Background: Lipoid pneumonia is a rare condition caused by the inflammation of lung tissue due to the accumulation of lipid substances from inhalation or aspiration. There are two main types: exogenous lipoid pneumonia, caused by the inhalation or aspiration of external sources like vegetable oil or mineral oil typically in industrial settings, and endogenous lipoid pneumonia, caused by internal factors such as airway obstruction, abnormal lipid metabolism or gastro-esophageal reflux disease. Both types present respiratory symptoms like chest pain, cough and shortness of breath. Prompt diagnosis is crucial for preventing complications and promoting 
lung healing. There are limited case reports on endogenous lipoid pneumonia. We present a case of a 72 year-old elderly patient with microscopic airway obstruction leading to endogenous lipoid pneumonia.
Case Presentation: A 72-year-old chronic smoker male presents with cough, sputum 
production and shortness of breath with no fevers, chills, rigors except for right sided pleuritic chest pain which is being treated for pneumonia with Augmentin and azithromycin along with prednisone for 6 months. CT scan of chest revealed a right upper lobe anterior segment newly discovered lung mass along with mediastinal adenopathy. The patient underwent bronchoscopy with biopsy of the lung mass which showed the combination of focal organizing pneumonia and prominent non-necrotizing granulomatous inflammation along with foamy macrophages, suggesting proximal airway obstruction also known as microscopic obstructive pneumonia.
Discussion: Endogenous lipoid pneumonia usually develops in association with bronchial obstruction from lung cancers, infection or lipid storage disease. In this case, the patient with endogenous disease didn't have any above mentioned conditions except for obstruction from granulomatous inflammation. And thus the microscopic proximal airway obstruction can lead to endogenous lipid accumulation causing pneumonia.

Endogenous lipoid pneumonia due to microscopic airway obstruction: A 
diagnostic dilemma

Background: Mental illnesses following an ICU stay are prevalent among patients and can be triggered by physical and emotional stress associated with critical illness, compounded by invasive procedures and sedatives administered in the ICU setting. Despite their frequency, these conditions are often not recognized or addressed in the ICU setting. However, in recent years, the mental health outcomes of patients who have survived an ICU stay have been a growing concern, and evolving methodologies are on the ascent particularly in European countries. The goal of this study is to assess the efficacy of existing methods for prevention of post-ICU mental health disorders and to analyze advancing techniques implemented in other countries.
Methods: This study employed a systematic literature review utilizing PubMed, EMBASE, and Wiley online databases to investigate the mental health outcomes linked to ICU experiences and the efficacy of current methods of prevention.
Results: Mental health conditions are frequently observed in patients following an ICU stay, with anxiety occurring in 12% to 43%, depression in 10% to 30%, and PTSD in 64% of patients. Current preliminary approaches to prevention include ICU journals, psychological counseling, and follow-up care in outpatient settings. The aforementioned strategies have shown varying statistical efficacy in terms of reducing the incidence of new onset mental health disorders. A systematic review on the impact of ICU diaries reported that four of five randomized trials showed a significantly reduced rate of new onset PTSD after 3 months with the use of ICU diaries. In addition, a meta-analysis of studies on psychological interventions, such as counseling, found that these interventions can significantly reduce symptoms of anxiety and depression. Furthermore, one study found that follow-up consultations may reduce the symptoms of PTSD after ICU admission, although they did not significantly improve other factors such as quality of life, anxiety, or depression.
Conclusion: Patients that survive an ICU stay are at a significant risk for developing a mental illness following their discharge. While the aforementioned studies provide evidence for the efficacy of these approaches, further research is needed to determine the most effective strategies for preventing new-onset mental health diagnoses in patients after ICU stay, with the ultimate objective of establishing proper guidelines to better navigate this issue. By prioritizing mental health in the ICU setting and providing appropriate resources to address these conditions, we can improve outcomes for patients and support their overall well-being beyond the acute care setting.

