). Most patients were in the age group 61- 70 years. The M:F ratio of 1:1.38 showing female preponderance. Tzanck smears showed acantholytic cells in pemphigus group, eosinophils in bullous pemphigoid and multinucleate giant cells in viral blisters. Histopathology showed intraepidermal acantholysis in pemphigus vulgaris, subcorneal blister in pemphigus foliaceus and subepidermal in bullous pemphigoid. Conclusion: Cytohistopathological correlation showed an overall sensitivity of 79%. Tzanck smear showed 96% sensitivity for viral infections. Tzanck smear is a quick, non-invasive method for the early diagnosis of vesiculobullous disorders.

A 37-year-old Japanese man presented with a bulla with niveau-like opacity in the right upper lung on chest radiography. Air-fluid level gradually increased despite broad-spectrum antibiotic therapy. Right upper lobectomy was performed, and epithelioid granuloma with mycobacteria was histopathologically observed. Bacterial culture of the fluid was negative, but mycobacterial culture was positive for Mycobacterium avium; therefore, the patient was diagnosed with pulmonary infected bulla caused by Mycobacterium avium. He was further treated with antimycobacterial agents after resection of the infected bulla. To our knowledge, this is the first report of pulmonary infected bulla caused by only Mycobacterium avium in the English literature.

Oxidized regenerated cellulose (ORC) sheet, in surgery of primary spontaneous pneumothorax, is used to reinforce the visceral pleura around the staple line coverage aiming to prevent a postoperative recurrence. We evaluated the effect of ORC on recurrence within 2 years after surgery. A total of 201 patients aged

The recommended standard treatment for giant bullae is surgical bullectomy. However, with a relatively high risk for perioperative morbidity and mortality, it is unsuitable for some patients. Recently, bronchoscopic bullectomy with one-way valves has shown efficacy and safety in some cases. Locating the giant bulla and confirming the negative collateral ventilation are essential for the bronchoscopic bullectomy with valves. Here, we report a case with a giant bulla using the Chartis System to correct the previous mislocation by the high-resolution computed tomography (HRCT), thus helping to achieve a great efficacy in the bronchoscopic bullectomy with valves. Our case suggests that bronchoscopic bullectomy with valves could be an effective and safe choice. Chartis system can be helpful in determining the location of a bulla when difficulty is encountered using HRCT.

Computed tomography (CT) of chest organs is one of the most accurate diagnostic methods allowing the physician to assess the condition of lung parenchyma. Correct interpretation of CT results requires the clinician to recognize normal appearance of lung parenchyma on X-ray and know changes visualized in various bronchopulmonary diseases. It is important that the physician knows and understands underlying cause of a particular radiological pattern in order to discuss with the radiologist lung tissue changes that have been identified considering clinical symptoms. Descriptions of radiological patterns and discussion of corresponding typical clinical observations are presented in the article devoted to air cyst syndrome and cystoid changes in the lung tissue.

Most complications related to posterior spinal fusion (PSF) are reported to be caused by direct injury of the pedicle screws or by an indirect mechanical load generated by the deformity correction during surgery. Primary spontaneous pneumothorax (PSP) is caused by the rupture of bulla/bleb, and is a very rare complication after scoliosis surgery. Herein, we present two cases of delayed-onset PSP after scoliosis surgery. In Case 1, an 18-year-old woman with adolescent idiopathic scoliosis (Lenke 1CN) underwent PSF at T2-L2. The correction rate was 80%. The patient was discharged at 2 weeks after the operation. On the 18th postoperative day, she suddenly felt dyspnea after back pain at home, and walked to an outpatient clinic. She was diagnosed with PSP of the left lung by whole spine X-ray. In Case 2, a 20-year-old woman with idiopathic scoliosis (Lenke 6CN) underwent PSF at T3-L4. The correction rate was 73.6% in the thoracic region and 67.5% in the lumbar region. The patient felt dyspnea at three months after the operation. She was diagnosed with PSP (tension pneumothorax) in the left lung by whole spine X-ray. Both cases underwent video-assisted bulla resection following several days of emergency thoracic drainage, after which the subjects became asymptomatic. PSP should be considered as a complication of PSF when patients show dyspnea following back pain at several weeks after the operation. The presence of bullae/blebs should be examined by perioperative computed tomography to predict the occurrence of PSP.

