Vanishing Lung Syndrome, or Idiopathic Giant Bullous Emphysema, with Pneumothorax, and Subcutaneous Emphysema in a 58-Year-Old Female Smoker with Chronic Obstructive Pulmonary Disease

BACKGROUND Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is a rare manifestation of chronic obstructive pulmonary disease (COPD) and usually occurs in middle-aged smokers. This report presents a 58-year-old female smoker with COPD and VLS who presented with spontaneous pneumothorax. The pneumothorax was managed with a chest tube and was later complicated by massive subcutaneous emphysema. CASE REPORT A 58-year-old woman with a past medical history of long-term smoking and COPD presented with worsening shortness of breath. Upon initial evaluation, she had tachypnea and hypoxia (SpO₂ 93%). Chest radiography revealed a new right-sided pneumothorax on top of extensive bullous disease, which the patient already had. The drainage of the pneumothorax was successful with a pigtail catheter. However, during the following night, after insertion of the pigtail catheter, the patient developed massive subcutaneous emphysema, which was confirmed with imaging. The patient remained hemodynamically stable, and diffuse subcutaneous crepitus was present on examination. The pigtail catheter was repositioned, resulting in complete resolution of the subcutaneous emphysema in the following 2 weeks. CONCLUSIONS This case highlights the importance of a timely diagnosis and management of the possible presentations and complications of VLS. Complications such as pneumothorax are life-threatening and require urgent management, taking precedence over the curative treatment for VLS, surgical bullectomy.

A Case of Myxedema Coma Crisis Induced by Inhalation Injury

Myxedema coma is a life-threatening, critical condition in which many organ systems can be severely affected. It is considered the most severe presentation of hypothyroidism and should be treated immediately. Here, we discuss the case of a 58-year-old patient who presented with altered mental status, bradycardia, and hypothermia, the critical characteristics considered in this disorder after inhalation injury. In order to avoid a fatal outcome, aggressive therapy should be initiated upon presentation. This case will depict the typical presentation, the specific cause pertinent to this patient’s condition, and the management of the acute condition of myxedema coma.

Apical Hypertrophic Cardiomyopathy Prompting Aneurysm, Thrombus, and Cardiac Arrest in a 56-Year-Old Female

Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic cardiac disease while apical hypertrophic cardiomyopathy (apHCM) is a rare subset of HCM. The significance of this case report is to present apHCM, its chronological course, and its association with left ventricular aneurysm, thrombosis, and cardiac arrest. We present the case of a 56-year-old female with a past medical history of apHCM who was admitted for substernal chest pain, developed a ventricular storm (VT), and subsequently suffered cardiac arrest; resuscitation of spontaneous circulation (ROSC) was eventually achieved after 10 minutes. It was initially thought that her arrhythmia and hemodynamic decompensation were purely secondary to cocaine use at a party six hours prior to her presentation. During hospitalization, cardiac magnetic resonance imaging demonstrated a severe apHCM apical aneurysm, thrombosis, and a re-entrant circuit as a likely cause of this patient’s decompensation and eventual cardiac arrest. After several days of hemodynamic stability and decreased dependence on intravenous antiarrhythmic medication infusions, she was extubated and transitioned to oral amiodarone and beta-blocker therapy with the implantation of a cardioverter-defibrillator (ICD). In this case, we analyze the continuum of apHCM, a rare subset of HCM once thought to be benign but with the emergence of complications, including aneurysm, thrombus formation, resistant ventricular tachycardia, and cardiac arrest. Recognition and management of apHCM with medical and/or surgical intervention are therefore critical to prevent the aforementioned sequela.

Neoadjuvant bronchoscopic photodynamic therapy to facilitate airway and parenchymal sparing lobectomies in two patients with central airway neuroendocrine tumors: A patient centered approach

BACKGROUND

NCCN guidelines recommend surgical resection for well differentiated pulmonary neuroendocrine tumors (NETs), also known as carcinoid tumors, when they present in the lungs. Fortunately, most pulmonary NETs will not require extensive surgical resection beyond a lobectomy. We report two cases in which large pulmonary NETs would have required more extensive surgical resection, including a carinal pneumonectomy and a left lower lobe sleeve resection. However, after taking patient's preferences into account, neoadjuvant photodynamic therapy was able to decrease the overall tumor burden helping to facilitate airway and parenchymal sparing surgical lobectomies.

MATERIALS

Interventional pulmonology (IP) and Cardiothoracic surgery (CTS) discussed options extensively with each patient and formulated a plan to perform neoadjuvant bronchoscopic followed by surgical resection if there were any remaining NET on follow up bronchoscopy. Both patients received infusions of porfimer sodium (Photofrin ®, Pinnacle Biologics) at 2mg/kg. Per standard protocol, they each underwent a series of bronchoscopies 48 h after infusion, in which endobronchial NET was illuminated with a fiberoptic catheter delivering up to 200J/cm per treatment. After the initial illumination bronchoscopy, a cryo probe was used to debulk necrotic tumor and allow for repeat illumination of residual tumor. Both patients received extensive education on avoiding phototoxicity.

OUTCOMES

Both patients underwent follow up restaging bronchoscopies revealing cleared central airways and only residual NET at the subsegmental level. As such, both underwent lobectomies, avoiding more extensive surgical resection. Both are free of disease at four years and 18 months follow up, respectively. Both patients were satisfied with their outcomes and the autonomy they were given in formulating their treatment plan.

CONCLUSIONS

While photodynamic therapy has been shown to be an effective stand alone, neoadjuvant, and adjuvant therapy for pulmonary NETs, surgical resection is still required in select patients. We present two cases of in which desired patient outcomes led to the use of neoadjuvant PDT to help facilitate airway and parenchymal sparing lobectomies, thus avoiding more extensive surgical resection and possible long-term morbidity.