A case of hot tub lung secondary to mycobacterium avium complex in Victoria, Australia.

Hot tub lung (HTL) is a type of Hypersensitivity Pneumonitis (HP) caused by inhalation of aerosols containing non-tuberculous mycobacteria (NTM). We report the first case of hot tub lung in Victoria, Australia. A 31-year-old female presented with 3 weeks of dyspnoea, fevers and malaise, despite a course of antibiotics. She had used an indoor spa frequently for the past several months. She was hypoxic saturating 86% on room air. Examination revealed fine bilateral basal crepitations without wheeze. Inflammatory markers were elevated. A high resolution CT (HRCT) chest demonstrated extensive bilateral ground glass changes and centrilobular nodular opacities involving upper and lower zones. Bronchial washings were obtained and isolated Mycobacterium Avium Complex. Clinically, the patient had excellent response to empirical corticosteroids and avoidance of hot tub. This case highlights the importance of clinical history taking and suspicion of Hot Tub Lung as a differential diagnosis in a patient with a compatible clinical history, radiology and microbiology and exposure to a hot tub.

An unexpected case of broncholithiasis secondary to pulmonary nocardiosis.

Persistent productive cough despite appropriate treatment warrants consideration of flexible bronchoscopy to obtain bronchial specimens for culture. Endobronchial examination of airways may reveal signs of infection in the form of purulent secretions, sputum plugs or in this case, an unexpected finding of a calcified broncholithiasis secondary to Nocardia infection.

Antisynthetase syndrome with rare EJ-1 antibodies with antiphospholipid syndrome.

We describe the first case of antisynthetase syndrome (ASS) with antibodies to anti-glycyl tRNA synthetase (EJ-1) with antiphospholipid syndrome (APLS). A 66-year-old man presented with progressive dyspnoea, fever, dry cough and proximal muscle weakness over several months on a background of cryptogenic organizing pneumonia. Examination revealed bibasal fine chest crackles, proximal muscle weakness of the upper and lower limbs, digital skin thickening and facial telangiectasias. Creatine kinase was elevated and autoimmune screening was positive for anti-EJ-1, anti-beta-2-glycoprotein, anti-Ro and anti-La antibodies. Computed tomography of the chest revealed a usual interstitial pneumonia pattern and a ventilation-perfusion scan demonstrated scintigraphic evidence of bilateral pulmonary emboli. A diagnosis of ASS and APLS was made. Immunosuppressive therapy including pulsed methylprednisolone, rituximab and mycophenolate was commenced with improvement in symptoms. This case highlights the importance of evaluation for ASS in idiopathic interstitial pneumonia, and APLS in ASS patients.

Autoimmune pulmonary alveolar proteinosis prior to myelodysplastic syndrome.

We report the first case of autoimmune pulmonary alveolar proteinosis (PAP) associated with and preceding myelodysplastic syndrome. A 74-year-old female with a history of polymyalgia rheumatica presented with six months history of progressive exertional breathlessness. Examination revealed bilateral chest crackles and exertional desaturation. A diagnosis of autoimmune PAP was made based on the presence of autoantibodies to granulocyte-macrophage colony-stimulating factor and characteristic findings on chest computed tomography, bronchoalveolar lavage, and transbronchial biopsies. Bilateral whole lung lavage was performed with prompt improvement in symptoms. Fourteen months later, she presented with new breathlessness and was diagnosed with myelodysplasia on bone marrow biopsy. No recurrence of alveolar proteinosis was detected. This case highlights the importance of follow-up and screening of patients with autoimmune PAP for haematological conditions.

Some sustained improvements in pneumonia case management four and five years following implementation of paediatric hospital guidelines in Lao PDR.

In 2010, WHO paediatric hospital guidelines were implemented in Lao PDR, along with training workshops and feedback audits, achieving significant improvements in pneumonia case management when assessed one-year post-intervention. The sustainability of these improvements is hereby assessed, four and five years post-intervention. Medical records of children aged 1-59 months, diagnosed with pneumonia in 2010, 2011, 2014 and 2015 from a central Lao hospital were reviewed. Information relating to clinical steps in pneumonia case management was extracted and a scoring system applied based on the documentation of each clinical step, producing a pneumonia assessment score for each case. Comparisons of clinical steps and mean assessment score across study years were performed using Pearson's chi-squared and t-tests, respectively. Of 231 pneumonia cases, the mean assessment scores in 2010, 2011, 2014 and 2015 were 57%, 96%, 69% and 69% respectively, showing a significant reduction from the immediate post-intervention period (2011) to 2015 (p < 0.01). Mean assessment score in 2014/2015 was significantly higher than in 2010 (p < 0.01). The high standards of pneumonia case management in 2011 were not observed in 2014/2015 in the absence of ongoing intervention but overall quality of care remained higher than pre-intervention levels, suggesting some degree of sustainability in the long-term.