Himanshu Bhardwaj

Revisiting opioid overdose induced acute respiratory distress syndrome.

Sir, Opioids are commonly used analgesic drug class with morphine like activity. Although respiratory system is the most affected organ system in opioid overdose; acute lung injury and acute respiratory distress syndrome (ARDS) are infrequently reported. A 25-year-old male presented after ingesting unknown amounts of hydrocodone. Patient was found to be unresponsive, with agonal respiration. Initial vital signs showed blood pressure 100/60 mmHg, pulse 110 beats/min, respiratory rate 8 breaths/min and oxygen saturation (SpO2) of 70%. Chest examination revealed decreased air entry bilaterally with bibasal crackles. Initial arterial blood gas (ABG) analysis showed respiratory acidosis with pH 7.22, partial pressure of carbon dioxide (PaCO2) at 70 mmHg, partial pressure of oxygen (PaO2) at 42 mmHg and SpO2 of 72%. An emergent orotracheal intubation was performed due to severe hypoxemia and to maintain a patent airway. Pink frothy secretions were seen in the endotracheal tube immediately after intubation and a chest radiograph showed diffuse bilateral infiltrates [Figure 1]. Mechanical ventilation was started at assist control mode with initial tidal volume of 500 ml, fraction of inspired oxygen (FiO2) at 100% and positive end expiratory pressure (PEEP) at 5 cm H2 O. Patient remained hypoxemic and repeat ABG analysis showed partial pressure of PaO2 42 mm Hg and SpO2 80% prompting increase in the PEEP up to 10 cm H2O, which improved PaO2 to 85 mm Hg. Based on initial PaO2/FiO2 ratio of 52 and characteristic radiographic bilateral opacities, severe ARDS was diagnosed. An echocardiogram showed normal left ventricular function and serum levels of brain natriuretic peptide (BNP) was normal at 88 pg/ml. Lung protective ventilation to achieve adequate oxygenation was continued. Furosemide was given to maintain a negative fluid balance. Patient could be successfully extubated on the 2nd day. Chest radiograph on day 3 showed complete resolution of ARDS [Figure 2]. Figure 1 An antero-posterior chest radiograph demonstrating diffuse pulmonary edema in the intubated patient Figure 2 A postero-anterior chest radiograph in the same patient 48 h later demonstrates complete resolution of the pulmonary edema Opioid overdose has been implicated as a cause of ARDS.[1] Sporer and Dorn described 27 patients of non-cardiogenic pulmonary edema (NCPE) secondary to heroin overdose.[2] Overall, clinical presentation of opioid-induced ARDS is generally indistinguishable from other causes of ARDS. Presence of frothy, sometimes blood tinged pulmonary secretions and bilateral diffuse infiltrates on chest radiograph are characteristic. Occasionally, it may be necessary to demonstrate normal cardiac pump function through measurements of serum BNP levels, echocardiogram and rarely right heart catheterization. The mechanisms behind opioid induced NCPE and ARDS remain largely unknown. The role of increased pulmonary capillary permeability due to hypoxemia, potent histamine release and respiratory acidosis caused by depression of medullary respiratory centers have been implicated.[3,4] Interestingly, the use of reversal agents like naloxone itself has also been described as the primary cause of pulmonary edema.[5] Patients with opioid-induced NCPE and ARDS can have severe hypoxemia frequently needing invasive mechanical ventilation. An early orotracheal intubation should be considered in obtunded or severely hypoxemic patients. Following intubation, general management strategies used in any form of ARDS comprising of lung protective strategies of ventilation, appropriate PEEP and diuretics are used. Overall prognosis remains good with most patients recovering within 24 h. In summary, our case demonstrates an infrequently seen respiratory complication in opioid overdose. Timely management decisions about adequate use of reversal agents and considering early mechanical ventilation in severely hypoxemic patients can be lifesaving.

