Management of Refractory Chronic Obstructive Pulmonary Disease: A Review.

Chronic obstructive pulmonary disease (COPD) is a common condition with an estimated prevalence of 12% in adults over the age of 30 years worldwide. COPD is a leading cause of morbidity and mortality globally, with a substantial economic and social burden. There are an estimated 3 million deaths annually due to COPD. However, most of the patients with COPD respond to routine interventions like bronchodilator therapy, assessing supplemental oxygen needs, smoking cessation, vaccinations, and pulmonary rehabilitation. There is a significant number of patients who unfortunately progress to have persistent symptoms despite these interventions. Refractory COPD is not yet formally defined. Patients with severe persistent symptoms or exacerbations despite appropriate care can be considered to have refractory COPD. Managing refractory COPD needs a multidimensional approach. In this review article, we will discuss essential interventions like ensuring adequate inhaler techniques, exploring the need for non-invasive ventilatory support, use of chronic antibiotics and phosphodiesterase inhibitors to advanced therapies like bronchoscopic lung volume reduction surgery, and the upcoming role of anti-IL5 agents in managing patients with refractory COPD. We will also discuss non-pharmacologic interventions like psycho-social support and nutritional support. We will conclude by discussing the palliative care aspect of managing patients with refractory COPD. Through this review article, we aim to better the approach to managing patients with refractory COPD and discuss new upcoming therapies.

Role of Therapeutic Anticoagulation in COVID-19: The Current Situation.

Thrombotic complications from COVID-19 are now well known and contribute to significant morbidity and mortality. Different variants confer varying risks of thrombotic complications. Heparin has anti-inflammatory and antiviral effects. Due to its non-anticoagulant effects, escalated-dose anticoagulation, especially therapeutic-dose heparin, has been studied for thromboprophylaxis in hospitalized patients with COVID-19. Few randomized, controlled trials have examined the role of therapeutic anticoagulation in moderately to severely ill patients with COVID-19. Most of these patients had elevated D-dimers and low bleeding risks. Some trials used an innovative adaptive multiplatform with Bayesian analysis to answer this critical question promptly. All the trials were open-label and had several limitations. Most trials showed improvements in the meaningful clinical outcomes of organ-support-free days and reductions in thrombotic events, mainly in non-critically-ill COVID-19 patients. However, the mortality benefit needed to be more consistent. A recent meta-analysis confirmed the results. Multiple centers initially adopted intermediate-dose thromboprophylaxis, but the studies failed to show meaningful benefits. Given the new evidence, significant societies have suggested therapeutic anticoagulation in carefully selected patients who are moderately ill and do not require an intensive-care-unit level of care. There are multiple ongoing trials globally to further our understanding of therapeutic-dose thromboprophylaxis in hospitalized patients with COVID-19. In this review, we aim to summarize the current evidence regarding the use of anticoagulation in patients with COVID-19 infection.

The Impact of Anxiety and Depression in Chronic Obstructive Pulmonary Disease.

Patients with COPD (chronic obstructive pulmonary disease) are at a higher risk of comorbid conditions such as anxiety and/or depression, which in turn increase their symptom burden and rehospitalizations compared to the general population. It is important to investigate the pathophysiology and clinical implications of mental health on patients with COPD. This review article finds that COPD patients with anxiety and/or depression have a higher rehospitalization incidence. It reviews the current screening and diagnosis methods available. There are pharmacological and non-pharmacologic interventions available for treatment of COPD patients with depression based on severity. COPD patients with mild depression benefit from pulmonary rehabilitation and cognitive behavioral therapy, whereas patients with severe or persistent depression can be treated with pharmacologic interventions.

A Case of Hemothorax as Manifestation of Thoracic Endometrial Syndrome.

Thoracic endometriosis is a rare progression of a mostly benign disease of ectopic endometrial activity involving the pleura and lung. This is a case of a young female who presented with progressive shortness of breath and was found to have significant anemia. Further investigations showed a massive right-sided pleural effusion and ascites. Subsequent thoracentesis and pelvic diagnostic laparoscopy showed a hemorrhagic pleural effusion and ascites, along with dense pelvic adhesions. Pathology was consistent with endometriosis. Patient improved on leuprolide acetate and norethindrone. This case illustrates an important consideration in the differential of a reproductive-age female with new onset shortness of breath and anemia.

Spontaneous intercostal artery bleeding in a patient with alcohol-induced liver cirrhosis.

Spontaneous intercostal artery bleeding is a rare disease seen in cirrhosis and can present with hemodynamically significant blood loss anemia, hypotension, and shock. Transcatheter arterial embolization is an effective treatment for severe cases.

Fungal infections in hematopoietic stem-cell transplant patients: a review of epidemiology, diagnosis, and management.

