50-year-old man with progressive dyspnea

Dental foreign body aspiration is a known complication in patients with maxillofacial trauma. Although diagnosis may be delayed, especially in elderly people with radiolucent dental appliances, clinician must be aware of dental tracheobronchial aspiration to minimize potentially serious consequences. We present a 50-year-old man with three months history of progressive dyspnea due to foreign body aspiration occluding distal trachea. The patient had a history of car accident with facial trauma and denture fracture two years before presentation. Fiberoptic bronchoscopy revealed almost totally obstructing mass-like lesion with nodular infiltration in distal trachea. The patient underwent rigid bronchoscopy and a piece of denture with three teeth was extracted

Effect of fluid balance on alveolar-arterial oxygen gradient in mechanically ventilated patients

Fluid balance affects outcome in critically ill patients. We studied the effect of fluid balance on oxygen exchange by assessing alveolar-arterial oxygen gradient [PA-a O[2] in mechanically ventilated patients. Our primary objective was to evaluate the difference in PA-aO[2] and the secondary goal was to evaluate the differences in age and mortality rate. Materials and Methods: This retrospective observational study was performed on patients who were admitted to medical and surgical ICUs of Sari Imam Hospital, Mazandaran University of Medical Sciences, from 2003 to 2009. Daily fluid balance was calculated by input minus output. Thirty patients with continuous positive fluid balance [PFB] and 30 subjects with continuous negative fluid balance [NFB] during 4 consecutive days were enrolled in this study. PA-a O[2] was calculated in these two groups. The mean [ +/- SD] age was 48.9+21.2 yrs. in PFB group [19 males and 11 females] and 37.1 +/- 15.7 yrs. in NFB group [25 males and 5 females] which showed a statistically significant difference in age between the two groups [p=0.017]. The 24h, 48h, and 96h fluid balances were 1226[cc] +/- 881, 1311[cc] +/- 751, and 957[cc] +/- 661 in PFB group and -1122[cc] +/- 92, -920[cc] +/- 394, and -1164[cc] +/- 695 in NFB group, respectively. The mean differences [ +/- SD] of PA-a O[2]in 24h, 48h, and 96h versus the same value in the admission day were 11.3 +/- 39.2, 1.69 +/- 51.1, and -1.50 +/- 64 in PFB subjects and -21.8 +/- 60.8, -27.8 +/- 84.9, and -19.3 +/- 68.7 in NFB patients. The difference was statistically significant only in the first day of admission [p=0.015]. However, no difference was detected in overall mean oxygen gradient during 96h among the two groups. Mortality rate was significantly higher in PFB patients [P<0.0001]. Positive fluid balance had no significant effect on PA-a O2 but can be used as a predictor of mortality

38-year-old woman with scimitar syndrome

Scimitar syndrome is a rare clinical syndrome which consists of anomalous right pulmonary venous return to the inferior vena cava. Scimitar syndrome classically involves the right lung and is most commonly reported in very early infancy. However, it is occasionally seen in adults. We present a 38 year-old woman complaining of dry cough and exertional dyspnea during moderate exercise with right lung scimitar syndrome. The chest radiography showed increased radiolucency of the left lung and heart dextroposition with a characteristic appearance of scimitar sign which is a curvilinear density in the right middle and lower pulmonary fields resembling a curved Turkish sword

48-year-old woman with left subclavian artery occlusion and intrathoracic lymphadenopathy

Sarcoidosis is a systemic disorder characterized by noncaseating granulomas, involving multiple organs including thyroid and great vessels. We present a 48 year-old women with sarcoidosis, left subclavian artery occlusion and sarcoidal thyroid gland involvement. The patient presented with a 1 week history of progressive left upper limb pain with coldness of left hand and fingers. On examination, radial, ulnar, and brachial artery pulses were not palpable. She had also enlarged thyroid gland with firm consistency. CT angiography of aortic arc demonstrated occlusion of left subclavian artery. Because of progressive ischemic necrosis of left hand and fingers, amputation above elbow was performed. Fine needle aspiration [FNA] was suspicious for thyroid neoplasm and total thyroidectomy was performed. Thoracic CT scan showed mediastinal and bilateral hilar lymphadenopathy. Fiberoptic bronchoscopy with transbronchial needle aspiration [TBNA] from right hilar lymph nodes and endobronchial biopsy showed multiple granulomas with negative acid-fast stain. Pathologic examination of thyroid also revealed fibrosis and granulomatous inflammation. On follow up, the ACE level was 104 u/l

Diagnostic yield of transbronchial needle aspiration in intrathoracic lymphadenopathy

Transbronchial needle aspiration [TBNA] is a safe and effective technique for the diagnosis of mediastinal lesions. The aim of this study was to evaluate diagnostic yield of TBNA in patients with benign and malignant lesions involving mediastinal and hilar lymph nodes. TBNA procedures were performed using a flexible bronchoscope and a 22-gauge cytologic needle in 22 patients with mediastinal or hilar adenopathy identified on CT of the chest. Based on the clinical diagnosis or presence of endobronchial lesions, other procedures such as bronchoalveolar lavage, bronchial biopsy, and transbronchial lung biopsy were performed Among 22 patients with a mean age of 50 +/- 18 years, 13 were males [59%] and 9 were females [41%]. Adequate lymph node samples were obtained in 16 patients [72.7%]. Among 9 patients with malignancy, TBNA provided diagnostic results in 5 patients [55.5%]. TBNA provided adequate specimen in 10 out of 13 patients with sarcoidosis, but in 2 patients [15.4%] diagnosis was made by TBNA. Overall, TBNA yield was 31.8%. There was no complication during TBNA procedures. TBNA is a minimally invasive technique for diagnosis of intrathoracic lymphadenopathy, especially in malignant diseases. The procedure also can be used as a diagnostic tool in patients with sarcoidosis, although the yield is low