'Long COVID' syndrome

SARS-CoV-2 has resulted in a global pandemic and an unprecedented public health crisis. Recent literature suggests the emergence of a novel syndrome known as 'long COVID', a term used to describe a diverse set of symptoms that persist after a minimum of 4 weeks from the onset of a diagnosed COVID-19 infection. Common symptoms include persistent breathlessness, fatigue and cough. Other symptoms reported include chest pain, palpitations, neurological and cognitive deficits, rashes, and gastrointestinal dysfunction. We present a complex case of a previously well 28-year-old woman who was diagnosed with COVID-19. After resolution of her acute symptoms, she continued to experience retrosternal discomfort, shortness of breath, poor memory and severe myalgia. Investigations yielded no significant findings. Given no alternative diagnosis, she was diagnosed with 'long COVID'.

Aortic intramural haematoma associated with the use of nintedanib

We report a 74-year-old patient who developed an acute aortic syndrome (AAS) with intramural haematoma (IMH) during treatment with nintedanib, a tyrosine kinase inhibitor. As we suspected a role for nintedanib, this was immediately interrupted. Four months later, a computed tomographic angiography (CTA) showed significant regression of the IMH. Therefore, we state that, when patients use nintedanib and develop acute chest or back pain, diagnostic work-up for AAS should be considered. Furthermore, other risk factors for AAS, such as hypertension, genetic diseases and comedication should be taken into account when prescription of medication of this class is considered.

Right middle lobe obstruction associated with synchronous endobronchial carcinoid and aspergillosis

Pulmonary carcinoids originate from neuroendocrine cells of the lung and comprise 0.5%-5% of all lung malignancies. Endobronchial carcinoids are rare, low-grade malignant tumors that occasionally coexist with other infectious diseases, including tuberculosis and nontuberculous mycobacterial infection. We treated a 63-year-old woman who presented with a right middle lobe obstruction. A chest computed tomography scan demonstrated a mass-like lesion in the right middle lobe with mediastinal lymphadenopathy. She underwent an exploratory operation after 2 weeks of antibiotic treatment. The pathology revealed a right middle lobe bronchial carcinoid tumor and aspergillosis. Chest computed tomography scans have revealed no recurrence of the carcinoid or aspergillosis during the 5-year follow-up.

Pulmonary mucormycosis in immunocompetent hosts diagnosed by bronchioalveolar lavage

Mucormycosis is a rare infection caused by Mucorales fungi belonging to Zygomycetes class. It can present with spectrum of symptoms and signs based of organ involvement. Common forms of mucormycosis includes rhinocerebral, cutaneous, gastrointestinal, pulmonary, disseminated and miscellaneous forms involving bones, breast, kidney and central nervous system. Pulmonary mucormycosis usually present with fever, cough, haemoptysis and is usually seen in immunocompromised patients like patients with diabetes or leukaemia, or those on chemotherapy or immunosuppressive therapy and rare in immunocompetent patients (6.25% of cases). Pulmonary mucormycosis can be diagnosed by radiological imaging studies, bronchoalveolar lavage (BAL) and histopathological evaluation of biopsy of the lesion; however, the gold standard is a positive fungal culture. Here, we describe two cases of pulmonary mucormycosis diagnosed by BAL in an immunocompetent patient.

Case of e-cigarette or vaping product use-associated lung injury (EVALI) in London, UK

We present a case of a 38-year-old man with no medical comorbidities who presented to the hospital with haemoptysis and shortness of breath on a background of vaping home-manufactured cannabis oil. He developed e-cigarette or vaping product use-associated lung injury (EVALI) visible on chest X-ray requiring oxygen, and corticosteroid treatment before making a recovery. Research reports that the contents vitamin E acetate and tetrahydrocannabinol are frequently found in substances acquired from informal sources which increase the likelihood of EVALI developing. Further research into their synergistic effect is ongoing. Although safer than smoking, vaping is not risk free and EVALI should be considered in patients presenting with respiratory disease.

Bilateral spontaneous chylothorax presenting as a left-sided neck mass

A previously well 36-year-old woman presented with a 2-day history of a tender left-sided neck mass associated with left-sided otalgia and odynophagia. On examination, there was a diffuse, tender swelling of the left anterior triangle of the neck with extension onto the anterior chest wall. Ultrasound and CT scans of the neck revealed extensive inflammatory changes in the soft tissues of the neck and a chest X-ray showed blunting of both costophrenic angles. A diagnostic pleural aspiration was subsequently performed and yielded chyle. The patient was commenced on total parenteral nutrition and placed on a low-fat diet; symptoms completely resolved within 5 days, and at follow-up at 6 weeks, there were no further episodes or complications. Bilateral spontaneous chylothorax is a rarely reported phenomenon in the literature; it has been reported in females following the possibility of minor physical exercise such as stretching or hyperextension of the neck.

