Indwelling pleural catheters for persistent pleural effusions secondary to post lung resection for malignancies

Background

Malignant and nonmalignant pleural effusions (NMPEs) such as those due to hepatic hydrothorax have been successfully treated with an indwelling pleural catheter (IPC) with a low complication rate. There is no literature on the utility or safety of this treatment modality for NMPE post lung resection. We aimed to assess the utility of IPC for recurrent symptomatic NMPE secondary to post lung resection in lung cancer patients over a period of 4 years.

Methods

Patients who underwent lobectomy or segmentectomy as part of the treatment plan for lung cancer between January 2019 and June 2022 were identified, these patients were screened for post-surgical pleural effusion. A total of 422 underwent lung resection, of which 12 had recurrent symptomatic pleural effusions requiring IPC placement and were selected for final analysis. The primary end points were improved symptomatology and successful pleurodesis.

Results

Mean time to IPC placement was 78.4 days post-surgery. The mean length of IPC catheter was 77.7 days standard deviation (SD) 23.8. All 12 patients achieved spontaneous pleurodesis (SP), there was no second pleural intervention or re-accumulation of fluid on follow up imaging in any of the subjects after IPC removal. Two patients (16.7%) had skin infection related to catheter placement that was managed with oral antibiotics, there were no cases of pleural infections that required catheter removal.

Conclusions

IPC is a safe and effective alternative in managing recurrent NMPE post lung cancer surgery with high rate of pleurodesis and acceptable complication rates.

Idiopathic pulmonary vein thrombosis treated with apixaban

Pulmonary vein thrombosis (PVT) is a rare clinical finding that is potentially fatal and with an unknown incidence rate as known cases exist predominantly in case reports. We present the case of a 58-year-old female who reported sudden onset of chest pain, shortness of breath, and dyspnoea on exertion. A computed tomography (CT) pulmonary angiogram was negative for evidence of pulmonary embolism; however, it did demonstrate the evidence of thrombosis of the right lower lobe segmental pulmonary vein. She had no identifiable aetiologies for her PVT; therefore, she was diagnosed with idiopathic PVT and was treated successfully with apixaban. This case represents the 14th incidence of idiopathic PVT in the current body of medical literature and the first case of successful treatment with apixaban.

The Utility of Point-of-Care Ultrasound for Post-Bronchoscopy Pneumothorax Evaluation

We present a case of a 65-year-old female with a prior history of B-cell lymphoma with new CT chest findings of a nodule requiring an electromagnetic navigational bronchoscopy with transbronchial biopsies. Post-bronchoscopy, the patient complained of dyspnea and left scapular pain despite two normal anterior-posterior chest X-rays. Point-of-care ultrasound of the lung demonstrated a lack of lung sliding, which was confirmed via a right lateral decubitus chest X-ray. This case illustrates the utility and superiority of lung point-of-care ultrasound while highlighting the limitations of conventional imaging modalities in a post-bronchoscopy evaluation.

Metastatic Cutaneous Angiosarcoma: A Rare Entity

We present a case of a 56-year-old female presented with a chief complaint of four months of dyspnea that had acutely worsened. The patient also reported a chronic right thigh wound.

Chest radiograph on initial presentation demonstrated multiple bilateral rounded opacities. CT pulmonary angiogram demonstrated multiple bilateral rounded nodules seen on chest radiograph along with a right upper lobe pulmonary artery with near-complete compression secondary to large right hilar adenopathy. CT of right lower extremity showed evidence of ulceration with multiple conglomerate subcutaneous masses, predominately anteriorly and laterally.

She underwent a bronchoscopy; a fine-needle aspiration of the subcarinal lymph node was taken. A surgical biopsy from the right thigh wound was also performed. A histological examination from the right thigh ulcer and subcarinal lymph node demonstrated high-grade spindle cell neoplasm, positive for CD-31 and consistent with angiosarcoma. 

Solitary Fibrous Tumors of the Pleura

Solitary fibrous tumors of the pleura (SFTP) are rare neoplasms. We present a case of a 53-year-old female presenting to the pulmonary clinic after an incidental finding of a right-sided chest wall tumor on a chest X-ray. A CT scan of the chest showed a pleural-based right upper lung mass; a biopsy of the mass was consistent with a solitary fibrous tumor.

Euglycemic Diabetic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitor Use Post-Bariatric Surgery: A Brief Review of the Literature

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. SGLT-2 Inhibitors function by inhibiting renal cotransporters, which reduces the reabsorption of glucose in the kidney, ultimately decreasing the concentration of glucose in the body. They have gained popularity in recent years due to their protective effects on the heart and kidneys - both organ systems that diabetes mellitus has shown to have a deleterious effect on. However, despite their growing fame, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is particularly dangerous as there is a chance that it can be missed by clinicians due to glucose levels generally being less than 200 mg/dL. There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a brief review of the literature regarding this important side effect of SGLT-2 inhibitors seen in patients after bariatric surgery.

Platypnea-Orthodeoxia Syndrome: A Rare and Treatable Cause of Positional Dyspnea

Platypnea-orthodeoxia means low oxygen saturation and dyspnea in the upright posture which improves on lying down. The causes can be classified into the intrapulmonary shunt, intracardiac shunt, and ventilation-perfusion mismatch.