Preventing New Onset Mental Health Diagnoses After ICU Stay: Current and Emerging Approaches

Background: Point-of-Care-Ultrasound (POCUS) has become an increasingly useful tool in modern medical practice. These non-invasive diagnostic instruments can be used to quickly assess many pathologies, including pleural effusion. In particular, there are several equations described in the literature that aim to estimate pleural effusion volumes using lung ultrasound (US) imaging. Among these described equations, we seek to determine the accuracy of these formulas with consideration of their practicality in clinical use. 
Methods: To assess this, a search was conducted using PubMed in which fourteen articles were found. We included articles that attempted to answer the question regarding volume estimation using POCUS within the last 20 years. Within these articles, ten different formulas were identified which were defined and described in relation to the patient’s position, the probe orientation, and the distance between the thoracic wall and lung or lung to the diaphragm. Our exclusion criteria were based on the age of the article, availability of free publications, review of the articles’ abstracts, determining their relevance to fluid volume estimation, and their use of lung ultrasound for pleural effusions. 
Results: Upon review, we determined that the pleural effusion estimated volume (EV) using the Goeke and Schwerck 2 formula (EV= (H + D) x 70, where H is the craniocaudal extent of the effusion at the dorsolateral chest wall and D is the distance from lung base to the apex of diaphragm cupola) in erect patients yielded the most accurate results. The most accurate simplified formula, requiring only one variable measurement in erect patients, proved to be the Hassan formula (EV = H x 100). With consideration of practicality in the Point-of-Care setting and patient’s performance status, we determined that the Balik formula (EV = C x 20, where C is the maximum perpendicular distance between the pulmonary surface and the chest wall) and Usta formula (EV=D×16, where D=distance from lung base to the apex of the diaphragm cupola) provide a sensitive and practical approach for measuring pleural effusion volume in the supine position when compared with other equations, albeit sacrificing accuracy.
Conclusions: In patients with reduced performance status and inability to be placed in the erect position, the Balik and Usta formulas provide a sensitive and practical approach for measuring pleural effusion volume when compared with the gold standard left lateral decubitus chest X-ray. In addition, our investigations noted that the most accurate equation used as an estimation tool for pleural effusion volume across multiple studies proved to be the Goecke and Schwerck 2 formula in erect patients. The most accurate simplified formula proved to be the Hassan formula, sacrificing some accuracy for practicality. With this in mind, providers should note the patient’s positioning (supine vs. erect) when performing a POCUS examination to decide which formula is best to use. POCUS offers a practical way to measure pleural effusion volume that facilitates timely care, supports and considers the patient’s performance status, and reduces both patient and hospital costs.


Pleural Effusion Volume Estimation Using Handheld Lung Ultrasound

Idiopathic Pulmonary Fibrosis (IPF) is a spontaneously occurring, progressive, fibrosing disease of the lung, most commonly identified in adults 50 years of age and older.[1] Diagnosis may be made via high-resolution CT (HRCT) when a Usual Interstitial Pneumonia (UIP) pattern is present; however, if the diagnosis remains questionable, surgical lung biopsy (SLB) is often pursued.[2]

We present the case of a 39-year-old African-American male with a medical history of bronchiectasis accompanied by chronic, productive cough and social history including ongoing tobacco use and prior shipyard employment. He presented with two weeks of progressive exertional dyspnea, increased sputum production, and fever. 

Examination revealed tachycardia, bilateral inspiratory rales and digital clubbing. Progression of baseline bilateral interstitial opacities was noted on chest x-ray, and HRCT revealed diffuse interstitial thickening and ground-glass opacities with basilar predominance, and diffuse bronchiectasis. Evaluation for alpha-1 antitrypsin deficiency, cystic fibrosis mutations, celiac disease, autoimmune serologies, and immunoglobulin deficiency were unremarkable. Bronchoalveolar lavage analysis demonstrated neutrophil predominance with negative microbiologic testing. He ultimately underwent SLB of the right upper and lower lobes demonstrating diffuse alveolar damage superimposed on patchy collagen fibrosis with associated architectural distortion in the form of honeycomb changes consistent with UIP. Per the 2019 IPF guidelines, he was diagnosed with IPF and given an “IPF Likely” grade.[2]

