Separating Out Pulmonary Sequestration.

Pulmonary sequestration (PS) is a rare congenital anomaly that accounts for 1% to 6% of all pulmonary malformations at birth. It is characterized by a focal area of pulmonary tissue that does not have direct communication with the tracheobronchial tree and does not get blood supply from the pulmonary circulation. We present the case of a 28-year-old female with a history of recurrent pulmonary infections who was found to have intralobar sequestration and underwent curative surgical excision. Because pulmonary sequestration is commonly misdiagnosed, as it can mimic other conditions on chest X-rays, this case illustrates the importance of recognizing pulmonary sequestration as a separate entity and diagnosing/treating it appropriately. The patient presented to the hospital with a one-week history of upper chest pain. Chest radiograph showed mild hyperinflated right lung. Computed tomography angiogram (CTA) revealed an 8.9 x 8.3 cm area of hyper-lucency and decreased normal lung architecture in the right lower lobe with an aberrant arterial blood supply suggestive of intralobar pulmonary sequestration. The patient was referred to cardiothoracic surgery and underwent preoperative outpatient pulmonary function testing, which was unremarkable. The patient subsequently underwent successful robotic resection of the right lower lobe sequestration and the pathology report confirmed PS. A diagnosis of pulmonary sequestration is commonly missed, as it can mimic other conditions on chest X-rays. It can present as a solitary nodule or mass, cystic lesion, consolidation, or an air-fluid level. The period between symptom onset and diagnosis is typically more than five years. While digital subtraction angiography is considered the gold standard for imaging, CTA is now preferred because it allows for clear visualization of lung parenchyma and vascular assisting in surgical planning. For our patient, CTA demonstrated a prominent tubular vessel, which showed less enhancement than the opacified pulmonary artery and pulmonary veins, suggestive of an abnormal vascular supply for the right lower lobe sequestration. Management of intralobar sequestration is curative surgical excision. Both video-assisted thoracoscopic surgery (VATS) and posterolateral thoracotomy are viable options for resection. It should be noted that in symptomatic patients, it is recommended to proceed with surgical resection. However, in asymptomatic individuals with intralobar sequestration (ILS), surgical resection is not required but could be considered as prophylaxis to prevent recurrent infections. Asymptomatic individuals with extralobar sequestration (ELS), on the other hand, should undergo serial monitoring as non-operative management is appropriate. This case highlights the importance of including pulmonary sequestration, especially intralobar sequestration in the differential diagnosis of recurrent localized pulmonary infections, especially in a patient who is otherwise healthy. Although rare, it is important to consider this congenital anomaly when evaluating patients with recurrent localized pulmonary infections, chest pain, or hemoptysis.

Immediate complications and flow volume changes during treatment phases of bronchial thermoplasty: a single-center descriptive study.

INTRODUCTION: Bronchial thermoplasty (B.T.) is a therapeutic bronchoscopic procedure in which controlled thermal energy is applied to the airway wall to decrease smooth muscle mass. Immediate complications of B.T. include acute exacerbation of bronchial asthma, upper and lower respiratory tract infection, hemoptysis, among others. Our study assessed these immediate adverse events and the changes in forced expiratory volume in one second (FEV1%) measured four hours after each procedure from baseline. The study also aimed to examine the number of activations during each cycle of treatment and its correlation to the corresponding change in FEV1% from baseline. METHODS: A case-series analysis of 17 patients who underwent B.T. between 2014 and 2019 was done. Demographic, clinical characteristics, including pre and post-BT FEV1% measures, and the number of activations were obtained. RESULTS: Acute exacerbation of asthma was the commonest complication accounting for 33%, 57%, and 75% after BT1, BT2, and BT3, respectively. There was deterioration in FEV1% after each treatment phase, the most significant being in BT3. There was no correlation between the number of heat activations with the change in FEV1% from baseline. CONCLUSION: The number of activations in B.T. does not correlate with the immediate deterioration in FEV1%, although exacerbation of asthma is the commonest complication post-B.T.

The Association of Unreported Sleep Disturbances and Systemic Inflammation: Findings from the 2005-2008 NHANES.