Molecular targeted therapy to improve radiotherapeutic outcomes for non-small cell lung carcinoma

Effective treatments for non-small cell lung carcinoma (NSCLC) remain elusive. The use of concurrent chemotherapy with radiotherapy (RT) has improved outcomes, but a significant proportion of NSCLC patients are too frail to be able to tolerate an intense course of concurrent chemoradiotherapy. The development of targeted therapies ignited new hope in enhancing radiotherapeutic outcomes. The use of targeted therapies against the epidermal growth factor receptor (EGFR) has offered slight but significant benefits in concurrent use with RT for certain patients in certain situations. However, despite theoretical promise, the use of anti-angiogenics, such as bevacizumab and endostatin, has not proven clinically safe or useful in combination with RT. However, many new targeted agents against new targets are being experimented for combined use with RT. It is hoped that these agents may provide a significant breakthrough in the radiotherapeutic management of NSCLC. The current review provides a brief discussion about the targets, the targeted therapies, the rationale for the use of targeted therapies in combination with RT, and a brief review of the existing data on the subject.

Transudative chylothorax in a patient with liver cirrhosis: A rare association

Chylothorax is an unusual type of pleural effusion which results from the accumulation of chyle in the pleural cavity. High triglyceride content and presence of chylomicrons in the chyle give this fluid a characteristic milky appearance. Chylothorax most commonly results from the obstruction of the thoracic duct by a malignant lesion or from its traumatic disruption. Liver cirrhosis is an uncommon and frequently underappreciated cause of chylothorax. Pleural effusion in chylothorax is typically described as a lymphocytic predominant, exudative type and it is exceedingly rare to encounter a transudative type of chylothorax. To date, very few cases of transudative chylothoraces have been described in the literature, most commonly in association with liver cirrhosis. Only a limited range of other clinical settings have been linked to transudative chylothorax and timely recognition of these associations can prevent unnecessary, expensive and sometimes invasive workup in this patient population.

A rare case of scimitar syndrome with horseshoe lung.

Scimitar syndrome is a rarely seen congenital cardiopulmonary anomaly characterised by partial or complete anomalous pulmonary venous drainage into the inferior vena cava via an anomalous descending vein that runs parallel to the right border of the heart giving an appearance of a curved Turkish sword or scimitar on plain chest radiography. Clinicians should also be aware of other interesting cardiopulmonary anomalies that can be seen in association with scimitar syndrome. A 41-year-old female presented to the Chest Medicine Clinic (University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA) with lifelong worsening dyspnoea. As part …

A case of spontaneous pneumothorax following radiation therapy for non-small cell lung cancer.

Spontaneous pneumothorax (SPTX) is a potentially devastating rare complication of the thoracic radiation therapy. Most of the cases in the medical literature, have been described in lymphoma patients receiving radiation therapy. The pathogenesis of this adverse event remains undefined although different mechanisms have been proposed. We present a case of post-radiation therapy SPTX in a non-small cell lung cancer (NSCLC), following intensity modulated radiation therapy (IMRT), which to our knowledge is the first such reported case related to this newer mode of radiation therapy. This report highlights the importance of keeping a close eye for this complication as timely treatment with chest tube insertion and drainage of the pneumothorax can be a lifesaving in these patients.

Pulmonary Adenocarcinoma in a Young Patient of Pulmonary Langerhans Cell Histiocytosis (PLCH)

tonic-clonic seizure. Magnetic resonance imaging of the brain showed a partially cystic and partially solid left frontal lobe mass lesion (Fig. 1). The patient underwent a surgical resec- tion of the lesion, and pathological examination of the lesion was consistent with adenocarcinoma (AC) of unknown ori- gin. We ordered a positron emission tomography-computed tomography scan to look for the primary site of the AC, which showed a hypermetabolic left upper lobe lung mass with hypermetabolic activity in the left hilar region (Fig. 2). A computed tomography scan of the thorax was done subse- quently, which showed the left upper lobe lung mass (2.7 cm × 2.1 cm) with hilar lymphadenopathy (Fig. 2) and innumerable bizarre shaped, disorganized cystic lung lesions consistent with the diagnoses of pulmonary Langerhans cell histiocyto- sis (PLCH) (Fig.3). A computed tomography-guided biopsy of the left upper lobe lung lesion was done, which was consis- tent with diffusely infiltrating AC of the lung (Fig. 4). Biopsy specimen was tested for two most common types of somatic epidermal growth factor receptor mutations, exon 19 dele- tion and exon 21 L858R point mutation, both of which were absent. Fluorescence in situ hybridization analysis of tumor specimen showed absent anaplastic lymphoma kinase (ALK) rearrangement on chromosome 2p23 but interestingly showed amplification of ALK signal in 58.5% of the analyzed cells. The patient was started on cisplatin and pemetrexed for the treatment of primary metastatic lung AC.

