Autologous blood-patch pleurodesis for persistent air leak in an AIDS patient with pneumothorax.

Autologous blood-patch pleurodesis (ABPP) is a common technique used to manage patients with persistent pleural air leaks caused by pneumothorax. Other treatment options for persistent air leak (PAL) include chemical pleurodesis or placement of endobronchial valves, though severity of illness, risk of complications such as infection, or patient comorbidities may impact treatment decisions. The use of ABPP in patients with HIV and AIDS has not been reported in the literature. We present a case of a 32-year-old man with a history of AIDS (noncompliant with medications) and schizophrenia who presented with acute hypoxemic respiratory failure complicated by pneumothorax and PAL. He safely underwent ABPP without complications and eventually had resolution of PAL.

Diaphragmatic thickening fraction as a predictor for intubation in patients with COVID-19.

The diaphragm is the primary respiratory muscle, and its dysfunction predisposes patients to respiratory failure. Diaphragm function can be assessed by ultrasound measurement - Diaphragmatic Thickening Fraction (DTF). Respiratory viral infections (including SARS-CoV-2) can cause diaphragm dysfunction. Our case series follows three patients infected with COVID-19 pneumonia. Bedside diaphragmatic ultrasound assessments measuring DTF were trended over patient's hospital course until clinical improvement (i.e., off oxygen) or worsening (i.e., intubation). Our preliminary results suggest a correlation between DTF trends and respiratory status in patients requiring 100% oxygen. Further studies are required to assess DTF and its possible correlation to respiratory failure.

Ultrasound for Pleural Disease. Beyond a Pocket of Pleural Fluid.

The evolution of pleural disease imaging modalities through the years has helped the scientific community understand and treat various disease states. Ultrasound (US) has been an image modality that has reigned superior to those used in the past such as chest X-ray and computed tomographic scan in terms of cost effectiveness, portability, and reduction in unwarranted radiation exposure to patients. Here we provide a succinct review of US use in pleural disease including imaging techniques, identifying safe pleural space for access, and predicting pleural fluid volume and etiology along with specificities regarding trapped lung identification and pleural mass biopsy. We believe bedside chest US is an adjunct to the physical exam adding superior diagnostic abilities. Further research is warranted in more specific aspects of sonographic use such as in fibrinolytic therapy management, evaluation for trapped lung, and the utility of specific modes like the color flow Doppler.

MAC Attack: Clinical Correlates of Mycobacterium avium Complex Infection Among Patients With and Without Cancer.

BACKGROUND: In 2007 the American Thoracic Society (ATS) released guidelines on management of Mycobacterium avium complex (MAC), an increasingly common respiratory organism worldwide. Determining when this represents a true respiratory pathogen remains controversial and becomes increasingly challenging in patients with cancer. This study aims to 1) describe the phenotype that exists among cancer patients with MAC colonization and MAC pulmonary infection when compared to non-cancer patients; 2) assess whether cancer, symptoms, and radiographs, were associated with the decision to treat MAC pulmonary infection with antibiotics. METHODS: We retrospectively analyzed 550 adult, non-human immunodeficiency virus (HIV) patients, among whom MAC was identified in respiratory cultures or tissue. Radiographs, clinical symptoms and cancer status were studied. Patients were categorized as having MAC pulmonary infection based on 2007 ATS guidelines, and antibiotic treatment was thereafter reviewed. Fisher's exact test and Wilcoxon Rank sum assessed differences. RESULTS: Median age of the 550 patients was 68 years; most were female (56%) and white (83%). Symptoms and radiographic abnormalities accompanying MAC isolation were common, occurring among 83% and 99.6% respectively of all patients. There were 444 patients with MAC who had current or inactive cancers, most commonly hematologic (30%) and lung (25%) malignancies, while 106 patients never had cancer. Cancer patients were younger (P = 0.028), less often female (P < 0.001), and had less-frequent pre-existing lung disease (P = 0.017) than those without cancer. There were 196 (35%) patients determined to have MAC pulmonary infection, among whom 49 (9%) received directed antibiotics. Those receiving antibiotics had lower body mass index (BMI) (P < 0.0001), more frequent pre-existing lung disease (P = 0.003) and lower cancer rates (P = 0.008) than those not receiving antibiotics. Patients receiving antibiotics were more likely to have cavitary disease (P = 0.001), cough/dyspnea (P = 0.012), hemoptysis (P < 0.001), and constitutional symptoms (P = 0.001). CONCLUSIONS: In concordance with ATS guidelines, hemoptysis, constitutional symptoms, cough/dyspnea and cavitary disease were associated with highest likelihood to treat with antibiotics. The phenotype in cancer patients was quite different than the classic Lady Windermere syndrome. MAC pulmonary infection was treated less often in cancer patients. This study extends beyond the ATS guidelines to examine the potential import of malignancy on the colonization and potential treatment of MAC.

Medullary Sponge Kidney: Current Perspectives.

Medullary Sponge Kidney (MSK) disease is a rare congenital malformation of the distal nephron where cystic dilatation is appreciable in the collecting ducts and renal papillae. Most cases of the malformation are thought to arise from a malfunction within neurotrophic factor and tyrosine kinase interactions. Presentation and prognosis are usually indolent; however, they include urinary tract infections (UTI), nephrolithiasis and nephrocalcinosis, distal renal tubular acidosis (dRTA) and hypocitraturia. With an insidious and asymptomatic onset, MSK is a difficult renal manifestation to both diagnose and treat. Difficulty diagnosing MSK today arises from clinical settings deviating from the usage of contrast methods when assessing the urogenital tract. Many healthcare standards for kidney disorders center diagnosis around imaging techniques rather than contrast methods. This ultimately leads to a decrease in the total number of confirmed cases of MSK. Though intra-venous urogram (IVU) remains as the current gold standard to diagnose MSK, other methods such as endoscopy and Multi-detector computed tomography (MDCT) are being put into place. Endoscopic examination and renal biopsy may allow definitive diagnosis; however, such invasive methods may be considered excessive. Moving forward, differential diagnoses for MSK can be made more precisely when patients present with other renal manifestations, especially in groups at risk. These groups include patients between the age of 20 and 30, patients with other renal malformations, high sodium diet patients, hyperparathyroid patients, and patients with family history of MSK. Basic treatment is aimed at controlling stone formation by stabilizing urinary pH. Treatment for patients, especially those prone to forming stones, includes the application of potassium citrate compounds, prophylactic water and diet control, surgical intervention or lithotripsy for removal of symptomatic kidney stones.

Acquired Perforating Dermatosis in a Patient on Peritoneal Dialysis: A Case Report and Review of the Literature.

Acquired perforating dermatosis (APD) is a debilitating and itchy skin disease. Its diagnosis is based on biopsy and the treatment is not very clear. It is not well established as to how wide spread it is in patients on peritoneal dialysis (PD) and its implications in this population have not been well studied. Here we present a case of APD that developed in a patient on PD. Its pathology and treatment options are reviewed. More studies are needed to assess the prevalence of APD in PD population.

A rare case of bronchial elastosis: An unusual presentation of an unexpandable lung.

Endobronchial obstruction is a known cause of an unexpandable lung. Endobronchial lesions are usually malignant, however benign cause like hemartoma, lipoma, amyloidosis and neuroendocrine tumors are known. We, hereby present the rare cause of bronchial elastosis presenting as right lower lobe lung collapse.