Chest Disease Reports

A 70-year-old man with a drooping eyelid and distended chest veins

Rahul Tyagi — 2024-06-28

Horner’s Syndrome and central venous obstruction are usually seen in patients with superior sulcus tumour, and their presence, especially in elderly patients, is alarming. Benign causes of Horner’s Syndrome and central venous obstruction are rare but well-documented in the literature. A combination of both occurring due to clavicular trauma is extremely rare. We report a case of an elderly male with clavicular trauma who presented with Horner’s Syndrome and central venous obstruction. He was managed conservatively and had a complete resolution of symptoms. This case highlights that even “red flag” clinical signs may represent relatively innocuous etiology, and thorough evaluation is essential before reaching a diagnosis.

The unusual connection between Right-Sided Aortic Arch and bronchial asthma

Marco Umberto Scaramozzino — 2024-05-29

This work describes a rare clinical case of anomalous positioning of the aortic arch in a female patient with asthma. It highlights literature suggesting that this anomaly may sometimes mimic bronchial asthma, underscoring the importance of conducting bronchodilator reversibility tests more frequently to identify underlying asthma. The patient, a woman presenting with asthma symptoms, was found to have a Right-Sided Aortic Arch (RSAA), which is an unusual finding in the absence of congenital heart disease. Given the rarity of this presentation, it underscores the need for thorough evaluation and consideration of alternative diagnoses in patients with atypical asthma symptoms. This case emphasizes the importance of comprehensive diagnostic approaches, including spirometry and bronchodilator testing, to accurately diagnose and manage patients with asthma-like symptoms associated with rare anatomical variations such as RSAA.

Exfoliated dermatitis and hepatitis to first line Anti-Tubercular Therapy with treatment of Drug-Sensitive Tuberculosis with second line Anti-Tubercular Therapy: a roller coaster ride

Sonam Spalgais — 2024-06-03

The Adverse Drug Reactions (ADRSs) to Anti-Tubercular Therapy (ATT) have been reported from 8% to 85% worldwide, while the prevalence of ADRSs to 1st line ATT from India reported 2.3% to 17%, with more during the intensive phase and daily regime. However, cutaneous ADRSs related to ATT are less commonly seen. Common cutaneous ADRSs are maculopapular rash, urticarial, erythema multiforme, exfoliative dermatitis, and Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Among the 1st line ATT, pyrazinamide is the most common cause at 2.38%, and isoniazid is reported the least at 0.98%. Exfoliated dermatitis is rarely seen with 1st line ATT therapy limited to some case reports and case series.

Conservative management of complicated retropharyngeal abscess with Antitubercular Therapy

Sakshi Boora — 2024-05-08

Retropharyngeal abscess, the infection of deep neck spaces, extends from the base of the skull to the posterior mediastinum. It develops as a sequela of dental infection, upper respiratory tract infection, or any interventional procedure like laryngoscopy, endotracheal intubation, etc. Retropharyngeal abscess is a rare presentation of Tuberculosis (TB), with an annual incidence rate of 2.64 per 100,000 population, and gender-based incidence rates of 3.34 for males, and 1.94 for females per 100,000 population.1 It, as a part of head and neck TB, has a prevalence of 0.1-1% among all forms of TB. If not managed timely, it may lead to the spread of its infection to the mediastinum, which can be life-threatening at times, owing to airway compromission and other catastrophic complications like mediastinitis, mediastinal abscess, pericarditis, pyopneumothorax pleuritis and empyema. We hereby present a case of a middle-aged woman diagnosed with a complicated retropharyngeal abscess but managed conservatively with Antitubercular Therapy (ATT).