Non-bullous neutrophilic lupus erythematosus is a rare form of cutaneous lupus erythematosus (LE). We hereby present a case of 24-year-old female, known case of discoid LE (DLE) with negative ANA stabilized on hydroxychloroquine for 2 years. She reported new occurrence of erythematous, mildly pruritic, papular lesions and painful mucosal ulceration. The ANA became strongly positive by ELISA and urine showed proteinuria. A provisional diagnosis of Rowell syndrome was made, skin biopsy was taken, and patient started on steroids. Histopathology showed interface vacuolar change and many neutrophils in the dermis with leukocytoclasia without any bulla formation. The skin lesions responded promptly to addition of dapsone following biopsy report. We conclude that the presence of neutrophils associated with interface pathology on biopsy represents a muted form of bullous LE, especially in patients on immunosuppression. This case highlights the importance of histopathologic examination in the evaluation of any new skin lesions in a patient of lupus on therapy.

In December 2019, coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was reported in Wuhan, China. An 82-year-old woman presented to our hospital with high fever (39°C) and chest computed tomography revealed ground-glass opacities in the left lung apex. She was positive for SARS-CoV-2 based on a polymerase chain reaction test, and diagnosed with COVID-19 pneumonia. 6 months after treatment, chest CT showed a large bulla (47 mm × 29 mm) in the left lung apex, although pneumonia had partially resolved. Radiologic follow-up is needed after COVID-19 pneumonia, because patients may develop bullae after treatment.

Toxic epidermal necrolysis is a life-threatening dermatological emergency with high mortality if not treated in time. Here we report a case of toxic epidermal necrolysis due to carbamazepine in rural Nepal in COVID-19 pandemic who was successfully treated with the help of mobile teledermatology. The clinical impression of toxic epidermal necrolysis was made from “WhatsApp” video calls using a smart phone. The supportive features were the history of starting of carbamazepine 2 weeks prior for seizure disorder, clinical findings in serial photographs of skin with 40 percent body surface area involvement of necrotic skin lesions and bulla, and involvement of oral mucosa and eyes. The patient was immediately asked to stop carbamazepine and was treated with intravenous fluids and systemic steroids along with symptomatic management. As the whole world was suffering from lockdown due to COVID-19 crisis, it was impossible for the rural area patient to visit a dermatologist. Thus, with the help of paramedics staff in a community health center and mobile teledermatology, the patient was diagnosed as carbamazepine-induced toxic epidermal necrolysis and treated successfully with good outcome.

A 41-year-old woman was admitted with a recurrent pneumothorax coincident with menstruation 2 months after a first occurrence. Video-assisted thoracic surgery was performed for definitive diagnosis and pneumothorax treatment. Bluish diaphragmatic spots and three lung bullae were noted. A lung fistula was observed in one of the bullae, and the diaphragmatic lesion and bullae were resected. The bulla with air leakage and the diaphragmatic lesion were diagnosed as endometrial tissue by pathology. This case is rare as a fistula from a bulla with endometriosis was identified intraoperatively, suggesting the check-valve mechanism might be one of the etiologies of catamenial pneumothorax.