Stenting of critical tracheal stenosis with adjuvant cardio-pulmonary bypass

Severe and critical central airway obstruction causing impaired ventilation and/or oxygenation can impose tremendous challenges on the interventional pulmonologist. Near total airway obstruction can rapidly evolve into potentially fatal complete airway occlusion during bronchoscopic airway manipulation under moderate sedation; as well as during the induction of the general anesthesia. Although there are currently interventional pulmonary procedures available to tackle the critical airway obstruction in extreme situations, cardio-pulmonary bypass should be considered prior to the intervention to maintain the adequate gas exchange during the procedure. Orotracheal intubation with mechanical ventilation in this situation can be fatal itself if the obstructing airway lesion functions as a “one way valve” allowing air to follow distally during inspiration but impeding expiratory flow leading to gas trapping, high intrathoracic pressure, tension pneumothorax, and ultimately a cardiac arrest.

Bilateral Hemotympanum Following Diagnostic Bronchoscopy.

1. Tashtoush B, Schroeder J, Memarpour R, et al. Food particle aspiration associated with hemorrhagic shock: a diagnostic dilemma. Case Rep Emerg Med. 2015;2015:275497. 2. Voets PJ, Van Helvoort HA. The role of equal pressure points in understanding pulmonary diseases. Adv Physiol Educ. 2013;37:266–267. 3. Rittner F, Döring M. Curves and loops in mechanical ventilation. Draeger Medical. 1996;1:17–20. 4. West JB. Respiratory Physiology— The Essentials, 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2011.

ID: 58: ACUPUNCTURE THERAPY, AN UNDERREPORTED CAUSE OF PNEUMOTHORAX

Introduction Acupuncture is usually portrayed as a risk-free therapy; but is it? We report a case of a tension pneumothorax following acupuncture therapy. Case Presentation A 70 year-old-man was receiving acupuncture therapy for right-sided post-herpetic neuralgia involving the 4th–7th intercostal nerves. Shortly after, he started complaining of severe dyspnea and pleuritic chest pain and was transferred to the emergency department. His SpO2 was 77% on room air, respiratory rate 38/min, heart rate 129/min and blood pressure 154/82 mm Hg. Absence of breath sounds was noted on the right side. Chest X-ray (CXR) revealed a right-sided pneumothorax with mediastinal shift (figure 1). A 14F chest tube was placed and a follow-up CXR showed resolution of the pneumothorax. On hospital day#2, the air leak resolved and the chest tube was clamped, but the patient developed subcutaneous emphysema requiring unclamping of the chest tube and attaching it to suction (–40 cm H2O). On day#4, the chest tube was removed. Serial CXRs were done showing stable subcutaneous emphysema and absence of pneumothorax. He was discharged home on day#7 only to be readmitted 48h later with recurrent pneumothorax requiring placement of another 14F chest tube. Due to persistent air leak on suction, a chest CT was done showing small anterior right-sided pneumothorax and right-sided subpleural bullae (figure 2). Thoracic surgery was consulted and a Video-assisted thoracoscopic excision of ruptured bullae with talc pleurodesis was performed. He was discharged home on hospital day#13. At one month follow-up, he remained asymptomatic. Discussion Acupuncture is one of the most popular of all alternative therapies, and is a relatively safe procedure. Although rare; pneumothorax is the most reported serious complication. In a prospective observational study in Germany, the incidence of acupuncture-related pneumothorax was 1/100000 patients (1). Unfortunately, this study included various acupuncture treatments and not only the ones where needling of the thorax occurred. High quality studies are absent and most data come from case reports. In a review of the Chinese literature, 30 cases were reported between 1980 and 2013(2). In the English literature, 26 cases were reported between 1965 and 1999(3), and 13 cases between 2000 and 2011, with only 3 cases in the USA(4). Most reported cases have in common the lack of an informed consent. We are reporting this case to increase the awareness toward recognizing pneumothorax as a potential complication of acupuncture, and reinforce the need of an informed consent where benefits and risks of acupuncture therapy are discussed. Abstract ID: 58 Figure 1