A case report of an intra-pleural foreign body successfully retrieved by semi-rigid thoracoscopy and systematic review of worldwide literature

Sanchit Mohan — 2024-05-08

Intra-pleural foreign bodies occur due to thoracic trauma or iatrogenic. Extraction of an intra-pleural foreign body is done either by thoracotomy or Video-Assisted Thoracoscopic Surgery (VATS). A 58-year-old woman presented with a right pleural effusion. Ultrasonography (USG)-guided right pleural fluid aspiration complicated as the needle broke down in the pleural cavity. Computed Tomography (CT) of the thorax documented the needle in the muscular plain between intercostal muscles and the pointing edge in the pleural cavity. A surgical exploration of the muscular plane to retrieve the needle was unsuccessful. The needle was successfully extracted by semi-rigid thoracoscopy under local anesthesia without any complications.

A 31-year-old female with diffuse pulmonary infiltrates and intracardiac thrombus

Nitesh Gupta — 2024-05-07

Intracardiac masses on echocardiography can represent thrombi, vegetations, or tumors. Cardiac Magnetic Resonance Imaging (MRI) is a sensitive tool that differentiates between the three. Intracardiac thrombi can develop during various pathological conditions that cause stasis of blood and predispose to the aggregation of thrombotic material. Atrial clots can occur in conditions like atrial fibrillation, structural heart diseases, thrombophilia, and chronic inflammations. Tuberculosis (TB) is a prothrombotic state and can predispose to venous and sometimes arterial clot formation. But intracardiac clots in TB are rare. We report a young patient presenting with bilateral intracardiac clots and diagnosed to have disseminated tuberculosis. Treatment with anti-tubercular therapy and therapeutic anticoagulation leads to complete resolution of the thrombi.

Transesophageal Bronchoscopic Ultrasound-guided Cryobiopsy (EUS-B-Cryo) for mediastinal lesions in critical airway obstruction: a case series with a systematic review

Sanchit Mohan — 2024-05-06

Tissue diagnosis of mass lesions in the mediastinum poses a challenge, particularly when the mass is not in direct contact with the chest wall, rendering techniques such as Ultrasonography (USG) or Computed Tomography (CT) guided biopsies ineffective. In cases of Critical Airway Obstruction (CAO), utilizing routine endobronchial ultrasound-guided biopsies can lead to complications, including respiratory failure. As an alternative technique, Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) is utilized. However, when smears yield inconclusive results for histopathological diagnosis, mediastinoscopy remains the preferred modality. We present two cases of CAO where Transesophageal Bronchoscopic Ultrasound (EUS-B)-guided cryobiopsy was performed, eliminating the necessity for mediastinoscopy. Histopathological examination of the cryobiopsy samples revealed squamous cell carcinoma and small cell carcinoma. A detailed systematic review only revealed two similar studies in the past. Thus, EUS-B-guided cryobiopsy emerges as a novel technique with the potential to diagnose lesions located in the concealed regions of the mediastinum.

Lung adenocarcinoma - a diagnostic challenge

Chellamuthu Sivaselvi — 2024-05-06

Cavitary lung nodules are produced by a variety of diseases ranging from benign to malignant disease. According to the Fleischner Society, the pulmonary cavity is characterized by a gas-filled space, seen as a lucency or low-attenuation area, within pulmonary consolidation, a mass, or a nodule. Though the number and thickness of the wall of the cavity may help to differentiate causes, arriving at a diagnosis is challenging. Even though radiological findings will help to differentiate benign from malignant etiology, histopathology is needed for confirmation of diagnosis. Here, we describe a metastatic lung adenocarcinoma case presenting as multiple cavitary nodules.

Burkholderia pseudomallei - an unusual cause of septic embolism

Chellamuthu Sivaselvi — 2024-05-02

Melioidosis is an infection caused by the Gram-negative bacterium Burkholderia pseudomallei. It is endemic in many regions, including Southeast Asia, Northern Australia, South Asia (including India), and China. The presentation of melioidosis varies from localized infection to systemic sepsis. The most common causes of septic emboli are Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, and the Salmonella group, but here we reported a case of pulmonary septic emboli, necrotizing pneumonia, and septic arthritis in case of systemic melioidosis infection.