1 INTRODUCTION Humans infected with SARS‐CoV‐2 are at risk of developing serious and life‐threatening conditions, such as severe acute respiratory syndrome. Recent data suggest the more common signs and symptoms of SARS‐CoV‐2 infection to be headache, sore throat, hyposmia, hypogeusia, diarrhea, dyspnea, and in severe cases pneumonia. (Wang et al., 2020). Some authors in Italy reported cases of dermatologic implication in patients affected by SARS‐CoV‐2 infection (Recalcati, 2020). Since then, we have seen more reports describing dermatologic involvement, including lesions that range from affectation of hands and feet in teenagers to vasculitis, rash, urticaria, and varicella‐like lesions. (Estebanez et al., 2020). Spain has been severely affected by the COVID‐19 outbreak (Bonanad et al., 2020). The majority of dental clinics and university clinics are closed, only treating emergencies if the entity has the protective measures necessary. There is a nationwide lack of serological tests available, both for patients and for healthcare providers. We here present three cases associated with this virus: two where there is a suspicion of COVID‐19 and one case of confirmed infection. All cases presented ulcers or blisters in the oral cavity, appearing and developing during the isolation period between the last week of March and the first week of April 2020. We were not able to examine them in our clinic due to the state of alarm declared from the 14th of March, but offered the possibility of video consultations. 2 PATIENT 1 A 56‐year‐old healthy male patient without any relevant medical history was isolated with suspected infection of SARS‐CoV‐2. He presented asthenia and fever for 2 days, reporting hyposmia, dysgeusia, and enlargement of lymph nodes in the neck. Testing for COVID‐19 was not performed in the hospital due to the non‐severity of his case. He was sent home by his general practitioner. He complained of pain in his palate and sore throat. We asked him to send us a photograph (Figure 1). The lesions resembled a herpetic recurrent stomatitis; however, it was the first time the patient had them. We prescribed valaciclovir 500 mg every 8 hr for 10 days, and topical antiseptics with chlorhexidine and hyaluronic acid. After 10 days, there was a full recovery of the oral lesions. The patient is currently waiting for serological testing to confirm whether or not he had a non‐severe COVID‐19 disease. Figure 1 Multiple orange‐colored ulcers with an erythematous halo and symmetric distribution on the right hard palate of the patient 3 PATIENT 2 A 58‐year‐old male patient with diabetes and hypertension reported pain on his palate. He assumed it was a bacterial infection of a tooth and reached out to us for an appointment. His wife had been diagnosed with COVID‐19, and they were both isolated in their home. We asked for a photograph, and we could see multiple small ulcers on his palate with unilateral affection (Figure 2). The patient did not have any previous history of herpetic infection. Figure 2 Multiple pinpoint yellowish ulcers with an erythematous halo on the left hard palate of the patient The lesions were painful and solved within 1 week using topical antiseptic mouthwash. 4 PATIENT 3 A 65‐year‐old female patient developed high fever, diarrhea, and pain on her tongue, on the 12th of March 2020. She suffered from obesity and hypertension controlled by diuretics and an ACE inhibitor. A week after developing symptoms, she fainted at home and was taken to the hospital where she was diagnosed with bilateral pneumonia due to SARS‐CoV‐2 infection. She was given antibiotics, corticosteroids, and antiviral drugs (lopinavir 200 mg, ritonavir 50 mg, hydroxychloroquine 200 mg). On the 30th of March, she was discharged. On the 4th of April, she developed a rash under her breasts and other parts of the skin, including her back and genital area. She had complained of pain on her tongue from the beginning, but she told us she had not been given an intraoral examination yet. She was taken back to the hospital where the dermatologist performed a biopsy and prescribed antifungals. A week later, she developed blisters in her internal lip mucosa as well as a desquamative gingivitis (Figure 3). We prescribed hyaluronic acid and chlorhexidine mouthwash. Her general practitioner prescribed prednisolone 30 mg per day. Her lesions improved within 3 days, and she is now recovering in isolation at home. The result of the biopsy revealed non‐specific morphological findings with some criteria suggestive of viral exanthema or urticariform dermatitis with discrete blood extravasation. Figure 3 (a) The aspect of the back of the patient the day the biopsy was performed at the hospital. The patient reported that the lesions were more pruritic than painful. (b) The patient presented 3 blisters on the inner lip mucosa. The blister located closer to her right commissure was intact and tense. The bulla located on the left appeared to be broken. The lesions were affecting both intra‐ and extraoral mucosa, and the patient developed crusts on the external lip mucosa 3 days after this photograph was taken In our opinion, it makes good sense that this virus provokes exanthematic lesions that may resemble other viral processes we are used to diagnosing in the dental clinic. The patients presented ulcers or blisters, which are common elementary lesions observed in other viral processes, such as aphthous fever, hand, foot, and mouth disease and herpetic gingivostomatitis, as described by Scully and Samaranayake (2016). In the first 2 cases, lesions were affecting keratinized tissue, as seen in herpes simplex lesions (Scully & Samaranayake, 2016). In the last case, oral lesions affected both keratinized and non‐keratinized tissue and were more compatible with an erythema multiforme (Trayes, Love, & Studdiford, 2019; Schwartz & Janniger, 2020). As we were not able to perform biopsies, further studies need to be carried out in order to determine whether oral manifestations are common in patients affected by SARS‐CoV‐2 infection or if the emotional distress of the situation itself could trigger such lesions (Suzich & Cliffe, 2018; Chida & Mao, 2009). It is important to mention that the 3 cases all reported having had pain, oral ulcers, or blisters before seeking medical advice. We suspect that intraoral lesions often are misdiagnosed due to the lack of intraoral examinations, considering the severity of other pathological processes that might concur with this viral infection. To the best of our knowledge, this is the first case report of a COVID‐19 patient presenting intraoral manifestations. We encourage all medical doctors, dentists, and dermatologists to perform intraoral examinations in patients suspected or affected by SARS‐CoV‐2, always when having the recommended protection measures available. CONFLICTS OF INTEREST None to declare. AUTHOR CONTRIBUTION Carmen Martin Carreras‐Presas: Writing‐original draft. Juan Amaro Sanchez: Writing‐original draft. Antonio Francisco Lopez‐Sanchez: Writing‐review & editing. Enric Jane‐Salas: Resources. Maria Luisa Somacarrera Perez: Supervision.

