Search

Disseminated histoplasmosis can occur in immunocompromised patients such as in HIV disease and patients with medication-induced immunosuppression. Most of these patients present with fever, weight loss, hepatosplenomegaly, lymphadenopathy, and pancytopenia. There are increasing reports of coronavirus disease 2019 (COVID-19) pneumonia associated with fungal infections including aspergillus and mucormycosis. It is not typical for immunocompetent patients to present with disseminated fungal disease. We herein report a case of a 50-year-old immunocompetent male with a recent recovery from COVID-19 pneumonia who presented with fever and pancytopenia. Chest computed tomography (CT) demonstrated new-onset right upper lobe lung mass, subcarinal lymphadenopathy, and splenomegaly. Mediastinal lymph nodes and bone marrow biopsies were performed, and the patient was diagnosed with disseminated histoplasmosis. The association between COVID-19 pneumonia and fungal infections is increasingly reported. Diagnosis requires a high index of suspicion, especially in immunocompetent patients.

Rationale: Usual interstitial pneumonia (UIP) is the defining morphology of idiopathic pulmonary fibrosis (IPF). Guidelines for IPF diagnosis conditionally recommend surgical lung biopsy for histopathology diagnosis of UIP when radiology and clinical context are not definitive. A "molecular diagnosis of UIP" in transbronchial lung biopsy, the Envisia Genomic Classifier, accurately predicted histopathologic UIP.Objectives: We evaluated the combined accuracy of the Envisia Genomic Classifier and local radiology in the detection of UIP pattern.Methods: Ninety-six patients who had diagnostic lung pathology as well as a transbronchial lung biopsy for molecular testing with Envisia Genomic Classifier were included in this analysis. The classifier results were scored against reference pathology. UIP identified on high-resolution computed tomography (HRCT) as documented by features in local radiologists' reports was compared with histopathology.Measurements and Main Results: In 96 patients, the Envisia Classifier achieved a specificity of 92.1% (confidence interval [CI],78.6-98.3%) and a sensitivity of 60.3% (CI, 46.6-73.0%) for histology-proven UIP pattern. Local radiologists identified UIP in 18 of 53 patients with UIP histopathology, with a sensitivity of 34.0% (CI, 21.5-48.3%) and a specificity of 96.9% (CI, 83.8-100%). In conjunction with HRCT patterns of UIP, the Envisia Classifier results identified 24 additional patients with UIP (sensitivity 79.2%; specificity 90.6%).Conclusions: In 96 patients with suspected interstitial lung disease, the Envisia Genomic Classifier identified UIP regardless of HRCT pattern. These results suggest that recognition of a UIP pattern by the Envisia Genomic Classifier combined with HRCT and clinical factors in a multidisciplinary discussion may assist clinicians in making an interstitial lung disease (especially IPF) diagnosis without the need for a surgical lung biopsy.

Rationale: Bronchoscopic lung volume reduction with Zephyr Valves improves lung function, exercise tolerance, and quality of life of patients with hyperinflated emphysema and little to no collateral ventilation. Objectives: Post hoc analysis of patient-reported outcomes (PROs), including multidimensional measures of dyspnea, activity, and quality of life, in the LIBERATE (Lung Function Improvement after Bronchoscopic Lung Volume Reduction with Pulmonx Endobronchial Valves used in Treatment of Emphysema) study are reported. Methods: A total of 190 patients with severe heterogeneous emphysema and little to no collateral ventilation in the target lobe were randomized 2:1 to the Zephyr Valve or standard of care. Changes in PROs at 12 months in the two groups were compared: dyspnea with the Transitional Dyspnea Index (TDI), focal score; the Chronic Obstructive Pulmonary Disease Assessment Test (CAT; breathlessness on hill/stairs); Borg; the EXAcerbations of Chronic pulmonary disease Tool–PRO, dyspnea domain; activity with the TDI, magnitude of task/effort/functional impairment, CAT (limited activities), and the St. George’s Respiratory Questionnaire (SGRQ), activity domain; and psychosocial status with the SGRQ, impacts domain, and CAT (confidence and energy). Results: At 12 months, patients using the Zephyr Valve achieved statistically significant and clinically meaningful improvements in the SGRQ; CAT; and the TDI, focal score, compared with standard of care. Improvements in the SGRQ were driven by the impacts and activity domains (P

Rationale: This is the first multicenter randomized controlled trial to evaluate the effectiveness and safety of Zephyr Endobronchial Valve (EBV) in patients with little to no collateral ventilation out to 12 months.Objectives: To evaluate the effectiveness and safety of Zephyr EBV in heterogeneous emphysema with little to no collateral ventilation in the treated lobe.Methods: Subjects were enrolled with a 2:1 randomization (EBV/standard of care [SoC]) at 24 sites. Primary outcome at 12 months was the Delta EBV-SoC of subjects with a post-bronchodilator FEV1 improvement from baseline of greater than or equal to 15%. Secondary endpoints included absolute changes in post-bronchodilator FEV1, 6-minute-walk distance, and St. George's Respiratory Questionnaire scores.Measurements and Main Results: A total of 190 subjects (128 EBV and 62 SoC) were randomized. At 12 months, 47.7% EBV and 16.8% SoC subjects had a Delta FEV1 greater than or equal to 15% (P Conclusions: Zephyr EBV provides clinically meaningful benefits in lung function, exercise tolerance, dyspnea, and quality of life out to at least 12 months, with an acceptable safety profile in patients with little or no collateral ventilation in the target lobe.