Cytomegalovirus: Unusual Etiology of Lung Pseudotumor

C ytomegalovirus (CMV) can cause severe diseases in immunocompromised patients, either by reactivation of latent CMV infection or acquisition of primary CMV infection. Clinical syndromes that may be observed in this setting include encephalitis, pneumonitis, hepatitis, uveitis, retinitis, colitis and graft rejection. In immunocompromised patients, CMV pneumonia usually presents as diffuse interstitial infiltrates. However, in immunocompetent patients, CMV infection typically manifest as viral symptoms or undifferentiated mononucleosis-like syndrome. CMV infections in immunocompetent and immunocompromised patients are not rare; seroprevalence is estimated at 50.4%. CMV pneumonia has been documented rarely in immunocompetent patients. The authors describe a case of a primary lung pseudotumor due to CMV, arising in immunocompetent patient with advanced chronic obstructive pulmonary disease (COPD) successfully treated medically with Valganciclovir resulting in resolution of the lesion radiographically. This patient was found to have no risk factors commonly associated with CMV infection, such as human immunodeficiency virus (HIV), immunosuppression related to organ transplantation or chronic high-dose steroid use. Review of the literature reveals that CMV may be an underrecognized pathogen in patients not traditionally considered at risk, such as the critically ill and patients with underlying comorbidities, making diagnosis and treatment more challenging. To the authors’ knowledge, this is the 1st described case of pulmonary mass due to CMV described in an immunocompetent patient treated successfully with antiviral medication. A 70-year-old man presented for pulmonary evaluation for progressive dyspnea on exertion, weight loss and fatigue. He had a history of very severe COPD (forced expiratory volume in first second 16.7% of predicted improved to 23% of predicted with bronchodilator) and hypoxia requiring continuous nasal oxygen supplementation at 3 L/min through conserving device to maintain oxygen saturations .90% at rest. He used inhaled corticosteroids and long-acting bronchodilator through nebulizer for the treatment of his COPD as chronic therapy. He had a 60-pack year smoking history and had not traveled recently. He was last hospitalized approximately 7 months before presentation with methicillin-resistant Staphylococcus aureus pneumonia. He underwent chest radiography and computed tomography (CT) of the chest as part of his lung transplant evaluation and was found to have a 4.3 3 3.8 cm mass in the right lower lobe (Figure 1A). Arterial blood gas showed PaCO2 of 50 mm Hg and PaO2 of 65 mm Hg. HIV testing was negative. Lesion on chest CT was concerning for malignancy; however given the severity of his pulmonary function tests, surgery was not an option. Diagnostic bronchoscopy was performed with broncho-alveolar lavage (BAL), brushings and washings from the area of the lesion. There were no endobronchial abnormalities. All results, including acid-fast bacilli smear and culture, Legionella, Pneumocystis, viral and fungal culture came back negative. Pathology slides of BAL showed binucleate cells consistent with CMV infection (Figure 1B). The authors decided against CT-guided biopsy of the lung mass because of high risk for pneumothorax due to underlying severe emphysema. The patient was started on antiviral treatment with Valganciclovir 450 mg orally twice a day for 1 month. Subsequent CT scans showed progressive resolution of this lesion on above treatment. Overall in the United States, CMV seroprevalence is estimated at 50.4% by the latest analysis of NHANES, with increased prevalence in lower socioeconomic groups as well as ethnic and racial minority groups. CMV seropositivity was independently associated with older age, female sex, foreign birthplace, low household income, high household crowding and low household education. These multiple associations are not surprising, given the multiple ways that CMV can be transmitted. Episodes of CMV pneumonitis are quite common among organ transplant recipients and HIV-positive patients; however, CMV infections in immunocompetent patients have been reported. Eddleston et al reviewed more than 30 cases of CMV infections in immunocompetent individuals. These patients have relatively high mortality rates, and investigators recommended specific antiviral therapy. However, primary drug used to treat CMV infections, ganciclovir, has potential severe toxicities, including bone marrow suppression, infertility, renal impairment and teratogenesis. So, patient must be selected cautiously before starting ganciclovir in otherwise healthy individuals because of potential side effects. As mentioned earlier, in immunocompetent patients, CMV can manifest as viral prodrome or undifferentiated mononucleosis-like syndrome, rarely it can present as lung mass. To the authors’ knowledge, there is only 1 previously