BACKGROUND/OBJECTIVE: Sleep apnea is associated with elevated inflammatory markers. A subgroup of patients never report sleep disturbances to their physician. The inflammatory status of this subgroup is not known. The present study aims to evaluate two inflammatory markers, C-reactive protein (CRP) and red cell distribution width (RDW), in those with unreported sleep disturbances and compares these findings to those with and without reported sleep disorders. We also investigate the utility of RDW as an inflammatory marker in sleep disorders. METHODS: Sample includes 9,901 noninstitutionalized, civilian, nonpregnant adults from the 2005-2008 National Health and Nutrition Examination Survey, a nationally representative, cross-sectional U.S. study. Sleep questionnaire and laboratory data were used to compare inflammatory markers (CRP and RDW) in five subgroups of individuals: reporting physician-diagnosed sleep apnea, reporting another physician-diagnosed sleep disorder, reported sleep disturbance to physician with no resulting diagnosis, unreported sleep disturbance (poor sleep quality not reported to physician), and no diagnosed sleep disorder or sleep disturbance. RESULTS: Individuals with unreported sleep disturbance had significantly higher odds of elevated RDW (>13.6%) when compared to those without a sleep disturbance in adjusted models (OR=1.33). Those with unreported sleep disturbance had significantly higher odds of elevated CRP levels (>1 mg/L) than those without sleep disturbances (OR 1.34), although the association was not significant when adjusted for obesity and other controls. CONCLUSION: Self-identified unreported sleep disturbances are associated with significantly higher odds of elevated RDW than those without sleep disturbances. RDW may serve as a valuable indicator in identifying individuals at higher risk for sleep apnea and other sleep disorders.

Fibrosing Mediastinitis: Uncommon Life-threatening Complication of Histoplasmosis.

Histoplasmosis involving mediastinum is very rare which can present as a mediastinal mass or fibrosing mediastinitis. Fibrosing mediastinitis can be life-threatening if left untreated due to the involvement of the surrounding visceral and vascular structures. We present an interesting case of fibrosing mediastinitis due to histoplasmosis presented with palpitations, chest pain and dyspnea. The patient had mediastinal and hilar lymphadenopathy with calcification on chest imaging. The patient was diagnosed on lymph node biopsy and treated with antifungals.

Focal neurological presentation in Hashimoto's encephalopathy mimicking a vascular occlusion of the middle cerebral artery.

Hashimoto's encephalopathy is a rare form of autoimmune encephalopathy. It is likely an underdiagnosed entity especially in the setting of focal neurological defects. We report a case of a 49-year-old man who presented with "strange behavior"of a day's duration. Examination was significant only for lethargy, poor attention span and agitation. Routine labs revealed leucocytosis. Head CT scan was unremarkable. Lumbar puncture showed high white blood cells with lymphocytosis and elevated protein level. The patient was empirically treated for meningitis without improvement. His symptoms progressed to sudden right-sided weakness, ataxia and right facial droop. The MRI and magnetic resonance angiogram (MRA)were normal. The patient’s focal neurological signs improved spontaneously. Encephalopathy work-up was negative except for positive anti-Thyroid Peroxidaseand antithyroglobulin. The patient was treated as Hashimoto encephalopathy with steroids and azathioprine with marked improvement. Our case highlights how focal neurological findings can potentially mislead the provider to consider vascular aetiologies in Hashimoto's encephalopathy.

Vitamin D status and monitoring in female veterans.

An increasing number of women are serving in the military. We initiated a retrospective study to evaluate vitamin D status and monitoring in female veterans, and to examine the potential link between vitamin D status, age, race, post-traumatic stress disorder (PTSD), health care costs, and utilization. Approximately 44 percent of the 3,608 female veterans evaluated between 2001 and 2010 were vitamin D deficient (25(OH)D < 20 ng/ml), a rate substantially higher than that of the general population. While younger (<55 years) and older (55+ years) women did not differ significantly in initial vitamin D status, older women had significantly more vitamin D monitoring and follow-up testing than younger women. Approximately 44 percent of vitamin D deficient women did not receive follow-up vitamin D testing. Minority female veterans were most likely to be vitamin D deficient. Female veterans with PTSD did not differ from others regarding their initial vitamin D status; those that were initially deficient were significantly more likely to receive follow-up testing and were more likely to achieve a replete state. Vitamin D deficiency in female veterans was also associated with increased health-care costs. Appropriate monitoring and replacement of vitamin D should be offered to all female veterans.