The advent of bone marrow transplant has opened doors to a different approach and offered a new treatment modality for various hematopoietic stem-cell-related disorders. Since the first bone marrow transplant in 1957, there has been significant progress in managing patients who undergo bone marrow transplants. Plasma-cell disorders, lymphoproliferative disorders, and myelodysplastic syndrome are the most common indications for hematopoietic stem-cell transplant. Despite the advances, invasive fungal infections remain a significant cause of morbidity and mortality in this high-risk population. The overall incidence of invasive fungal infection in patients with hematopoietic stem-cell transplant is around 4%, but the mortality in patients with allogeneic stem-cell transplant is as high as 13% in one study. Type of stem-cell transplant, conditioning regimen, and development of graft-versus-host disease are some of the risk factors that impact the risk and outcomes in patients with invasive fungal infections. Aspergillus and candida remain the two most common organisms causing invasive fungal infections. Molecular diagnostic methods have replaced some traditional methods due to their simplicity of use and rapid turnaround time. Primary prophylaxis has undoubtedly shown to improve outcomes even though breakthrough infection rates remain high. The directed treatment has seen a significant shift from amphotericin B to itraconazole, voriconazole, and echinocandins, which have shown better efficacy and fewer adverse effects. In this comprehensive review, we aim to detail epidemiology, risk factors, diagnosis, and management, including prophylaxis, empiric and directed management of invasive fungal infections in patients with hematopoietic stem-cell transplant.

Radiation-Induced Lung Injury-Current Perspectives and Management.

Radiotherapy plays an important role in the treatment of localized primary malignancies involving the chest wall or intrathoracic malignancies. Secondary effects of radiotherapy on the lung result in radiation-induced lung disease. The phases of lung injury from radiation range from acute pneumonitis to chronic pulmonary fibrosis. Radiation pneumonitis is a clinical diagnosis based on the history of radiation, imaging findings, and the presence of classic symptoms after exclusion of infection, pulmonary embolism, heart failure, drug-induced pneumonitis, and progression of the primary tumor. Computed tomography (CT) is the preferred imaging modality as it provides a better picture of parenchymal changes. Lung biopsy is rarely required for the diagnosis. Treatment is necessary only for symptomatic patients. Mild symptoms can be treated with inhaled steroids while subacute to moderate symptoms with impaired lung function require oral corticosteroids. Patients who do not tolerate or are refractory to steroids can be considered for treatment with immunosuppressive agents such as azathioprine and cyclosporine. Improvements in radiation technique, as well as early diagnosis and appropriate treatment with high-dose steroids, will lead to lower rates of pneumonitis and an overall good prognosis.

Pulmonary Hyalinizing Granuloma: A Rare Cause of a Benign Lung Mass.

Pulmonary hyalinizing granuloma (PHG) is a rare, benign lung disease of unknown etiology. It usually manifests as solitary and sometimes as multiple pulmonary nodules. It may have irregular margins, cavitation, or calcifications mimicking metastasis or primary lung neoplasm. It should be considered in the differential diagnosis of pulmonary nodules or masses. In this report, we present an unusual case of incidental slow-growing lung mass in a patient with 30 pack-year smoking history, construction-based occupation. The pleural-based calcified nodule in the left upper lobe gradually increased in size over ten years without any hilar or mediastinal lymphadenopathy. For an accurate diagnosis, PET-scan and histopathological analysis through wedge resection by video-assisted thoracoscopic surgery (VATS) were done. The biopsy findings were consistent with pulmonary hyalinizing granuloma, a rare benign cause of lung mass with an excellent long-term prognosis.

Hematologic disorders associated with COVID-19: a review.

Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2. Primarily an infection of the lower respiratory tract, it is now well known to cause multisystem abnormalities. Hematologic manifestations constitute a significant area of concern. Severe acute respiratory syndrome coronavirus 2 infects monocytes and endothelial cells leading to a complex downstream cascade, cytokine storm, and eventual intravascular thrombosis. Coronavirus disease 2019 causes lymphopenia, neutrophilia, and thrombocytopenia. Prophylactic anticoagulation is vital in patients with coronavirus disease 2019, as its effect on the coagulation system is associated with significant morbidity and mortality. The disease can cause both arterial and venous thromboses, especially pulmonary embolism and pulmonary microthrombi. A high index of suspicion is indispensable in recognizing these complications, and timely institution of therapeutic anticoagulation is vital in treating them. Virus-induced disseminated intravascular coagulation is uncommon but shares some similarities to sepsis-induced disseminated intravascular coagulation. Marked elevations in hematologic biomarkers such as lactate dehydrogenase, D-dimer, ferritin, and C-reactive protein are associated with worse outcomes. Understanding the pathophysiology and recognizing factors associated with poor prognosis are crucial in improving patient outcomes with coronavirus disease 2019.

The Impact of Diabetes Mellitus in Patients with Chronic Obstructive Pulmonary Disease (COPD) Hospitalization.