IPF is thought to develop from repetitive micro-injury to chronically dysregulated alveolar epithelium, though the exact etiology remains undetermined. Our patient’s tobacco history or occupational exposures may have been the nexus for his interstitial lung damage[1] 

UIP is the radiologic/histopathologic hallmark of IPF, demonstrating reticular fibrosis and subpleural honeycombing with basilar predominance. Bronchiectasis in IPF is the result of fibrosis applying traction to the airways with diffuse bronchiectasis being uncommon.[2,3] Conversely, our case demonstrates a diffuse bronchiectatic process that preceded significant fibrotic changes of IPF. Whether the development of IPF is attributable to recurrent injury from exacerbations of idiopathic bronchiectasis, or this patient’s bronchiectasis was an unappreciated indicator of an underlying, progressive ILD is difficult to ascertain.

This case raises questions about the potential benefit of periodic imaging in bronchiectasis patients. Society guidelines only recommend it at time of diagnosis and clinical deterioration.[2,4] We argue that periodic imaging should be tailored to bronchiectasis etiology, as otherwise unexplained disease may be an indicator of risk for ILD development.

We encourage physicians to be mindful that patients with bronchiectasis may be at risk for IPF development.

1. Richeldi L, Collard HR, Jones MG. Idiopathic pulmonary fibrosis. Lancet. 2017;389(10082):1941-1952. doi:10.1016/S0140-6736(17)30866-8
2. Raghu G, Remy-Jardin M, Richeldi L, et al. Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2022;205(9):E18-E47. doi:10.1164/rccm.202202-0399ST
3. Piciucchi S, Tomassetti S, Ravaglia C, et al. From “ traction bronchiectasis ” to honeycombing in idiopathic pulmonary fibrosis : A spectrum of bronchiolar remodeling also in radiology ? BMC Pulm Med. Published online 2016:1-4. doi:10.1186/s12890-016-0245-x
4. Lynch DA, Sverzellati N, Travis WD, et al. Diagnostic criteria for idiopathic pulmonary fibrosis: a Fleischner Society White Paper. Lancet Respir Med. 2018;6(2):138-153. doi:10.1016/S2213-2600(17)30433-2

Which Came First: Bronchiectasis or IPF?

Background

Adenocarcinoma of the lung has shown an increasing incidence, but Pulmonary mucinous adenocarcinoma, a variant of invasive adenocarcinoma, remains a rare entity with non-specific clinical manifestations. Invasive mucinous adenocarcinoma (IMA) accounts for 5 % of pulmonary adenocarcinoma. IMA exhibits distinct characteristics, including invasive patterns characterized by either columnar or goblet cells. Because of its unique clinical characteristics, such as its peripheral location and a high incidence of multifocal, multi-lobular, and bilateral presence, it has been recognized as a distinct entity. 

Case Presentation

A 69-year-old male patient with a known history of interstitial lung disease presented with a gradual onset chronic nonproductive cough with exercise intolerance on exertion, which significantly worsened over the past six months. Two bronchoscopies with transbronchial biopsy and bronchoalveolar lavage in the past year failed to give any diagnosis. A recent scan, one month ago revealed worsening of bilateral infiltrates on CT from the previous scans; along with interstitial thickening, mosaic attenuation, and a new cavitary lung lesion with a left lobe atelectatis, and necrotic lung tissue. Cell count at that time did not show eosinophilia. The patient had no exposure to asbestos, chemicals, fumes, dust, silica, or mold nor weight loss. Antinuclear antibody and Antineutrophilic-cytoplasmic-antibody were negative. Due to travel history to southeast Asia and South America, workup for Mycobacterium Tuberculosis , Histoplasma , Blastomyces , and Aspergillus was done which came negative. A wedge biopsy of the left lung revealed involvement morphologically similar to adenocarcinoma with mucinous features which were characterized by atypical mucinous tumor cells. These findings can be found in IMA However, the adenocarcinoma had atypical features and presented as a diffuse and multifocal distribution, which is uncommon for this type of tumor. 