An unusual case of upper airways obstruction

Marco Umberto Scaramozzino — 2024-04-22

Tracheal stenosis poses a diagnostic challenge that can mimic other respiratory pathologies, particularly bronchial asthma. It is characterized by a narrowing of the tracheal caliber, leading to respiratory symptoms such as dyspnea, cough, and wheezing. However, these manifestations can overlap with those of bronchial asthma, making the differential diagnosis a challenging yet crucial task for an appropriate therapeutic approach. This study aims to underscore the importance of a comprehensive clinical approach, utilizing bronchoscopy and global spirometry with bronchodilator reversibility testing, to differentiate tracheal stenosis from bronchial asthma, thereby contributing to accurate and timely surgical treatment. Bronchoscopy stands as a cornerstone in investigating tracheal stenosis, allowing for a direct assessment of the site, extent, and nature of the stenosis. Endoscopic observation of the morphological characteristics of the stenosis, such as concentric narrowing or mucosal irregularities, can guide towards a more precise diagnosis. Asthma, characterized by a reversible bronchial obstruction, responds positively to bronchodilators, whereas tracheal stenosis shows a limited or absent response.

Pulmonary "cannonball" metastasis from endometrial cancer: a rare case report

Marco Umberto Scaramozzino — 2024-04-22

Endometrial cancer is the most common gynecological neoplasm in Italy and developed countries. Pulmonary metastases, though uncommon, signify advanced disease, with "cannonball" metastases being a distinctive pathological finding requiring careful management. Despite advancements in bronchoscopy technology, fundamental diagnostic procedures like Bronchoalveolar Lavage (BAL), Transbronchial Lung Biopsy (TBLB), and Transbronchial Needle Aspiration (TBNA) remain essential for evaluating bronchopulmonary diseases. These techniques enhance the diagnosis and staging of oncological diseases of the genitourinary system with pulmonary involvement. Traditional bronchoscopic procedures continue to play a vital role in managing lung disorders effectively.

Miliary Tuberculosis in In Vitro Fertilization pregnancy: a series of three cases with a history of hypothyroidism

Apoorva Singh — 2024-04-16

In Vitro Fertilization (IVF) pregnancy is associated with a higher risk of tuberculosis as compared to normal pregnancy. This increased risk remains unexplained. Most of the reports are based on small case series, and the risk profile is not well described. Hypothyroidism has not been described as a potential risk factor in any series. In this case series, we elaborate on the profile of three military tuberculosis cases of IVF pregnancies, all having hypothyroidism history as the common factor, and were referred to our super-specialty center with the onset of symptoms during the late first or mid-second trimester of pregnancy. All three cases were diagnosed on X-ray chest Posterior-Anterior (PA) view, showing miliary tuberculosis and a known case of hypothyroidism. Antitubercular treatment was started. In this report, we describe the clinical course and unfavorable outcomes of these three cases.

A giant intrapulmonary malignant teratoma - a rare case presentation

Vinay V — 2024-04-05

Germ cell tumors such as teratomas are unusual and most commonly occur in the gonads. Extra-gonadal teratomas are rare, and the thorax, especially the mediastinum, is the commonly involved extra-gonadal site. Teratoma of the intrapulmonary region is rare and often involves the left upper lobe of the lung. In this report, we describe a case of a 20-year-old male diagnosed with an intrapulmonary malignant teratoma arising from the left lower lobe. Teratomas emerging from the lungs present with vague symptoms like breathing difficulty, cough, and hemoptysis. We report this rare appearance of malignant intrapulmonary teratoma that originated from the left lower zone of the lung.

A curious case of idiopathic eosinophilic pleural effusion post swimming pool diving

Shrinath V. — 2024-03-21

Eosinophilic pleural effusion is defined as pleural effusion with >10% eosinophil count. Even though the mechanism underlying eosinophilic pleural effusion is poorly understood, it is considered to be caused by pleural fluid sequestration of bone marrow-derived eosinophils. Even though there is a wide spectrum of diseases recognized to be associated with eosinophilic pleural effusion, including pleural irritation, trauma (hemothorax, pneumothorax, thoracic surgery), malignancy, parasitic infection, drug/toxin-induced and pulmonary embolism; almost 25% of cases remain idiopathic. We herein report a curious case of eosinophilic pleural effusion, which has developed post blunt trauma to the chest, sustained after diving into a swimming pool. The patient was extensively evaluated for possible etiologies but was found negative for any underlying known pathology that could lead to eosinophilic pleural effusion.

