A patient with Mycobacterium abscessus lung disease was mistaken to have pulmonary tuberculosis with airway colonization by the non-tuberculous mycobacterium. Appropriate antibiotics were only given when the patient's signs and symptoms worsened while on anti-tuberculosis therapy. Despite treatment with a combination of antibiotics showing in vitro susceptibility, the pathogen persisted in the respiratory secretions for longer than 6 months and the patient suffered a spontaneous pneumothorax 14 months into treatment. This case illustrates the chronic course of M. abscessus lung infection, the tendency for flare-ups, the inadequacy of current treatment regimens, and the necessity for prolonged patient follow-up.
We report a man presenting with dyspnea, cough, and hemoptysis due to left lung collapse from an endobronchial tumor obstructing the left main bronchus. Endobronchial biopsy of the tumor showed renal cell carcinoma, identical to a previous specimen of renal cell carcinoma removed by a radical left nephrectomy five years ago. The endobronchial tumor was removed by snare diathermy through a flexible bronchoscope, following which his symptoms resolved and the left lung re-expanded. Endobronchial metastasis from renal cell carcinoma is rare and can mimic obstruction from other endobronchial etiologies, such as bronchogenic carcinoma. Total lung collapse as a result is even more uncommon, although atelectasis is well described. Endobronchial techniques, such as snare diathermy, can relieve obstruction, providing symptom palliation even in advanced disease.
Breast metastases from non-small cell lung carcinoma are rarely reported. We report a case of a female patient with primary adenocarcinoma of the lower lobe of her right lung presenting with a massive right-sided malignant pleural effusion. The tumor harbored an epidermal growth factor receptor insertion mutation in exon 20 but was anaplastic lymphoma kinase translocation negative. She did not respond to treatment with erlotinib. First- and second-line cytotoxic chemotherapy resulted in stable disease as the best responses. She developed right breast metastasis 20 months after her initial presentation. The rarity of the condition and the likely mechanism of the breast metastasis are discussed.
We report a case of a 34-year-old lady with past history of asthma and pulmonary tuberculosis, who presented 5 weeks pregnant with acute dyspnea. Her chest X-ray showed left-sided complete lung collapse and concomitant right-sided pneumothorax. The pneumothorax was initially managed conservatively with a chest tube but due to its persistence despite suction, was subsequently changed to a Pneumostat(TM), with which she was later discharged. She had a normal echocardiography (ejection fraction [EF] 67%) at 5 weeks of gestation but developed pulmonary hypertension (EF 55%, pulmonary arterial pressure 40.7 mmHg) as the pregnancy progressed. She delivered a healthy baby at 35 weeks via elective lower section caesarean section with spinal anesthesia. We followed her up postnatally and noted the presence of left-sided pulmonary embolism, hypoplastic left lung, and left pulmonary artery. The management of this complex case involved a multidisciplinary effort between general medical, respiratory, obstetric, and cardiothoracic teams.
Chylothorax is defined as the presence of chyle in the pleural cavity. Central vein thrombosis is an under-recognized cause of chylothorax in the adult population and is commonly related to central venous catheterization. Case 1 illustrates a patient with AIDS and disseminated tuberculosis with left chylothorax and central vein thrombosis after a month of antituberculosis therapy. Case 2 was a patient with advanced seminoma who presented with left chylothorax and central vein thrombosis while on chemotherapy. Chylothorax resolved with anticoagulation for both cases. Case 3 was a lymphoma patient with central vein thrombosis who developed chylothorax during chemotherapy. Chylothorax resolved with the continuation of anticoagulation and did not recur despite his progressive underlying lymphoma. There was no central venous catheterization in any of these three cases. These cases illustrate the unique association of central vein thrombosis and chylothorax and the importance of anticoagulation in its management.
The use of Cannabis sativa, also known as marijuana, is believed to have dated back to thousands of years B.C. More than 200 decades later, it remains a popular recreational psychoactive substance that can be smoked through a water pipe. We report a case of marijuana smoking via a "bong" device, which has resulted in severe Pseudomonas aeruginosa necrotizing pneumonia treated with conservative medical therapy. This case highlights the importance of recognizing that life-threatening pneumonia can potentially be linked to marijuana and "bong" usage. Complicated cases should be considered for early surgical intervention.
Primary pleural synovial sarcoma (PPSS) is an extremely rare malignancy without a known cause. The diagnosis is made after excluding metastasis from an extra-thoracic sarcoma. We report a case of a 67-year-old gentleman who presented with an incidental finding of a left lung mass on a routine chest X-ray. A computed tomography (CT) of the thorax and whole-body positron emission tomography (PET)-CT was done confirming a left lung mass with no other extra-thoracic involvement. A lobectomy was performed with a diagnostic and therapeutic intent. The histopathological examination and immunohistochemistry study revealed a pleural-based tumour with features suggestive of synovial sarcoma. Subsequently, he underwent post-operative radiotherapy. However, three months later, he developed an endobronchial recurrence, complicated by post-obstructive pneumonia resulting in his demise. This case highlights a rare form of malignancy with a rare site of recurrence.