Autoimmune pulmonary alveolar proteinosis and idiopathic pulmonary haemosiderosis: a dual pathology

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary condition which leads to excessive accumulation of proteinaceous material within the alveoli. Idiopathic pulmonary haemosiderosis (IPH) is another orphan lung disease and results in recurrent alveolar haemorrhage. This case study describes a case of these two rare pathologies occurring together. A man in his 50s presented with a 6-week history of haemoptysis and worsening dyspnoea. A CT scan of the thorax showed multifocal, bilateral ground glass opacification with a wide differential diagnosis. Full autoantibody screen including myositis panel and coeliac screen were negative. Bronchoscopy with bronchoalveolar lavage and tissue from a transbronchial lung cryobiopsy were non-diagnostic. Tissue from a video-assisted thoracoscopic surgery biopsy confirmed a diagnosis of PAP with IPH as a second separate pathology. The association of IPH and PAP has not previously been described. We discuss these conditions and postulate how and if they may be related.

Tailoring NIV by dynamic laryngoscopy in a child with spinal muscular atrophy type I

Dynamic laryngoscopy during noninvasive (NIV) respiratory therapy is feasible and may facilitate optimal and individualized treatment in patients with chronic respiratory failure, also in children.

Relapse of treated anti-GBM disease following hair dye use

An 18-year-old woman was treated for acute kidney injury (AKI) secondary to antiglomerular basement membrane (GBM) disease with prednisolone, cyclophosphamide and plasma exchange. She also had epistaxis at initial presentation with no other organ involvement and achieved good recovery of her kidney function. Two weeks after completing induction treatment, she re-presented with further AKI and pulmonary haemorrhage. She was recommenced on plasma exchange and steroids and was given rituximab. She recovered from her illness with significant improvement to her kidney function. The cause of her relapse was thought to be possibly due to the use of hair dye. This case highlights the importance of acknowledging potential environmental exposures to prevent relapses of disease. We were also able to demonstrate a case of successful treatment of anti-GBM disease with rituximab.

[The advanced practice nurse in post-COViD-19 respiratory follow up]

The setting up of an advanced practice nursing activity to monitor patients with severe or very severe pneumonia associated with Severe Acute Respiratory Syndrome Coronavirus 2, is a reponse to the population's new health care needs and a massive influx of patients. The skills of the advanced practice nurse are mobilised in this context in order to carry out prevention missions and screening for potential sequelae which could lead to chronic respiratory failure.

Spontaneous pneumothorax as a clinical manifestation of neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is a genetic disorder affecting the skin, nervous system, eyes and bones. Pulmonary involvement is unknown to many physicians. Yet, patients may be affected by lung bullae and cysts, which represent an increased risk for secondary spontaneous pneumothorax (SSP). We present a 56-year-old patient with a pathogenic variant of the NF1 gene, who suffered from NF1 with lung manifestations and recurrent SSP. It is essential to identify the patients having an increased risk of developing SSP as preventive surgery seem to decrease the risk of new events. Pneumothorax can be a clinical manifestation of NF1 but is not yet widely acknowledged as such.

COVID-19-induced granulomatosis with polyangiitis

COVID-19 and granulomatosis with polyangiitis share many clinical and radiological features, making it challenging for clinicians to distinguish between the two. In this case report, we describe a patient who was diagnosed with COVID-19 in October 2020. One month later, she presented with persistent fatigue, shortness of breath and anaemia with worsening renal functions, found to have elevated antineutrophil cytoplasmic antibodies and antiproteinase 3 antibodies, and diagnosed with granulomatosis with polyangiitis.

Gorham-Stout disease: interesting cause of pleural effusion

Gorham-Stout disease (GSD) is a rare disorder characterised by massive painless osteolysis due to lymphangiomatous tissue progression. GSD's pathogenesis is still unclear, but osteoclasts' activation may play a role in its pathogenesis. There are multiple complications associated with GSD. One of the most severe and life-threatening complications is a chylothorax. Herein we discuss a case of a patient with a history of GSD who presented to the hospital with progressive dyspnoea secondary to a large left-sided pleural effusion, which was later confirmed to be a chylothorax. We will further discuss the current literature and treatment of chylothorax associated with GSD.

Successful use of CPAP in a pregnant patient with COVID-19 pneumonia

A 35-year-old nurse, who was 27 weeks pregnant at the time, was admitted to hospital with a short history of cough, fever and worsening shortness of breath. Oral and nasopharyngeal swabs were positive for SARS-CoV-2 on real-time viral PCR. During her admission, her breathing further deteriorated and she developed type 1 respiratory failure. A decision was made to trial treatment with continuous positive airway pressure (CPAP) as a means of avoiding intubation. The patient tolerated this well and made rapid improvements on this therapy. She was quickly weaned off and fully recovered before being discharged home. This case highlights the potential for CPAP to be used as a means of avoiding mechanical ventilation and iatrogenic preterm birth in COVID-19 pneumonia in pregnancy. Furthermore, it highlights the need for robust evidence to support this treatment.

Possible COVID-19 reinfection in a patient with X-linked agammaglobulinaemia

This report highlights the case of a patient with X-linked agammaglobulinaemia (XLA) and resultant bronchiectasis who was discharged from hospital after recovering from real-time reverse transcriptase-PCR positive COVID-19 infection having had a subsequent negative swab and resolution of symptoms, but was readmitted 3 weeks later with recrudescent symptoms and a further positive swab. Although there are reports of COVID-19 infection in XLA, for the first time we report a case of possible reinfection. Lessons learnt from this case include the potential for reinfection of COVID-19 in a patient with a weakened immune system and the importance of repeating COVID-19 swabs in inpatients. Extra caution needs to be taken when providing care in groups of patients who have a weakened or absent immune system.