Epicardial Adipose Tissue and cardiovascular disease: unmasking the hidden culprit

Fulvio Cacciapuoti — 2024-02-14

The role of Epicardial Adipose Tissue (EAT) has evolved in the latest years from a passive energy repository to a dynamic contributor in cardiovascular health. This case discusses the role of EAT in residual cardiovascular risk and the potential benefits of GLP-1 receptor agonist liraglutide in mitigating its effects. We describe the case of a 62-year-old male patient, obese, hypertensive, and with a history of ischemic heart disease, was admitted to the emergency room complaining palpitations and shortness of breath. The ECG showed atrial fibrillation with rapid ventricular response with evidence of a new-onset left bundle branch block. The echocardiogram revealed heart-rate dependent regional dyskinesias, while both echocardiogram and CT scan evidenced the presence of EAT. Intrastent restenosis in the left anterior descending artery was found and treated with percutaneous revascularization. The patient was initiated on liraglutide to address residual cardiovascular risk. Follow-up showed reduced Low-Density Lipoprotein Cholesterol (LDL-c) and High-Sensitivity C-Reactive Protein (hs-CRP) levels, as well as decreased EAT thickness and Body Mass Index (BMI). EAT’s contribution to residual cardiovascular risk underscores the need for targeted interventions and treatments. Glucagon-Like Peptide-1 Receptor Agonists (GLP-1-RA) like liraglutide offer promise in addressing this risk, representing a potential venue for therapeutic exploration.

Bronchoscopic bronchial brush cytology: an underutilized modality for diagnosing lung cancer in resource limited facilities: a case series of nine patients

Aditi Gupta — 2024-01-31

Lung cancer incidence is on the rise with increasing industrialization across the globe. Early diagnosis is the key to a better prognosis. In the current scenario, in developing countries, the majority are diagnosed late, when surgical or curable treatment is not possible, and only palliative treatment options are left. Bronchoscopy is the most widely used modality for the diagnosis of lung cancer. Perhaps, all its accessories are not widely used. Bronchial brush is an easy, cost effective, easily available, without significant complication rates, safe, feasible, with high specificity which offers early preliminary report where biopsy is not possible. It should be used along with biopsy to increase the yield and accuracy in all suspected lung cancer patients who require bronchoscopy.

Germ cell tumor impersonating as a pleuropericardial cyst: a rare phenomenon

Gaurav Pandey — 2024-01-31

A Mixed Germ Cell Tumor (MGCT) is a rare tumor with a low degree of differentiation. The most common sites are yolk sac and astrocytoma. Usually, it is gonadal, but in 5% of cases, it can present as extragonadal. The most common extragonadal site is the mediastinum, where the mediastinal mass sometimes mimics thymoma, lymphoma, pericardial cyst, and also occasionally causes pericardial tamponade. The presentations vary, ranging from accidental findings on routine radiography to life-threatening respiratory and cardiovascular compromission. We present an extragonadal MGCT case presenting as a mediastinal mass with symptoms of 1 year duration. The diagnosis was confirmed on Histopathological Examination (HPE) of surgically excised specimen. Given a possible life-threatening condition, a timely diagnosis is required.

Talus osteomyelitis - tubercular or not?

Nidhi Girdhar — 2024-01-30

Tuberculosis is a communicable infective disease caused by Mycobacterium tuberculosis (MTB). The most commonly involved organ is the lung (Pulmonary tuberculosis), however, MTB can affect any organ other than lungs; in this cases, it is known as Extrapulmonary Tuberculosis (EPTB), which can lead to significant morbidity and mortality. Patients with EPTB can rarely develop ankle or foot arthritis, which usually is either misdiagnosed or diagnosed very late, leading to complications. Early diagnosis and timely treatment are very important to prevent permanent functional disability, thus a high suspicion, even in the absence of specific symptoms, is a must. We report a rare case of osteoarthritis of talus which was tubercular, and in which the patient responded well to treatment.