A 62-year-old male presented with shortness of breath, which had worsened over a period of one year. Various investigations were done to rule bacterial, viral infection, pulmonary embolism, and other respiratory and cardiac causes. The initial echocardiogram showed an ejection fraction of 55%. The patient was observed to be having dyspnea only in the upright position. In the recumbent position, the dyspnea disappeared with a marked improvement in oxygen saturation. A repeat echocardiogram with a bubble study was done which showed an atrial septal defect. Surgical closure of the defect was performed which improved the patient’s oxygen saturation to baseline normal. This case demonstrates that a vigilant approach is required in cases of dyspnea, keeping in mind the not-so-common phenomenon like platypnea-orthodeoxia syndrome

Rhabdomyolysis in a Patient With Coronavirus Disease 2019

Coronavirus disease 2019 has rapidly enveloped the world in a pandemic after emerging in Wuhan, China, in December 2019. We describe a 49-year-old man presenting with fever, cough, dyspnea, and myalgia diagnosed with coronavirus disease 2019 along with rhabdomyolysis and acute kidney injury. The creatine phosphokinase was elevated to 23,800 U/L before trending down to normal levels. Rapid identification and treatment with aggressive intravenous hydration and correction of electrolyte abnormalities remain key to successful management. In a pandemic, often atypical presentations of this new disease have to be considered as differentials for early diagnosis and treatment of life-threatening conditions.

Intrapulmonary Sequestration: A Rare Occurrence

Pulmonary sequestration is a rare occurrence. Here, we present a case of a 45-year-old female who, on CT scan of the chest, was found to have a left lower lobe consolidation. Despite antibiotic treatment, the consolidation remained persistent. On repeat imaging with CT scan with contrast, it was found that the consolidation was pulmonary sequestration. The patient was referred to cardiothoracic surgery to remove pulmonary sequestration through video-associated thoracoscopic surgery.

Long-term Impact of E-cigarette and Vaping Product Use-associated Lung Injury on Diffusing Capacity for Carbon Monoxide Values: A Case Series

There has been an outbreak of lung injury associated with e-cigarettes and vaping in the United States since early 2019. We present two cases who were admitted to the hospital with shortness of breath and cough. Chest imaging showed they had interstitial changes. They were diagnosed with e-cigarette and vaping product use-associated lung injury (EVALI) and treated with steroids and supportive management. With an improvement in symptoms, they were discharged home.

On follow-up in the clinic, both patients were asymptomatic and had complete resolution of radiographic abnormalities. However, pulmonary function testing showed reduced diffusion capacity for carbon monoxide (DLCO). Total lung capacity (TLC), forced vital capacity (FVC), forced expiratory volume in the first one second (FEV-1), and the FEV-1/FVC ratio were normal.

Vaping-associated Lung Injury

Many cases related to vaping-associated lung injury have recently been reported to the Center for Disease Control (CDC). It is, therefore, important for clinicians to be aware of this disease.

Here, we present the case of a 46-year-old female patient, who had recently started vaping. She presented to the hospital with dyspnea; since her condition deteriorated quickly, she was mechanically ventilated for acute respiratory failure. When a computed tomography angiography (CTA) chest was performed, patchy alveolar opacities were seen throughout both lungs. The patient’s workup for infectious and cardiac etiology was negative. She was diagnosed with vaping-associated lung injury. Later, she recovered and was discharged to a rehabilitation center.

Hydrocortisone Reduces 28-day Mortality in Septic Patients: A Systemic Review and Meta-analysis

The goal of this study was to determine the utility of hydrocortisone in septic shock and its effect on mortality. We performed a systematic search from inception until March 01, 2018, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines comparing hydrocortisone to placebo in septic shock patients and selected studies according to our pre-defined inclusion and exclusion criteria. Four reviewers extracted data into the predefined tables in the Microsoft Excel (Microsoft Corp., New Mexico, US) sheet. We used RevMan software to perform a meta-analysis and draw Forest plots. We used a random effects model to estimate risk ratios. A two-sided p-value of ≤ 0.05 was considered statistically significant. A total of five randomized control trials (RCTs) with 5,838 patients were included in our analysis. The primary outcome was mortality at 28 days. Secondary outcomes were intensive care unit (ICU) and in-hospital mortality, mortality at 90 days and one year, reversal of shock, intensive care unit (ICU) and hospital length of stay, incidence of superinfections, and incidence of limb and/or cerebral ischemia. The 28-day mortality was significantly reduced with hydrocortisone, 808 vs. 880 with placebo, Risk Ratio (RR)=0.92, confidence interval (CI) =0.85-0.99, p=0.04, I²=0%. There was no difference in ICU mortality (RR=0.93, CI=0.81-1.08), in-hospital mortality (RR=0.95, CI=0.84-1.08), 90-day mortality (RR=0.93, CI=0.84-1.02, p=0.10), and one-year mortality (RR=0.97, CI=0.84-1.12). Superinfections were significantly common with hydrocortisone, RR=1.16, CI=1.05-1.28, p=0.003. In conclusion, the use of hydrocortisone showed a significant reduction in mortality at 28 days and a trend toward reduced ICU mortality. This mortality reduction was observed at the cost of significantly higher superinfections.