Discussion
Common symptoms observed in individuals with IMA include nonspecific manifestations such as sputum production, cough, shortness of breath, and fever but our patient presented with a chronic nonproductive cough and dyspnea on exertion, without other symptoms. Diffuse, right upper lobe involvement was present instead of the typical peripheral lower lobe, predominance in IMA. Surgical lung biopsy and CT-guided percutaneous lung biopsy have been known to achieve a diagnostic yield of 100%. However, it is worth noting that biopsied specimens obtained through this approach may primarily consist of acellular mucin pools. A multidisciplinary approach should be adopted to address respiratory symptoms, facilitate the use of anticancer drugs, and extend patient survival while carefully weighing the risks and benefits of surgery.

Hidden in Plain Sight: A Unique Presentation of Lung Adenocarcinoma

Background
Hypertonic saline is a mainstay treatment of cerebral edema in neurological emergencies. The risk of acute kidney injury (AKI) with use of balanced versus unbalanced hypertonic saline solutions is equivocal across studies. Hypertonic sodium acetate (NaOAc) instead of hypertonic sodium chloride (NaCl) has been used as an alternative to prevent renal injury, with little evidence supporting this. We evaluated patients receiving either NaCl or NAOAc to evaluate the risk of development of AKI.

Methods
We performed a retrospective analysis of patients admitted to our neuroscience ICU from June 2013 to February 2023 who have received continuous intravenous infusions of either NaCl or NaOAc at either 2% or 3% concentration for therapeutic hypernatremia. We excluded patients receiving renal replacement therapy, patients who expired within 24 hours of administration of hypertonic saline, and those receiving treatment for hyponatremia. Renal injury was based of KDIGO criteria (elevation in serum creatinine greater than 0.3 mg/dL within 48 hours of starting intravenous infusion).

Results
Out of 1133 patients who received hypertonic saline, 880 met study inclusion criteria, with 812 patients receiving NaCl and 68 patients receiving NaOAc. Of these patients, 30.4% had acute ischemic strokes, 29.7% had intracerebral hemorrhages, 15.0% had subarachnoid hemorrhages, and 24.9% had other intracranial pathologies. 399 (38.5%) of the patients were female. 79 patients (9.7%) receiving sodium chloride developed AKI, while 11 patients (16.2%) receiving sodium acetate developed an AKI (X2 = 2.8408, p = 0.092) within 48 hours of initiation of intravenous therapy. 

Conclusion
Contrary to some reported observations, we found no statistical difference in the development of AKI as defined by KDIGO criteria in patients treated with NaCl versus NaOAc. Our study is limited by a small subset of patients receiving NaOAc. A larger cohort is needed to establish the protective effect of balanced hypertonic saline on AKI.

Effects of Balanced Versus Unbalanced Hypertonic Saline on Renal Function in Neurocritical Care