Pleural effusions occur in 1.5 million patients yearly and are a common cause of dyspnea. For nonmalignant effusions, initial treatment is directed at the underlying cause, but when effusions become refractory to medical therapy, palliative options are limited. Tunneled pleural catheters (TPCs) are commonly used for palliation of malignant effusions, but many clinicians are reluctant to recommend these devices for palliation of nonmalignant effusions, citing concerns of infection, renal failure, electrolyte disturbances and protein-loss malnutrition. Based on the published experience to date, TPCs relieve dyspnea and can result in spontaneous pleurodesis in patients with nonmalignant effusions. The infection rate compares favorably to that for malignant effusions with possible increased risk in patients with hepatic hydrothorax and posttransplant patients. Renal failure, electrolyte disturbance and protein-loss malnutrition have not been observed. TPCs are a reasonable option in select patients to palliate nonmalignant effusions refractory to maximal medical therapy.

Radiation therapy has emerged as a useful alternative therapy for patients with early-stage, non-resectable lung cancer. In patients whose malignancies are difficult to localize on computed tomography imaging, such therapy becomes difficult. Fiducial markers are frequently placed in peripheral pulmonary lesions to assist radiation therapy. Although placement of markers under linear endobronchial ultrasonography within mediastinal and hilar lymph nodes has been reported, no strategy has been described to assist radiotherapy of purely endobronchial tumors. We present a case of bilateral, unresectable, radiographically occult endobronchial squamous cell carcinoma treated with radiotherapy guided by fiducial markers placed under linear endobronchial ultrasonographic guidance. The patient subsequently underwent intensity-modified radiation therapy to both lesions with pathologic complete response. Linear endobronchial ultrasound is a promising tool for placement of markers to guide radiation therapy of these difficult-to-treat lesions.

63-year-old man with an extensive smoking history presented with a complaint of persistent dry cough for 3 months. His past medical history was signifi cant for severe COPD with an FEV 1 at 40% predicted (stage III by GOLD [Global Initiative for Obstructive Lung Disease] criteria). The patient was retired and a current cigarette smoker, and he had no pets. There was no history of prior malignancy or recent travels. He had no fever, night sweats, or weight loss. He was not receiving any angiotensinconverting enzyme inhibitors. There were no symptoms suggestive of upper airway cough syndrome or gastroesophageal refl ux disease. Physical Examination Findings The patient was afebrile with stable vital signs. BP was 127/87 mm Hg, heart rate was 85 beats/min, and oxygen saturation was 94% on room air. A complete physical examination was remarkable for yellow nicotine stains on the fi ngernails without clubbing, wide subcostal angle, distant heart sounds, and prolonged expiratory phase bilaterally, with left-sided monophasic expiratory wheezing best heard over the left upper lobe. Diagnostic Studies CBC was normal, apart from a normocytic anemia, with hemoglobin level of 12 g/dL (normal, 14-18 g/dL). Complete metabolic panel results, includ ing electrolytes, renal, and liver function testing, were within normal limits. No acute abnormalities were detected on chest radiograph. Because of the presence of localized wheezing on physical examination, an endobronchial lesion was suspected, and a CT scan of the chest was obtained. The chest CT scan showed emphysematous changes with an upper lobe predom inance and an ovoid low-density endobronchial lesion in the distal left mainstem bronchus measuring 2.3 cm in maximum diameter ( Fig 1 ).

Glomus tumors are uncommon soft tissue tumors that usually occur in the hands or feet but rarely have been described to appear in the tracheobronchial tree. Tracheal glomus tumors present with symptoms including cough, dyspnea, and wheezing that may be mistaken for other pulmonary disorders. Imaging and pulmonary function testing can detect tracheal obstruction, but pathology is necessary to differentiate glomus tumors from other airway tumors. On pathology, glomus tumors are made up of glomus cells, blood vessels, and smooth muscle and are classified based on the predominant cell type. The differential for this tumor includes carcinoid tumors, paragangliomas, and hemangiomas, and immunohistochemical stains can be used to obtain the correct diagnosis. The most common modality for treatment of these tracheal tumors has been surgical resection. However, there have been reported cases of successful removal with rigid or flexible bronchoscopy. We present a case of a tracheal glomus tumor that was successfully resected using electrocautery snare during flexible bronchoscopy. Our case adds to the evidence that flexible bronchoscopy is a safe, less invasive approach to management of tracheal glomus tumors in select patients.

Rheumatoid arthritis (RA) is a systemic disease, characterized by symmetric joint involvement, but it can also affect other organ systems, including the lungs. The better-known pulmonary manifestations of RA are interstitial lung disease, rheumatoid nodules, and pleural effusions. Less common manifestations include bronchiolitis obliterans and crycoarytenoid arthritis. Management of these conditions involves, by and large, supportive pulmonary care and control of the underlying articular process. Other pulmonary manifestations in RA patients can ensue as a result of the treatments used for it, mainly methotrexate. This article discusses the most common pulmonary manifestations of RA and their treatment. A discussion about the increasing impact that cigarette smoking is having on RA is also provided.

Bronchial carcinoid tumours can present with symptoms of distal airway obstruction, local airway irritation or bleeding due to hypervascularity. Presentation with a spontaneous pneumothorax (SP) is rare. We present a case of typical endobronchial carcinoid tumour that presented with a SP. We explored the possible mechanisms of this rare presentation, especially the check-valve mechanism of airway obstruction, which was evident during the fiberoptic bronchoscopic examination.