Chylothorax is an uncommon cause of pleural effusion. Recurrent chylous effusions are often resistant to conservative treatment and many need surgical intervention. We report a 69-year-old woman with refractory idiopathic chylothorax resistant to medium-chain triglyceride diet and intermittent thoracentesis. Lymphangiography and lymphoscintigraphy failed to identify the site of leakage. We initiated continuous positive airway pressure (CPAP) 12 h before and 48 hours after talc pleurodesis. Chest drain was removed at day 3 and she was discharged at day 5. To our knowledge, this is the first case of successful resolution of idiopathic refractory chylothorax with CPAP ventilation used in tandem with talc pleurodesis.
Indwelling pleural catheter (IPC) is a useful tool for refractory malignant pleural effusions (MPEs). It allows palliation by intermittent symptomatic relief of the effusion and improves quality of life. Its use in benign pleural effusions comes mainly from retrospective studies, case series, and case reports. Lupus effusion is common, causes minimal symptoms, and usually responds to either steroid therapy or immunosuppressants. Refractory lupus effusion is less common and treatment may require invasive surgical pleurectomy. We describe a 52-year-old woman whose first presentation of systemic lupus erythematosus (SLE) was a pleural effusion refractory to steroids and immunosuppressants. She successfully achieved spontaneous pleurodesis with intermittent IPC drainage at three months.
Spontaneous pneumomediastinum (SPM) and pneumothorax (PTX) have been described as rare complications of COVID-19 pneumonia. We present a case of COVID-19 pneumonia which was complicated by SPM on Day 13 of admission with progression to spontaneous PTX 2 days later which necessitated intercostal chest drainage. It was complicated by prolonged air leak (PAL) for the next 9 days despite being on continued low-dose suction and another additional larger bore intercostal drain inserted. Surgical pleurodesis was not an option in view of anaesthesia and operative risk expected in COVID-19. In view of this, autologous blood pleurodesis (ABP) to address the alveolar pleural leak was opted. ABP has been previously used for PAL in cases of non-COVID-19-related intractable spontaneous PTX. The air leak ceased with subsequent lung re-expansion, with good clinical and radiological improvement. He was discharged well after resolution of PTX which required intercostal drain for a total of 15 days.
Teratomas of anterior mediastinum are rare. They are often slow growing, asymptomatic, and detected incidentally on chest imaging. Mycobacterium abscessus (M. abscessus) is an acid-fast bacillus that is classified as a pathogenic "rapid growing" non-tuberculous mycobacteria. It is an uncommon cause of human pathology, which may cause skin and soft tissue infection after skin injury following inoculation, minor trauma, and surgery. Here, we present an unusual case of benign cystic teratoma mimicking recurrent pleural effusion, which was subsequently complicated by M. abscessus infection following thoracotomy. Cystic teratoma is rare, but it needs to be considered whenever clinical and investigative work-up fails to provide a convincing diagnosis. A combined clinical, radiological, surgical, and histopathological assessment is important to arrive at the correct diagnosis. Rapidly growing mycobacteria needs to be included in the differential diagnosis of patients with non-resolving infected post-thoracotomy wound and who do not respond to broad-spectrum antibiotics.
In clinical practice, chylothorax is usually suspected in any patient with milky pleural fluid. However, contrary to popular belief, milky appearance of pleural fluid is seen in less than half of patients with chylothorax. A high index of suspicion for chylothorax is therefore needed in any turbid, bloody, or serosanguinous effusions of unclear aetiology. In this case series, we present three patients with biochemically proven chylothorax: each with a different presentation, pleural fluid appearance, underlying cause, management strategy and clinical outcome. The first patient developed 'milky' chylothorax secondary to lymphoma while the second patient's 'yellow' chylothorax is related to pleural tuberculosis. The final patient suffered from 'pink' chylothorax in the setting of systemic amyloidosis. In each of the cases, prompt diagnosis of chylothorax followed by efforts to elucidate the underlying cause are crucial steps to guide subsequent management with the main aim to ensure a better clinical outcome.
Krukenberg tumours are unusual metastatic tumours of the ovary with primary tumours from the stomach, breast and gastrointestinal malignancies. Krukenberg tumour from pulmonary malignancy represents an extremely rare situation. This is an elaboration of a case of young women with Krukenberg tumour rising from lung adenocarcinoma. A 38-year-old woman presented with progressive abdominal distention for the past 2-years. Computed tomography (CT) of thorax, abdomen and pelvis revealed a huge ovarian mass with left lung nodules and left-sided pleural effusion. A detailed immunohistochemical staining on pleural fluid cytology confirmed the diagnosis of metastatic adenocarcinoma of lung origin. She underwent doublet platinum chemotherapy as molecular testing for oncogenic mutation was negative. The patient responded well to chemotherapy with a significant reduction in ovarian tumour size. Early identification of the primary source of Krukenberg tumour is paramount to avoid invasive diagnostic surgical intervention for ovarian metastasis.