Background: Pulmonary nodules pose a significant diagnostic challenge in clinical practice. These small, often asymptomatic lesions can be benign or malignant, necessitating accurate localization and sampling for appropriate management decisions. Traditional bronchoscopic procedures have limitations in reaching peripheral lung nodules, particularly in challenging locations. Shape-sensing robotic-assisted bronchoscopy, utilizing the IonTM Endoluminal System, has emerged as a potential breakthrough in the field of pulmonary nodule management. This cutting-edge technology combines advanced imaging, robotic control, and shape-sensing capabilities to enhance the precision and efficacy of bronchoscopic procedures. By providing real-time 3D mapping and navigation guidance, it allows physicians to accurately locate and biopsy pulmonary nodules, even in challenging anatomical regions.
However, despite its promising potential, there is still a knowledge gap regarding the experience and outcomes of using shape-sensing robotic-assisted bronchoscopy for pulmonary nodules. This study aims to bridge this gap by investigating the real-world experiences and outcomes of this innovative technology as a solution for accurate pulmonary nodule management.
Methods: A retrospective analysis was conducted using NVivo software at Chandler Regional Medical Center. The analysis focused on patients who underwent shape-sensing robotic-assisted bronchoscopy for pulmonary nodules. Patient demographics, nodule characteristics, procedural details, diagnostic yield, complications, and overall effectiveness were assessed using NVivo.
Results: A total of 9 patients (5 males, 4 females) with suspected lung nodules were included in this NVivo retrospective analysis. The mean age of the patients was 71.3 years (range: 60-77). The commonly involved lobes were the left upper and lower lobes, and the right upper and middle lobes. The sizes of the nodules ranged from 0.3 cm to 3.2 cm. Needle and forceps biopsies were the most common techniques used for tissue sampling, followed by bronchoalveolar lavage (BAL). Positive findings included malignancy (adenocarcinoma), hamartoma, inflammation, infection, and cellular abnormalities. Negative findings indicated the absence of carcinoma, granulomas, malignancy, fungal organisms, and acid-fast bacteria. One rare case of Mantle cell lymphoma, presenting as a cavitary lesion in the lung, was also diagnosed.
Complications were observed in 2 cases, including small pneumothorax, which were appropriately managed. The analysis also revealed gender differences in complications, with females experiencing pneumothorax and minimal bleeding, while males only suffered minimal bleeding.
Conclusion: This study unveils the transformative potential of shape-sensing robotic-assisted bronchoscopy to enhance diagnostic accuracy and reduce complications. This cutting-edge approach
revolutionizes medical practice, empowering physicians with precise tools while minimizing interventions.

Unleashing Precision: Shape-Sensing Robotic-Assisted Bronchoscopy for Pulmonary Nodules

Background
Alpha-1 Antitrypsin Deficiency (AATD) is an underrecognized genetic condition affecting an estimated 1 in 2,000 to 1 in 5,000 individuals worldwide, with approximately 70,000 to 100,000 cases reported in the United States. Alpha-1 Antitrypsin (AAT) plays a crucial role in protecting the lungs by inhibiting the activity of neutrophil elastase (NE), but in cases of AAT deficiency, uncontrolled NE activity can lead to lung damage through quantum proteolysis. Recurrent spontaneous pneumothorax is a significant complication observed in patients with underlying lung diseases like AATD and chronic obstructive pulmonary disease (COPD). The association between AATD and spontaneous pneumothorax remains relatively unexplored, presenting unique challenges in managing recurrent pneumothorax in these patients. This case report aims to provide valuable insights into the clinical features, diagnostic workup, and therapeutic interventions and associated challenges in managing a patient with recurrent spontaneous
pneumothorax in the context of AATD and COPD, with the objective of offering diagnostic and therapeutic considerations for similar cases.

Case Presentation
61 yo M with A1AT deficiency with severe bullous disease, no known cirrhosis, OSA intolerant of CPAP, hx of recurrent Lt pneumothorax and associated COPD presented with dyspnea. Examination revealed absent lung sounds on the left side. Oxygen support was initiated, and a chest x-ray confirmed left-sided pneumothorax. The patient underwent a successful left-sided pigtail catheter placement procedure to relieve the pneumothorax. This was his fourth episode of Secondary Spontaneous Pneumothorax. Two episodes occurred when he was younger, and the most recent two episodes required the implantation of a left chest tube. The very last episode
appeared on 5/2021. The patient's history of heavy smoking, substance abuse, and occupational asbestos exposure contributed to the severity of respiratory issues. Although his condition improved with pulmonary rehabilitation and medical therapy, the limitations of available interventions underscore the need for individualized approaches in complex cases. Lung volume reduction surgery and endobronchial valves were not viable due to extensive lung involvement and airway hyperdynamic collapse. The recommendation for lung transplantation aimed to enhance the quality of life and life expectancy. Pleurodesis emerged as a potential option if transplantation was not feasible. Further investigations were conducted for the transplant workup, leading to approval by the Medical Review Board. Following the successful placement of the Heimlich valve, the patient was discharged with instructions for outpatient follow-up.