Studies have been done extensively, about the difficulties of giving anaesthesia and endo-tracheal intubation, in patients with severe kyphoscoliosis, due to distortion of the airway anatomy. However, there is a little or no information about difficulties in doing thoracotomy, in such patients with distorted chest wall. We would like to report a case of severe kyphoscoliosis with deformed chest wall, who underwent thoracotomy for recurrent pneumothorax due to ruptured multiple bullae. The pitfalls and safety measures to be taken, have been explained.

Pembrolizumab is a humanized monoclonal antibody that targets programmed cell death receptor-1. Stevens–Johnson syndrome (SJS) secondary to pembrolizumab has rarely been described in the treatment of malignant melanoma (MM). A 62-year-old woman developed a widespread bullous eruption following administration of her third dose of pembrolizumab for the treatment of MM. A skin biopsy showed sub-epidermal bulla formation with lymphocytic infiltrate and a necrotic roof, consistent with a SJS/toxic epidermal necrolysis (TEN) disorder. Intravenous methylprednisolone was administered. Upon cessation of oral prednisolone, there was a recrudescence of the eruption. A repeat skin biopsy confirmed recurrent SJS. Following a prolonged taper with oral prednisolone, there was no further relapse of SJS. Severe cutaneous adverse reactions such as SJS/TEN have been reported with pembrolizumab and can be associated with significant morbidity and even mortality. High-dose systemic corticosteroids are frequently used in its treatment. Concerns about the potential negative effect of high-dose steroids have re-surfaced, given the observed reduced overall survival in patients with MM. Due to difficulties in performing studies in this population, the benefits and risk of steroids should be considered on a case-by-case basis.

Highlights • The main complication of PLCH is the occurrence of pneumothorax (PTX) and tension bullae with subsequent recurrence and persistence despite conservative management. • Although it is difficult to treat recurrent PTX and tension bullae in advanced PLCH, continuous treatment of the primary disease (LCH) and the complications of pulmonary lesions can improve prognosis. • Positive-pressure ventilation should be performed with extreme caution in suspected PLCH., Introduction Pulmonary Langerhans cell histiocytosis (PLCH) is a well known entity in adults but is exceedingly rare in children. The main complication of PLCH is the occurrence of pneumothorax (PTX) and tension bullae with subsequent recurrence and persistence despite conservative management. Case presentation A 3-year-old child was diagnosed with PLCH with thyroid involvement. Chemotherapy was immediately initiated and continued with chest tube drainage for repeated bilateral PTX. Tension bullae developed in the right lung 1 month after initiating treatment. Emergency resection of the bullae and ligation of pulmonary cysts were performed. On the tenth postoperative day, she developed a tension bulla in the left lung. Emergency thoracotomy was performed. On the tenth postoperative day, chest X-ray and CT suggested return of the right bulla and mediastinal shift, and reoperation was performed. Repeated lung biopsy showed no sign of active LCH. Although her condition improved after the operation, subsequent repeated PTXs occurred and were difficult to treat. She was discharged home after four months. Currently, she is receiving maintenance therapy as an outpatient. During the 12-month follow-up, the pulmonary lesions also showed a tendency for improvement. Discussion Although it is difficult to treat recurrent PTX and tension bullae in advanced PLCH, continuous treatment of the primary disease (LCH) and the complications of pulmonary lesions can improve prognosis. Conclusion Treatment of PLCH accompanied by recurrent PTX and tension bullae is challenging. The condition can be resolved by treating the primary disease in parallel with combined modality treatment, including surgical operation for complications.

This case report presents a unique clinical dilemma in the treatment of a large full-thickness dorsal hand wound in a 64-year-old Caucasian woman with recently diagnosed acquired hemophilia A. The wound was instigated by nominal blunt force trauma to the dorsal hand and progressed to a large desquamating bulla. Treatment was initiated by careful evacuation of the bulla and daily dressing changes. The resulting necrosis of the skin produced a loose eschar. Subsequent removal of the eschar left the extensor tendons with minimal hypodermis covering the paratenon. The potential for life-threatening hemorrhage limited treatment options. The wound was treated with Integra Dermal Regeneration Template and planned for delayed definitive coverage. Continued concern for hemorrhage and comorbid conditions delayed skin grafting. Wound surveillance demonstrated notable interval healing ultimately resulting in complete regeneration of the skin, providing full coverage of the wound and no functional deficits without surgical intervention or skin grafting. Key words: acquired hemophilia, hand, Integra, skin, wound

