Pulmonary sarcoidosis

The lung is the most common organ affected by sarcoidosis. Multiple tools are available to assist clinicians in assessing lung disease activity and in excluding alternative causes of respiratory symptoms. Improving outcomes in pulmonary sarcoidosis should focus on preventing disease progression and disability, and preserving quality of life, in addition to timely identification and management of complications like fibrotic pulmonary sarcoidosis. While steroids continue to be first-line therapy, other therapies with fewer long-term side-effects are available and should be considered in certain circumstances. Knowledge of common clinical features of pulmonary sarcoidosis and specific pulmonary sarcoidosis phenotypes is important for identifying patients who are more likely to benefit from treatment.Copyright © ERS 2022.

Chylothorax due to hepatic alveolar echinococcosis with infiltration of diaphragm and left pleura: a case report.

BACKGROUND: Alveolar echinococcosis (AE) is an endemic parasitic zoonosis in Germany. In most cases, the liver is the primary organ affected. CASE PRESENTATION: A 59-year old female patient presented with increasing exertional dyspnea and unintentional weight loss. A computed tomography (CT) scan showed a left-sided chylous pleural effusion and multiple intrahepatic masses with infiltration of the diaphragm and the pleura. The findings were initially misinterpreted as hepatocellular carcinoma (HCC) with infiltrating growth. Liver biopsy of one of the masses showed no evidence of malignancy, but an amorphous necrosis of unclear origin. HCC was further ruled out by magnetic resonance imaging (MRI). However, MRI findings were highly suspicious for hepatothoracic dissemination and complications due to AE. Typical histologic findings in a repeated and more specific examination of the liver tissue and a positive serology for echinococcosis confirmed the diagnosis of AE. As the hepatic and pulmonary manifestations were considered inoperable in a curative matter, an anti-parasitic treatment with albendazole was initiated. A video-assisted thoracoscopic surgery (VATS) with removal of the chylous effusion as well as a talc pleurodesis was performed to relieve the patient from dyspnea. Two months later, the patient was asymptomatic and a positron emission tomography (PET)-CT-scan with [18 F] fluoro-2-deoxy-d-glucose (FDG) showed a remarkable diminution of the hepatic manifestation. CONCLUSIONS: This case demonstrates a rare presentation of alveolar echinococcosis with a focus on pulmonary symptoms, emphasizing the importance of evaluation for pulmonary involvement in patients with AE and respiratory symptoms.

Acute Massive Thrombus Following Fontan Procedure

Background Patients with hypoplastic left heart syndrome (HLHS) undergo a Fontan procedure as part of single ventricle surgical palliation. Post-Fontan, sluggish blood flow and an imbalance in coagulant factor proteins may predispose to thrombus formation. Other risk factors may include chylothorax as well as acute and chronic inflammation. Currently, there is no standardized surveillance strategy to detect thrombus in Fontan patients. Case A 34-month old male with HLHS underwent an extracardiac non-fenestrated Fontan complicated by chylothorax treated with 5 days of IV steroids and diuretics. He was on therapeutic aspirin. After progressive worsening of right pleural effusion, a chest tube was placed three weeks post-Fontan with continued chylous output. Stool alpha 1 antitrypsin was negative. Decision-making Given persistent chylothorax, a repeat echocardiogram was performed revealing a large mass in the Fontan circuit less than one month post-op. Cardiac CT showed occlusive thrombus filling the entirety of the Fontan conduit extending into hepatic veins and bilateral pulmonary arteries. He underwent extensive surgical thrombectomy and Fontan conduit revision. Hypercoagulable work-up revealed elevated factor 8 and von Willebrand factor activity which persisted more than one month post-op. Patient's history was also significant for COVID-19 infection 6 months prior. He was initially anticoagulated with bivalirudin with tirofiban initiated for antiplatelet therapy. He was ultimately transitioned to rivaroxaban, pentoxifylline and aspirin with chylothorax resolution over one month without thrombus recurrence. Conclusion Development of risk stratification tools to identify patients at higher risk for thrombi formation post-Fontan may facilitate patient selection for more aggressive anticoagulation. Consideration of elevated factor 8 as well as persistent or recurrent chylothorax may be beneficial, as increased thrombosis risk has been reported for both conditions in Fontan patients.Copyright © 2023 American College of Cardiology Foundation

IT'S NEXT TO THE PLEURA

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION: A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1: 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89:891. Reference #2: 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82:197. Reference #3: 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;92:1062. DISCLOSURES: No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel

Tensioned space after pneumonectomy for cancer with mediastinal shift and cardiac tamponade-causes and treatment (Review).