Discussion
This case emphasizes the association between AATD and Recurrent secondary spontaneous pneumothorax, bringing attention to the difficulties encountered in the management of this condition. Further research is needed to optimize treatment approaches, explore the efficacy of alternative interventions, and understand long-term outcomes in this complex patient population.

Alpha-1 Antitrypsin Deficiency Unleashed:
A Case Report On Tackling Recurrent Secondary Spontaneous Pneumothorax

Pneumococcal pneumonia caused by Streptococcus pneumoniae (Spn) remains one of the main causes of morbidity and mortality worldwide in children and adults and is a leading pathogen of meningitis and sepsis in children. Laboratory tests to diagnose pneumococcal disease (PD) can be time consuming. Real-time PCR methods can deliver results within 3-4 hours, but with sample processing and DNA extraction, final results may take eight hours. The goal of this study was to evaluate the sensitivity and specificity of the antibodies to identify Spn strains.
We utilized nasopharyngeal (NP) specimens in which Spn+ (N=19) were identified by lytA-based qPCR, isolated by culture, and serotype obtained by Quellung reactions. To confirm specificity, lytA-negative NPs [Spn- (N=3)] were analyzed. NPs were DNA extracted, and serotype-specific qPCR reactions obtained bacterial load. An aliquot of the NP specimens was stained with serotype-specific antibodies labeled with Alexa-488 or type-specific Anti-S4. Stained NP and clinical specimens were mounted on slides and observed using fluorescence microscope.
Serotype-specific qPCR assays quantified bacterial load in Spn+ NP specimens ranging from 1.37x108 to 6.71x105 cfu/ml. The microbiota was observed in Spn+ and Spn- specimens. In most Spn+ specimens (N=19) the anti-Spn antibodies detected individual cells, diplococci and/or pneumococcal chains. Semi-quantitative detection by fluorescence microscopy (ie, +, ++, +++, or ++++) correlated with bacterial load obtained by qPCR. Identification of Spn, in Spn+ specimens, was completed within thirty minutes. Spn signal via fluorescence was not observed in nasopharyngeal homogenates from uninfected specimens (Spn-). 
Of the clinical specimens (N=23) obtained from either culture swab or endotracheal tube, fluorescence using the Alexa-488 antibody only was observed within thirty minutes in 17 samples total. Spn fluorescence was not observed in six samples that were suspended in a charcoal medium.
The goal of this study was to evaluate the sensitivity and specificity of antibodies to identify Spn strains. We evaluated fluorescent antibodies using in vitro studies with isolated strains and in vitro cultured lung cells infected with Spn to assess samples including nasopharyngeal swabs from healthy children, lung specimens Spn-infected mice, and clinical specimens from patients with PD. Identification with Spn was highly specific and sensitive, and detection using fluorescence microscopy occurred in thirty minutes. This study validates a conceptual model that can identify, within minutes, Spn strains in clinical specimens using fluorescence microscopy. Rapid and accurate identification of respiratory pathogens has the potential to save lives and improve antibiotic stewardship. 


Rapid, specific, and highly sensitive detection of S. pneumoniae directly in clinical specimens using a fluorescence-based method

Background: Obstructive sleep apnea (OSA) is associated with oxidative stress/inflammation, but indices of cytokine activation as measured by soluble cytokine levels, remains relatively unexplored. Moreover, how cytokine activation may be modified by continuous positive airway pressure (CPAP) and compliance to CPAP remains unknown. One critical molecular checkpoint for cytokine production is post-transcriptional control by microRNAs (miRs). The central hypothesis of this study was that cytokine activation occurs with OSA and is associated with a shift in a specific cassette of miRs which genetically map to these cytokines. Additionally, we postulated that CPAP would modify cytokine activation and miRs.