(1) Background: Chronic obstructive pulmonary disease (COPD) is the leading cause of morbidity and mortality worldwide. Diabetes mellitus (DM) has been shown to have adverse inflammatory effects on lung anatomy and physiology. We investigated the impact of DM on COPD patient outcomes during inpatient hospitalization. (2) Methods: We conducted a retrospective analysis using the Nationwide Inpatient Sample (NIS) over the years 2002-2014. Three groups, COPD without diabetes, COPD with diabetes but no complication, and COPD with DM and complication, were analyzed. (3) Results: A total of 7,498,577 were COPD hospitalization; of those, 1,799,637 had DM without complications, and 483,467 had DM with complications. After adjusting for clinical, demographic, and comorbidities, the odds of increased LOS in the COPD/DM with complication were 1.37 (confidence interval (CI): 1.326-1.368), and those of DM without complication were 1.061 (1.052-1.070) when compared with COPD alone. The odds of pneumonia, respiratory failure, stroke, and acute kidney injury were also higher in COPD hospitalizations with DM. Both DM with complication (odds ratio (OR): 0.751 (CI 0.727-0.777)) and DM without complication (OR: 0.635 (CI: 0.596-0.675)) have lesser odds of mortality during hospitalization than with COPD alone. (4) Conclusions: There is a considerable inpatient burden among COPD patients with DM in the United States.

Disseminated Mycobacterium abscessus infection and native valve endocarditis.

Mycobacterium abscessus is a rapidly growing mycobacterium. It rarely causes disseminated infection or endocarditis. A 55-year-old male with a history of hepatitis C, liver cirrhosis, intravenous drug use (last use was four years ago), and chronic back pain presented with a three-week history of a right calf nodular lesion. He did not have a fever, chills, rash, dyspnea, or cough. Laboratory data showed mild leukocytosis. Computed tomography of the chest revealed bilateral cavitating nodules. Skin biopsy, sputum, and blood cultures grew Mycobacterium abscessus. Therapy with meropenem, tigecycline, and amikacin was initiated. He was re-admitted with worsening lower back pain. A lumbar magnetic resonance imaging showed destructive changes of L4 and L5 vertebral bodies concerning for osteomyelitis. Blood culture and bone biopsy grew Mycobacterium abscessus again. An echocardiogram was performed due to persistent bacteremia, which revealed large vegetation on the tricuspid valve and small vegetation on the mitral valve. Therapy was changed to eight weeks of amikacin, with cefoxitin and imipenem for twelve months based on drug susceptibility. Treatment of disseminated Mycobacterium abscessus is challenging due to antibiotic resistance. Typically, multidrug therapy is warranted with at least three active drugs. In severe valvular endocarditis, valve replacement may be required.

A case of secondary tension pneumothorax in COVID-19 pneumonia in a patient with no prior history of lung disease.

Complications that arise in patients with severe COVID-19 pneumonia are acute respiratory distress syndrome, often leading to mechanical ventilation, shock requiring vasopressors, acute kidney injury, stroke, thromboembolic phenomena, and myocardial injury. To date, there are four cases of tension pneumothorax in patients with COVID-19, published in literature. We present a 33-year-old man with no prior history of lung disease who was admitted to our hospital on account of hypoxic respiratory failure secondary to COVID-19 pneumonia. During his hospitalization, he developed sudden onset of chest pain which worsened with coughing. A chest X-ray showed a right-sided pneumothorax with left-sided mediastinal shift. He required placement of chest tubes with eventual resolution of the pneumothorax several days later. This case highlights the need for clinical recognition, consideration of differential diagnoses, prompt evaluation, appropriate imaging, and management of this severe life-threatening unusual complication of COVID-19 pneumonia.

Paraganglioma of the middle mediastinum.

A 60-year-old female was evaluated for significant weight loss, nausea, vomiting, and dysphagia. A computed tomography (CT) of the chest showed a 3 cm mass in the middle mediastinum. CT scan of the abdomen and pelvis revealed no abnormality. Positron emission tomography (PET) of the whole body revealed tracer uptake in the pre-carinal nodal mass. There were no other suspicious foci of tracer uptake. Mediastinoscopy and biopsy revealed a well-differentiated low-grade neuroendocrine tumor. She underwent sternotomy, and after careful mobilization of the great vessels, the middle mediastinal mass was successfully resected. Final pathology revealed a paraganglioma with no morphological signs to suggest malignancy. The right lower paratracheal lymph node did not show any tumor cells. She did well postoperatively.

Cavitating pulmonary metastases from a renal cell carcinoma.

Cavitary lung lesions are quite common findings on chest imaging and often pose a diagnostic challenge to the clinicians. We describe a case of a 75-year-old male who presented to the emergency room with hemoptysis. Computed tomography of the chest demonstrated multiple cavitary pulmonary nodules with peripheral groundglass opacities. Bronchoscopy did not reveal any active bleeding source, and washings were negative for malignancy and infectious cause. Computed Tomography guided biopsy of the left lung nodule showed metastatic carcinoma consistent with papillary renal cell carcinoma. This case highlights the unusual presentation of metastatic renal cell carcinoma.