Synchronous multiple neuroendocrine primary lung cancer with endobronchial extension in a never smoker - An unusual manifestation

Vinay V — 2024-01-26

Synchronous Lung Cancer primaries (SLC) are uncommon, with diverse underlying histology, constituting only a small proportion. The scarcity also poses a challenge in formulating a standardized diagnostic approach. Consequently, the diagnostic and staging challenges for SLC are heightened, particularly when the tumors are located on opposite sides of the chest. We report an exceptionally rare phenomenon in synchronous multiple primary lung cancers with simultaneous occurrence of two neuroendocrine tumors with endobronchial extension, small cell carcinoma and typical carcinoid tumor. Immunohistochemistry proved valuable in confirming the diagnosis. Given the poor prognosis associated with such cases, an accurate diagnosis is crucial for determining appropriate treatment options.

Radiological distribution of bronchiectasis could be a clue for an infrequent cause of chronic cough

Anh Huynh-My — 2024-01-25

Foreign Body Aspiration (FBA) in the elderly is an uncommon but potentially life-threatening condition in the acute setting, but it can also persist in the clinical setting of neglected foreign body with chronic and subtle respiratory symptoms. Chest computed tomography scan can overlook radiolucent foreign bodies but prominently focal lesion and bibasilar bronchiectasis in the appropriate clinical setting should increase the suspicion of FBA. Here we reported a 75-year-old female patient with chronic cough induced by neglected airway foreign body. Bronchoscopic removal of the foreign body was performed successfully, and her cough improved enormously after that.

Hearing loss, why bronchial tree may be involved?

Marisa Anelli — 2024-01-25

A 62-years-old man former occasional smoker was hospitalized for progressive hearing loss and Magnetic Resonance Imaging (MRI) detected multiple round hyperdense lesions in each cerebral hemisphere. Total body Computed Tomography (CT) scan showed a lobulated consolidative lesion on the right lung lower lobe associated to conglomerate lymph nodes (11R) suspected for primary lung cancer. Endoscopy showed an endobronchial invasion and integrated endobronchial ultrasound did not demonstrate any accessible lymph node for sampling. Forceps biopsy report on the endobronchial specimen led to histopathological diagnosis of metastatic melanoma. Skin and ophthalmologic examinations were negative for suspicious pigmented lesions findings and patient had no history of familiarity for melanoma. Malignant melanoma is rarely observed to metastasize to endobronchial tissue and it is represented only in the 4.5% of cases. The vast majority of endobronchial metastases are metachronous, even after several years. Nevertheless, the anachronous manifestations are possible.

Vitamin D deficiency and level of asthma control and severity in an adult population in Morocco

Adil Zegmout — 2024-06-18

Vitamin D plays a critical role in immune modulation, with implications for the severity and control of asthma. The study included 174 asthmatic patients aged 18-65 whose serum 25(OH)D3 levels and their relationship with asthma severity, control, and lung function were assessed. The prevalence of hypovitaminosis D was 64%, with 36.3% of patients having normal levels, 29.8% insufficient, and 33.9% deficient. Lower vitamin D levels were significantly associated with increased asthma severity (p=0.04) and poorer asthma control (p=0.03). Patients with severe asthma had mean 25(OH)D3 levels of 24.1±11.8 ng/mL, compared to 32.5±13.1 ng/mL in patients with non-severe asthma. Controlled asthma was linked with higher vitamin D levels (28.3±12.5 ng/mL) compared to partially controlled (24.7±10.8 ng/mL) and uncontrolled asthma (23.3±12.1 ng/mL). A non-significant trend was observed toward reduced Forced Expiratory Volume in One Second (FEV1) in vitamin D-deficient patients. Vitamin D deficiency is significantly associated with asthma control level and severity, underscoring the need for further research on the therapeutic potential of vitamin D in asthma management.