Methods: Following informed consent, plasma profiles for cytokine activation (Milliplex, multiplex array) and miRs (Qiagen, miRNA PCR array) were performed in OSA patients (N=50) at baseline and following 90 days of CPAP therapy. CPAP compliance was monitored across the therapeutic interval and graded based on Centers for Medicare and Medicaid Service (CMS) criteria. Profiles were indexed to referent normal subjects (N=18). 

Results: Cytokine activation was evident in OSA patients such as an 8-fold increase in tumor necrosis factor receptor superfamily, member 8 (sCD30) and a 2-fold increase in epidermal growth factor receptor (sEGFR) and vascular endothelial growth factor receptor 2 (sVEGFR2) (p<0.05). Following 3 months of CPAP, cytokine activation was reduced in CPAP compliant patients (N=22) as evidenced by an average 14% reduction in sCD30, sEGFR, Interleukin 1 receptor, type I (sIL1RI), interleukin 1 receptor, type II (sIL1RII), Interleukin 2 receptor, alpha (sIL2Ra), vascular endothelial growth factor receptor 1 (sVEGFR1), and sVEGFR2 whereas these values were unchanged in CPAP non-compliant patients (N=28). A total of 7 miRs were changed in OSA patients, which mapped to several cytokine pathways (p<0.05). Notably, hsa-miR233-3p, hsa-miR233-5p changed with CPAP compliance and maps to a localized inflammatory process- the inflammasome.

Conclusion: A specific set of soluble cytokine receptors and regulatory miRs, including: sCD30, sEGFR, sIL1RII, sVEGFR2, hsa-miR233-3p, hsa-miR233-5p, may serve as a marker of inflammation severity in patients with OSA, and as an approach to determine therapeutic responses to treatment strategies such as CPAP.


Obstructive sleep apnea causes cytokine activation and alters microRNA levels; Effects of continuous positive airway pressure

Background
Pulmonary sarcomatoid carcinoma is a rare subtype of non-small cell lung carcinoma (NSCLC) characterized by the presence of sarcoma or sarcoma-like elements. It represents 0.2 to 1% of all lung cancers. PSC is identified by the presence of spindle and/or giant cells, which make up a minimum of 10% of the tumor or comprise the entire carcinoma.
Case Presentation 
A 49-year-old male with a medical history of cerebrovascular accident (CVA) complicated by chronic ambulatory difficulties, type 2 diabetes mellitus, chronic hydrocephalus, hypertension, hyperlipidemia, and clinically suspected chronic obstructive pulmonary disease, tobacco dependence with a history of over 50-pack years presented from a skilled nursing facility due to worsening dyspnea, acute on chronic progressive productive cough with clear to white sputum, moderate in amount. Upon presentation, the patient's vitals and initial labs were unremarkable, except for mild leukocytosis. However given the increased work of breathing on the exam, a CXR was ordered which was suggestive of consolidation in the right upper lobe. The patient was started on empiric antibiotic therapy for possible community-acquired pneumonia however, it failed to improve. This prompted a CT scan of the chest, revealing a large mass involving the right upper lobe measuring approximately 14.6 x 13.1 x 12.2 cm (anteroposterior and superior-inferior). The right upper lobe bronchus was not visible, raising suspicion of bronchogenic carcinoma. The mass caused compressive atelectasis of the right middle lobe and it was invading the upper portion of the middle mediastinum and posterior mediastinum, exerting mass effect on the esophagus. CT-guided biopsy of the mass revealed markedly atypical cells consistent with sarcomatoid non-small cell cancer, likely squamous cell lung cancer. Immunohistochemical staining was only positive for p63. Based on the labs, imaging, and biopsy results, the patient was diagnosed with Pulmonary Sarcomatoid Non-Small Cell Cancer, arising from the right upper lobe bronchus. The mass exhibited invasive properties, compressive atelectasis, and mass effect on adjacent structures in the mediastinum. Unfortunately, the patient clinically deteriorated before initiating treatment and was ultimately transitioned to inpatient hospice. 
Discussion 
With this case, we would like to reinforce the point that in patients with a history of smoking, and COPD and with initial imaging suggestive of a benign infectious process fitting with clinical exam, a low threshold must be maintained to further investigate with CT imaging, especially if patients do not improve with first-line therapy as malignant tumors may often mimic the appearance of a consolidative process which can further delay treatment and lead to a poor outcome.