Background: Virtual-assisted lung mapping (VAL-MAP) is a preoperative multi-spot bronchoscopic dye-marking technique. Marking failure reportedly occurs in approximately 10% of marks. The aim of the present study was to investigate whether the patient position during dye injection in VAL-MAP affected the quality of markings. Methods: This study was a retrospective review of patients with barely palpable pulmonary nodules who underwent VAL-MAP at a single institution between December 2016 and September 2017. Easily visible markings without bulla formation were defined as “appropriate”, while other markings were defined as “inappropriate”. Patients were divided in accordance with the position during dye injection into the supine position group (n=6) and the lateral position group (n=8). The two groups were compared regarding the appropriate markings rate. The Fisher exact test and logistic regression model were used for statistical analyses. Results: Fourteen patients with 17 nodules underwent VAL-MAP with a total of 48 markings (3.4±0.9 markings per patient). Of these, 21 markings were performed in supine position, whereas 27 were performed in lateral position. There were no significant differences between the two groups in lesion size, depth, and characteristics. Almost all of the performed procedures were thoracoscopic wedge resections (94%), while one procedure was thoracoscopic left upper division segmentectomy. The appropriate markings rate was significantly greater in the lateral position group than in the supine position group (88% vs . 57%, P=0.02). Among the markings located in dorsal and ventral lung segments, the appropriate markings rate in the lateral position group tended to be greater than that in the supine position group (89% vs . 59%, P=0.06). Multivariate logistic regression analysis revealed that the lateral position was independently associated with appropriate markings (P=0.014). Conclusions: The lateral position may enable the creation of better quality markings in VAL-MAP.

Introduction Oral lesions are divided into non-neoplastic lesions, potentially malignant lesions and neoplastic lesions. More clinical data are needed to determine their helpful clinical pattern. Aim To present the epidemiological, clinical and histopathological characteristics of the oral lesions. Material and methods The retrospective study group comprised records of 208 patients which were reviewed according to selected epidemiological and clinical features. All the biopsy specimens were classified into: reactive lesions, precancerous lesions/potentially malignant lesions, salivary gland pathologies, benign and malignant tumours. Results The lower lip was the most common site involved followed by buccal and vestibular mucosa. The most frequent diagnoses were fibroma, mucocele and papilloma. The predominant pathomorphological forms were nodule and bulla. The most frequent salivary gland pathology was mucocele. Fibroma was the most frequent pathomorphological diagnosis, followed by mucocele and reactive lesions such as irritation fibroma (IF) and granuloma. Conclusions In cases of oral mucosal lesions, we propose the following algorithm: the exclusion of all odontogenic and iatrogenic causes; the detection and elimination of harmful habits, parafunctions and irritants from the oral cavity especially from the vestibule of the oral cavity and from the lips; all surgical treatment should be performed only after the proper detection and elimination of causative factors to decrease the risk of recurrence; excisional biopsy or in more diffuse lesions incisional biopsy is recommended to confirm clinical diagnosis; and consideration of other factors that can modify the clinical pattern of oral lesions, such as oral hygiene, systemic diseases, and drugs.

Introduction: Bullous lung lesions from Corona Virus Disease 2019 (COVID-19) pneumonia-causing pneumothorax is a rare complication, affecting up to 1% of infected patients. Raoultella Planticola is an aerobic, gram-negative rod-shaped bacterium known to cause opportunistic infection. Only three cases of R. Planticola pneumonia reported in the United States until 2017. We present a rare case of spontaneous pneumothorax from rupture of lung bulla as a late sequela from COVID-19 pneumonia and superinfection of the bulla by R. Planticola. Case: A 37-year-old man presented to the emergency department (ED) with a sudden onset of sharp right-sided chest pain and shortness of breath after an episode of dry cough. One month before the presentation, he was tested positive for COVID-19, with the only symptom being dry cough, without hospitalization or treatment. He works in construction, never smoked. On arrival, he was in respiratory distress with tachypnea. Chest radiograph revealed subcutaneous emphysema and right-sided pneumothorax with large bleb at the right mid lung field. An emergent pigtail catheter tube was placed with the resolution of pneumothorax. Polymerase chain reaction (PCR) from nasopharyngeal swab detected infection by COVID-19. Serologic workup revealed leukocytosis and elevated erythrocyte sedimentation rate: 34 mm/hr. Computed tomography (CT) showed (Image) large right-sided bulla, bilateral patchy infiltrates. Sputum analysis was negative for bacteria, fungi, and mycobacterium tuberculosis. Further workup was negative for eosinophilia, aspergillus, autoimmune diseases, and HIV. His symptoms and leukocytosis improved without needing antibiotics or steroids. Later the chest tube was removed and was discharged. Post-discharge follow-up in the pulmonary clinic, he complained of hemoptysis and was referred to the ED. Repeat CT revealed patchy ground-glass opacities, new bullae in the left lung, and resolving right lung bulla with fluid and debris in the dependent portion, which led to suspect pneumonia and bullous infection. Sputum culture grew R. Planticola, resistant to ampicillin;he was started on amoxicillin-clavulanic acid with improvement in symptoms and was subsequently discharged. A repeat follow-up CT after a month showed resolution of bullae with scarring. Discussion: Bullous lung lesions in COVID-19 pneumonia were reported in the literature irrespective of mechanical ventilation status. Although superinfection of bullous lesions is known, this is the first reported case of R. Planticola pneumonia in a patient with COVID-19 lung bullae. COVID-19 patients are at heightened risk for bullous lung lesions and superinfection by opportunistic organisms;thus, they should be followed-up closely.