Pleural anthracosis is rare and, in most cases, is diagnosed incidentally or at autopsy. We report a 67-year-old man with pleural anthracosis. He was initially referred for possible tuberculous pleural effusion and had recurrent admissions for symptomatic pleural effusion, which increased with each subsequent episode. A thoracoscopic examination demonstrated diffuse hyperpigmentation in both parietal and visceral pleura. Parietal pleural biopsy indicated granuloma with foreign body giant cell. A contrast-enhanced computed tomography (CECT) thorax showed focal plaques in parietal pleura with calcifications in the ipsilateral lung. Investigations for tuberculosis, fungal, and malignancy proved to be negative. With these results, a diagnosis of pleural anthracosis was made. This case highlights the unusual presentation of pleural anthracosis with pleural effusion.
Endobronchial ultrasound (EBUS) is indispensable when it comes to evaluation of mediastinal lesion and staging of lung cancer. The incorporation of endoscopic ultrasound using an echobronchoscope (EUS-B) further extends this capability to the paraoesophageal and subdiaphragmatic structures. When combined, EBUS with EUS-B increases the diagnostic yield. Both procedures can be done in a single session and by a single operator; this translates into an overall reduction in the healthcare cost.
Pulmonary extra-nodal marginal zone B-cell lymphoma, also known as extra-nodal mucosa-associated lymphoid tissue (MALT) lymphoma, is rare among all non-Hodgkin lymphomas and generally among all pulmonary malignancies. We present a 46-year-old lady with persistent right lower lung consolidation despite earlier treatment efforts with intravenous antibiotics for community acquired pneumonia. Apart from initial presentation with a short 3-day history of fever, cough and shortness of breath, she had remained largely asymptomatic throughout the follow-up period. Flexible bronchoscopy done ruled out infectious aetiologies but transbronchial lung biopsies showed atypical lymphocytes. A computed tomography guided core biopsy of her right lung consolidation was subsequently performed, confirming a diagnosis of pulmonary MALT lymphoma. She was promptly referred to the haematology team for further management and commencement of chemotherapy. Pulmonary MALT lymphoma, albeit uncommon and often follows a relatively indolent cause, should be considered as a differential diagnosis among patients with persistent lung consolidation.
Neoadjuvant chemotherapy is a therapeutic option for potentially resectable non-small cell lung cancer (NSCLC). The role of neoadjuvant targeted therapy (NTT) remains less explored. This case highlights the use of neoadjuvant osimertinib in a case of advanced NSCLC. A 67-year-old woman had a left lower lobe lung mass measuring 5.0 × 5.1 × 7.0 cm with an enlarged subcarinal lymph node (LN) on her positron emission tomography scan. Following biopsy, a diagnosis of stage IIIB N2 (cT3N2M0) EGFR exon 19 deletion mutation-positive lung adenocarcinoma was established. NTT using osimertinib 80 mg once daily was commenced. Subsequent re-imaging at 3 months (ycT2bN2M0), 6 months (ycT1cN2M0) and 9 months showed tumour downstaging and resolution of the subcarinal LN (ycT1cN0M0). She underwent left lower lobectomy with systematic nodal dissection. All surgical specimens demonstrated no evidence of malignant cells (ypT0N0). Osimertinib could be the preferred NTT for potentially resectable NSCLC.
We report a 35-year-old woman who presented with dyspnoea and chest pain for 1 week. High-resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video-assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter (Rocket® IPC™; Rocket Medical plc; WASHINGTON) was inserted and the patient was discharged after 1 day with an atrium pneumostat (Pneumostat™; Atrium Medical Corporation, Hudson, NH, USA) chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL.
There is limited data on the use of benralizumab in patients with severe asthma, who have allergic bronchopulmonary aspergillosis (ABPA). We report the case of a 65-year-old woman with combined severe eosinophilic and allergic asthma, who presented with refractory respiratory symptoms, hypereosinophilia and high immunoglobulin E (IgE) level. The patient had consistently poor Asthma Control Test (ACT) scores, despite a maximum dose of inhalation therapy. Upon further investigations, she was diagnosed with concomitant ABPA. The patient was started on oral prednisolone and itraconazole, but her symptoms persisted. She was then started on subcutaneous omalizumab, but switched to benralizumab after developing a severe allergic reaction. The patient experienced rapid clinical improvements after the first dose of subcutaneous benralizumab. Benralizumab demonstrated a significant role in reducing the exacerbation rate and oral corticosteroid use in this patient, as well as improving lung function, asthma control, and quality of life measures.
Inflammatory endobronchial polyps (IEPs) are rare benign lesions that originate from the bronchial mucosa. While pneumothorax is a well-known complication of various pulmonary conditions, its association with IEPs is exceedingly uncommon and poorly understood. This case report presents a unique and explosive encounter of a patient with an inflammatory endobronchial polyp who experienced a pneumothorax, shedding light on the clinical presentation, diagnostic challenges, and management strategies for this rare entity.