Sarcomatoid NSCLC: A Rare Entity with Unpredictable Behavior

Introduction:

Unilateral diaphragmatic paralysis is a condition in which either side of the diaphragm loses the ability to contract resulting in inadequate ventilation eventually leading to respiratory failure. Even though hypothermia-induced hemi diaphragmatic paralysis is a well-established complication of cardiac surgery, a unilateral diaphragmatic paralysis can also occur after automatic implantable cardioverter defibrillator placement.

CASE:

A 61-year-old female with a past medical history of hypertension, left bundle-branch block, Mobitz type 2 block, and chronic systolic heart failure presented to the emergency department with shortness of breath, fatigue, and orthopnea. A Multigated Acquisition (MUGA) scan at the time showed a left ventricle ejection fraction of 28% and a biventricular implantable cardioverter defibrillator placement was recommended. The left ventricular lead was unable to be placed percutaneously and the patient was referred for surgical implantation. The patient underwent left mini thoracotomy with epicardial left ventricle lead placement; the procedure was tolerated well.

Over the course of the next few months, the patient had repeated presentations of shortness of breath and was started on a beta adrenergic-glucocorticoid combination inhaler. This was followed by spirometry which failed to show a reactive airway and hence the inhaler was stopped. Interestingly however, the spirometry did show an extra thoracic restrictive volume flow loop. A chest Xray was obtained that showed left sided hemidiaphragm elevation which was progressively worsening. Since the surgery had been performed recently, this appeared to be a complication that was expected to resolve in around 6-8 months. A follow up Xray in 9 months post-surgery did not show resolution of the paralysis a thus a formal diagnosis of hemidiaphragm paralysis secondary to AICD placement was established. The patient was referred for a sniff test for confirmation.

Discussion:

This case illustrates that post procedure complications may present in unlikely ways even months after the intervention. The emphasis of having an all-rounded approach to presenting complaints cannot be underemphasized. Surgical history should be obtained at every instance as an anatomical cause of an apparent medical symptom can sometimes be the answer.

Underline digital video library

Endogenous lipoid pneumonia due to microscopic airway obstruction: A diagnostic dilemma

Preventing New Onset Mental Health Diagnoses After ICU Stay: Current and Emerging Approaches

Pleural Effusion Volume Estimation Using Handheld Lung Ultrasound

Which Came First: Bronchiectasis or IPF?

Hidden in Plain Sight: A Unique Presentation of Lung Adenocarcinoma

Effects of Balanced Versus Unbalanced Hypertonic Saline on Renal Function in Neurocritical Care

Unleashing Precision: Shape-Sensing Robotic-Assisted Bronchoscopy for Pulmonary Nodules

Alpha-1 Antitrypsin Deficiency Unleashed: A Case Report On Tackling Recurrent Secondary Spontaneous Pneumothorax

Rapid, specific, and highly sensitive detection of S. pneumoniae directly in clinical specimens using a fluorescence-based method

Obstructive sleep apnea causes cytokine activation and alters microRNA levels; Effects of continuous positive airway pressure

Sarcomatoid NSCLC: A Rare Entity with Unpredictable Behavior

Unilateral diaphragmatic paralysis after Automatic Implantable Cardioverter Defibrillator placement

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