OBJECTIVES: Earlier diagnosis and the best management of virus-related, drug-related or mixed severe potentially life-threatening mucocutaneous reactions of COVID-19 patients are of great concern. These patients, especially hospitalised cases, are usually in a complicated situation (because of multi-organ failures), which makes their management more challenging. In such consultant cases, achieving by the definite beneficial management strategies that therapeutically address all concurrent comorbidities are really hard to reach or even frequently impossible. METHODS: According to the lack of any relevant systematic review, we thoroughly searched the databases until 5 October 2020 and finally found 57 articles including 93 patients. It is needed to know clinical presentations of these severe skin eruptions, signs and symptoms of COVID in these patients, time of skin rash appearance, classifying drug-related or virus-related skin lesions, classifying the type of skin rash, patients' outcome and concurrent both COVID-19 therapy and skin rash treatment. RESULT: Severe and potential life-threatening mucocutaneous dermatologic manifestations of COVID-19 usually may be divided into three major categories: virus-associated, drug-associated, and those with uncertainty about the exact origin. Angioedema, vascular lesions, toxic shock syndrome, erythroderma, DRESS, haemorrhagic bulla, AGEP, EM, SJS and TEN, generalised pustular figurate erythema were the main entities found as severe dermatologic reactions in all categories. CONCLUSION: We can conclude vascular injuries may be the most common cause of severe dermatologic manifestations of COVID-19, which is concordant with many proposed hypercoagulation tendencies and systemic inflammatory response syndrome as one of the most important pathomechanisms of COVID-19 so the skin may show these features in various presentations and degrees.

Background: Toxic epidermal necrolysis (TEN) is a rare life-threatening disease that mainly affects the skin and mucous membranes, resulting from a toxic delayed-type hypersensitivity (DTH) reaction (type IV reaction) to the presence of foreign antigens such as drugs. The clinical symptoms are caused by pathophysiological processes leading to massive apoptosis of keratinocytes in the dermo-epidermal junction. This results in the formation of a bulla and subsequent separation of the entire epidermis with the exposure of the dermis. The current approach in the local therapy of TEN prefers the use of biological dressings, which helps provide several critical requirements for defect healing; in particular, it helps in the acceleration of the spontaneous wound closure (re-epithelialization) of the skin defect and the reduction of the risk of development of various complications and infections, such as the risk of pathological scar maturation. This paper is a case report of the use of a lyophilized amniotic membrane (AM) for accelerating wound healing in a patient with TEN.Case Presentation: We report a case of an 8-year-old girl transferred to our center with a histologically confirmed diagnosis of TEN. Despite the application of immunosuppressive therapy consisting of corticosteroids and intravenous immunoglobulins, we have observed disease progression and exfoliation of up to 60% of the total body surface area (TBSA). In the facial area, which is cosmetically privileged, we decided to use the lyophilized amniotic membrane (Amnioderm®) to cover up approximately 2% of the TBSA. Within 2 days after the application, we observed accelerated reepithelialisation, with rapid wound closure. We have not observed any side effects nor infections during the subsequent phases of wound healing. Skin defects in non-facial areas of the body were treated with synthetic dressings. When compared to the areas covered with the lyophilized AM, the healing process was prolonged.Conclusions: To our knowledge, this is the first case study using a lyophilized amniotic membrane in the treatment of a patient with TEN. The AM application in the cosmetically-privileged area (face), proved to be very efficient in the treatment of TEN patients. The use of this allogeneic material demonstrated excellent biocompatibility and caused a unique acceleration of epithelialization and wound healing, yielding also excellent long-term results. The current study opens broad possibilities for clinical application of the used material, the improvement of current therapy of patients with TEN and better outcomes and recovery of patients.