Regarding the pleural space after pneumonectomy for malignancy, a vast number of studies have assessed early drop in the fluid level, suggesting a broncho-pleural fistula, but only a small number of studies reported on the abnormal increase in the fluid level-a potentially lethal complication. In the present study, the available databases worldwide were screened and 19 cases were retrieved, including 14 chylothorax and 3 hydrothorax cases, 1 pneumothorax and 1 haemothorax case. Tension chylothorax is caused by mediastinal lymph node dissection as an assumed risk in radical cancer surgery. For tensioned haemothorax, the cause has not been elucidated, although lymphatic stasis associated with deep venous thrombosis was suspected. Tensioned pneumothorax was caused by chest wall damage after extrapleural pneumonectomy combined with low aspiration pressure on the chest drain. No cause was determined for none of the tensioned hydrothorax-all 3 cases had the scenario of pericardial resection in addition to pneumonectomy in common. Tensioned space after pneumonectomy for cancer manifests as cardiac tamponade. Initial management is emergent decompression of the heart and mediastinum. Final management depends on the fluid type (chyle, transudate, air, blood) and the medical context of each case. Of the 19 cases, 12 required a major surgical procedure as the definitive management.

Paediatric Mediastinal Masses: Case Series: Intensivist Perspective

Introduction: Mediastinal masses in the paediatric population pose a challenge for diagnosis and acute management especially when they present with compression of mediastinal structures. Objectives: To study clinical, radiological, and pathological characteristics, treatment, complications, and outcome of patients with mediastinal masses admitted to IPCU with emphasis on respiratory support provided. Materials and methods: Retrospective analysis of medical records of patients admitted with mediastinal masses between 1st July 2020 and 31st October 2021 in PICU at B.J.Wadia Hospital for Children. Results: 10 patients (6 months to 16 years) were included. The common presenting symptoms were breathlessness (90%), orthopnea (44%), cough (40%), fever (40%), and weight loss (20%). One patient had superior vena cava syndrome, 50% had hepato-splenomegaly/lymphadenopathy. One patient was diagnosed outside as a yolk sac tumour and referred. Three patients were wrongly treated as TB before they were referred. The average duration of symptoms before presenting to the hospital was 82.7 days. Airway compression was seen on a CT scan in 6/10 patients. Mechanical ventilation was required in 6 patients and non-invasive ventilation in three. The mean duration of mechanical ventilation was 13.1 days. All the patients required PEEP >7 cm H2O, propped up position, and intermittent desaturations requiring an increase in ventilator settings for a short duration of time or use of paralytics/sedation boluses. Difficult intubation was encountered in 2 patients of whom a smaller size tube was used in 1 patient. Bronchoscopy, LMA insertion was not required in any. Tissue for diagnosis was obtained by CT-guided or USG-guided LN biopsy. 80% needed a mediastinal mass biopsy. During the biopsy, procedural sedation was done using drugs propofol or ketamine which was well tolerated. CT-guided retroperitoneal lymph node biopsy was inconclusive in 1 patient and eventually required open inguinal lymph node biopsy. Final diagnoses included: T cell ALL in 2 patients, AML, classical Hodgkin's lymphoma, neuroblastoma, alveolar rhabdomyosarcoma, yolk sac tumour, teratoma, tuberculosis, in single cases. Definitive diagnosis could not be confirmed in 1 child though blood EBV PCR came positive (viral copies >105 copies/mL) after the child expired. The mean time from symptom onset to diagnosis was 90 days. The mean time from presentation to diagnosis was 7.2 days. The mean duration of IPCU stay was 15.8 days. Patient with yolk sac tumour was COVID-19 positive who later developed peripheral digit gangrene. 7 patients received chemotherapy, 1 patient received AKT and one underwent surgical resection of tumour. Complications encountered were AKI (10%), TLS requiring hemodialysis (10%), and chylothorax (10%). Mortality was 50% of whom 2 did not respond to chemotherapy and 3 had intercurrent events. 5 children were discharged from the unit. Conclusion: At our centre, mediastinal masses are frequently malignant in origin. Though TB is common in our country, not all mediastinal masses are TB. All the effort should be made to obtain microbiological/tissue diagnosis before initiating the treatment. Intubating and ventilating a mediastinal mass is a challenging task and those who require intubation have a poor prognosis. Late diagnosis and associated poor prognosis are glaring, prompting for early intervention to improve outcome.

Chylothorax found in a patient with COVID-19.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its clinical spectrum ranges from mild to moderate or severe illness. A 78-year-old male was presented at emergency department with dyspnoea, dry cough and severe asthenia. The nasopharyngeal swab by real-time polymerase chain reaction confirmed a SARS-CoV-2 infection. The x-ray and the thoracic ultrasound revealed right pleural effusion. A diagnostic-therapeutic thoracentesis drained fluid identified as chylothorax. Subsequently, the patient underwent a chest computed tomography which showed the radiological hallmarks of COVID-19 and in the following weeks he underwent a chest magnetic resonance imaging to obtain a better view of mediastinal and lymphatic structures, which showed a partial thrombosis affecting the origin of superior vena cava and the distal tract of the right subclavian vein. For this reason, anticoagulant therapy was optimized and in the following weeks the patient was discharged for clinical and radiological improvement. This case demonstrates chylothorax as a possible and uncommon complication of COVID-19.