Mycobacterium avium complex (MAC)‐infected lung bulla was a rare type of pulmonary non‐tuberculous mycobacterial (NTM) infection. A 29‐year‐old man with a history of tetralogy of Fallot was admitted to our hospital because of a high fever and left chest pain. Chest computed tomography showed two bullae with intrabullous fluid in both the lower lobes and centrilobular small nodular shadow in the right upper lobe and the left lower lobe. Culture of bronchoscopic washing specimen from the right upper lobe bronchus and left lower lobe one and purulent fluid drained from the bulla in the left lower lobe revealed Mycobacterium intracellulare. Percutaneous drainage from the left bulla and anti‐NTM treatment were performed. Afterwards, symptoms improved and two intrabullous fluid disappeared. Therefore, a diagnosis of multiple infected lung bullae associated with M. intracellulare was made. This is the first documented case of multiple infected lung bullae associated with MAC., Here, we report the first documented case of multiple infected lung bullae associated with Mycobacterium avium complex (MAC) in a 29‐year‐old man.

Spontaneous hemopneumothorax is a rare encountered entity in clinical practice. It can be life threatening, so a prompt diagnosis and therapeutic intervention are required. We report a case of a right spontaneous hemopneumothorax in a 31-year-old man, complicated with hemorrhagic shock. Conservative therapy with only thoracic drainage with close monitoring of outflow and hemodynamic parameters was performed. In front of hemodynamic instability, an emergency video-assisted thoracoscopic surgery was performed. An apical bulla adhering to the parietal pleura has been identified as the source of the bleeding. The resection of the bullae and electrocauterization of the bleeding adhesion were effectuated. The hemostasis was easily achieved. The actual experience suggests that video-assisted thoracoscopic surgery should be performed as soon as possible after the diagnosis of spontaneous hemopneumothorax. Indeed, conservative therapy with chest drainage should only be performed as bridge to recovery for the stabilization before the video-assisted thoracoscopic surgery.

Herniation of bulla across mediastinum is rare, while transmediastinal giant bulla herniation accompanied with hydropneumothorax is even rarer. We report a case of an 18 years old male with dyspnea came to emergency department with trans-mediastinal giant bulla herniation, which appears as semilunar sign on chest x-ray, and righthydropneumothoraks. It appeared that the giant bulla also infected by the presence of air fluid level within. Semilunar sign was seen on the contralateral left mediastinum as the hallmark finding for trans-mediastinal herniation of bulla. Chest CT further confirms the diagnosis. Subsequently chest tube insertion and symptomatic relives were given, however the patient end up dead after 2 days of observation. Heart and lung compression by the lesions were the cause of this patient poor outcome. Bullous lung disease should be evaluated thoroughly and not underestimated since it could cause severe disease progression.

Pemphigus vulgaris (PV) is an autoimmune blister disease which is a common type of pemphigus. It affects the oral mucosa and skin area. PV blister looks the same as the other blister disease. Thus, diagnosis of PV disease is difficult because of the fact that only one characteristic is identifying the PV blister that is Nikolsky’s sign (bulla spread sign). Ruptures of the blisters make erosion on the surface of the skin area. The clinical diagnosis of PV is more painful. Therefore, selecting an area of relevant diagnosis through image processing is important not just for dermatologists but for non-expert person as well. The proposed work is an attempt to provide a solution for the detection of PV in the developmental stages of skin erosion. We developed a systematic and effective framework for identifying PV from relevant information, image data, and the description. Our system works in two sections, the first is interrogation about symptoms and the second to detect blister images. The accuracy rate of the system to successfully detect PV blister is 88.67%.

Tuberculosis (TB)-infected giant bullae are rare. A 55-year-old man was referred when an infected bulla did not respond to empirical treatment. Computed tomography showed a giant bulla in the right upper lobe with an air-fluid level and surrounding infiltrate. Sputum culture, acid-fast bacilli (AFB) stain, and polymerase chain reaction (PCR) for TB were negative. Percutaneous drainage of the bullous fluid was performed. AFB stain and PCR were positive in the drained fluid. The patient was given anti-TB drugs and later underwent obliteration of the pulmonary cavity using talc. To summarize, we report a patient with a TB-infected giant bulla that was treated successfully with anti-TB drugs and obliteration of the pulmonary cavity using talc.

The combination of extracorporeal membrane oxygenation with lung‐protective ventilation strategies could be a potential treatment option for intractable pneumothorax with coronavirus disease 2019 (COVID‐19) to avoid unnecessary surgical procedures and aerosol generation., Background Some patients with coronavirus disease 2019 (COVID‐19) develop pneumothorax. Tube thoracotomy and bulla resection could generate aerosols and cause virus transmission; the optimal treatment strategy remains unclear. Case Presentation A 57‐year‐old male was transferred as a severe COVID‐19 pneumonia case. On the 16th day after admission, the patient’s respiratory condition deteriorated, and the chest X‐ray revealed the presence of severe right‐sided pneumothorax. A chest drain was immediately inserted; however, a significant air leak continued, and severe ventilator settings were required. Thus, veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) treatment was initiated to allow the lungs to rest. After 10 days of lung‐protective ventilation, the patient was weaned from ECMO and the chest drain was removed on the following day with no major comorbidities. Conclusion The combination of ECMO with lung rest strategy could be a treatment option for intractable pneumothorax with COVID‐19 to avoid unnecessary surgical procedures and aerosol generation.

Background: Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet. Materials: This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis. Results: A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant. Conclusions: The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.

A 36-year-old-woman, smoker, without other relevant medical history, presented with symptoms of dyspnea, right localized chest pain, and non-productive cough. On the emergency department, the chest X-ray was interpreted as a giant right pneumothorax and a chest drain was inserted. Thoracic computed tomography demonstrated a giant emphysematous bulla with 23 cm on her right upper lobe. We report the first uniportal video-assisted thoracic surgery bullectomy for a bulla greater than 20 cm, in a patient with vanishing lung syndrome.

A nine-year-old male European shorthair cat was referred to our practice with severe head trauma after suffering a road traffic accident (RTA). The patient presented marked facial swelling and multiple skin wounds and bruising, inspiratory dyspnea, palpable mandibular and maxillary fractures, serosanguinolent oronasal discharge and right eye exophthalmos and buphthalmos with loss of menace and pupillary reflex. After stabilizing the patient, a CT scan was performed under general anesthesia and an oesophagostomy tube was placed. The scan revealed the presence of multiple right tympanic bulla fractures. Multiple mandibular, maxillary, and palatine fractures were also present. The cat underwent surgery. Mandibular symphyseal separation and maxillary fractures were stabilized using intraoral cerclage wire fixation reinforced with composite and the right eye was enucleated. The rest of the fractures were treated conservatively. A CT scan 4 months after the trauma was also performed. At this point, the maxillofacial fractures were healing properly, and a bone callus demonstrating fusion of fragments of the right tympanic bulla was evident. There was absence of abnormal content inside the right tympanic bulla. The patient recovered uneventfully with no neurological deficits. To the author''s knowledge this is the first case reporting a traumatic tympanic bulla fracture in the cat with case follow up, and the first case reported using CT as diagnostic imaging test.

BACKGROUND: Thin-walled lung cancer manifests as a cystic lesion, mostly adenocarcinoma. It is often misdiagnosed as a benign lesion in clinical practice, thus delaying the diagnosis and surgical treatment. Its natural course is rarely recorded and observed; thus, the pathogenesis and diagnosis need to be clarified and improved. CASE SUMMARY: A 66-year-old man developed a mass in the upper lobe of the right lung and a small, thin-walled cavity in the lower lobe of the right lung in 2007. The right upper lobe mass was confirmed to be adenocarcinoma after surgery. The cavity diameter increased from 11 mm to 31 mm over 10 years, and a ground glass opacity lesion appeared around the bulla on computed tomography. A second operation confirmed that the lesion was lepidic predominant adenocarcinoma. Here we report a rare case of lung cancer developing from a focal bulla to a thin-walled adenocarcinoma for more than 10 years and confirm that the check-valve mechanism explains the pathogenesis. CONCLUSION: Solitary thin-walled lung adenocarcinoma is a rare tumor in terms of its clinical manifestations, pathogenesis, and disease progression. The check-valve mechanism can explain the cause of thin-walled lung cancer. Close follow-up and accurate imaging are necessary.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is considered an acceptable treatment for recurrent primary spontaneous pneumothorax (PSP). However, recent reports have described a high postoperative recurrence rate in young patients with PSP. We hypothesized that ineffective VATS may have been performed for these patients (aged