Joseph G. Parambil

Causes and presenting features of pulmonary infarctions in 43 cases identified by surgical lung biopsy

BACKGROUND Although pulmonary infarction is usually associated with pulmonary thromboembolism, it can occur with other disorders such as vasculitis, angioinvasive infections, sickle-cell disease, tumor embolism, and pulmonary torsion. STUDY OBJECTIVE To identify causes and presenting features of pulmonary infarctions diagnosed by surgical biopsy in a consecutive series of patients encountered at a single institution. DESIGN Retrospective review. SETTING Tertiary care, referral medical center. PATIENTS Forty-three patients with pulmonary infarction identified on surgical lung biopsy over a period of 7 years, January 1996 through December 2002. RESULTS The median age of these 43 patients was 55 years (range, 22 to 85 years); 17 patients (40%) were women, and 26 patients (60%) were men. Thirty-five patients (81%) had a smoking history. Twenty-eight patients (65%) presented with solitary or multiple lung nodules/masses of undetermined etiology. The underlying cause was identifiable in 31 cases (72%) based on a review of clinical, laboratory, radiologic, and histopathologic data. The two most common causes were pulmonary thromboembolism (18 cases, 42%) and pulmonary infections (5 cases, 12%). Thromboembolic pulmonary infarctions typically presented as solitary or multiple nodules located in the subpleural regions. Other causes included diffuse alveolar damage in two cases (5%), pulmonary torsion in two cases (5%), and one case each of lung cancer, amyloidosis, embolotherapy, and catheter embolism. In 12 cases (28%), the underlying cause was not directly identifiable but was probably due to previous pulmonary thromboembolism. CONCLUSION We conclude that although pulmonary thromboembolism is the most common cause of pulmonary infarction identified by surgical lung biopsy, a variety of other causes are clinically encountered, including infections, inflammatory or infiltrative lung diseases, pulmonary torsion, malignancy, and nonthrombotic embolism. Pulmonary infarction should be considered in the differential diagnosis of peripheral lung nodules or masses.

Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage

Quantification of haemosiderin-laden macrophages in bronchoalveolar lavage fluid (BALF) has been used to diagnose diffuse alveolar haemorrhage (DAH) but has not been assessed in patients with diffuse alveolar damage (DAD). The present study analysed BALF obtained from 21 patients with DAD diagnosed by surgical lung biopsy. The median age of 21 patients with DAD was 68 yrs (range 18–79 yrs); 14 (67%) were male and 12 (57%) were immunocompromised. The median proportion of haemosiderin-laden macrophages in BALF was 5% (range 0–90%), but was ≥20% in seven (33%) patients, fulfilling the commonly used BALF criterion for DAH. There was a trend toward a positive correlation between the percentage of haemosiderin-laden macrophages in BALF and parenchymal haemorrhage assessed semiquantitatively by histopathological analysis. Patients with ≥20% haemosiderin-laden macrophages in BALF showed a significantly increased mortality rate (p = 0.047) compared to those with <20%. In patients with an acute onset of diffuse lung infiltrates and respiratory distress, ≥20% haemosiderin-laden macrophages in BALF can occur with DAD, and is not necessarily diagnostic of DAH. The finding of ≥20% haemosiderin-laden macrophages in BALF is associated with a worse prognosis in patients with DAD.

Obstructive bronchiolar disease identified by CT in the non‐transplant population: Analysis of 29 consecutive cases

Background and objective:  Obstructive bronchiolar disease or constrictive bronchiolitis, particularly in non‐transplant patients, is poorly understood. This study identified the associated diseases, presenting features, and clinical course of obstructive bronchiolar disease identified by CT in the non‐transplant adult population.

Solitary Pulmonary Metastasis Presenting 20 Years After Primary Resection of Wilms Tumor

Wilms tumor is the most common renal malignancy of childhood. Relapse occurs most often within 4 years of initial diagnosis, and the most common site of metastasis is the lung. We describe a 22-year-old man who presented with hemoptysis and a solitary pulmonary lesion 20 years after primary resection of Wilms tumor. Computed tomography of the chest showed an indeterminate pulmonary mass of heterogeneous attenuation with no other intrathoracic abnormalities. Surgical resection revealed a solitary pulmonary metastasis from Wilms tumor. Further evaluation yielded no evidence of extrathoracic metastases. This case shows that late relapse in the form of a solitary pulmonary mass can occur in patients with Wilms tumor.

Selected ReportsAlkaptonuria Diagnosed by Flexible Bronchoscopy

A 68-year-old white man was evaluated for failure to wean from mechanical ventilation after cardiac surgery. Bronchoscopy performed prior to percutaneous dilatational tracheotomy revealed circumferential strikingly dark-colored airways, most prominent in the trachea and mainstem bronchi, extending distally into all airways with overlying desiccated black secretions. Histologic examination of bronchial mucosal biopsy samples and the desiccated secretions showed acute bronchitis and necrotic debris, respectively. This finding and the patients history led to testing for plasma homogentisic acid, which was found to be elevated at 12.6 mug/mL, establishing the first diagnosis of alkaptonuria made using flexible bronchoscopy.

Effect of Shifting Costs to Patients on Specialty Evaluation for Sleep Disorders

OBJECTIVE To determine whether the introduction of out-of-pocket expenses to medical center employees would lead to decreased use of sleep disorder services. PATIENTS AND METHODS We retrospectively analyzed and compared the clinical and medical accounting data from visits by Mayo Clinic employees to the Sleep Disorders Center from January 1 to March 31, 2003, with that of January 1 to March 31, 2004, le, before and after a January 2004 increase in co-payments for evaluation and testing. RESULTS The total number of new patients evaluated in the first quarters of 2003 and 2004 was similar (113 vs 119; P = .37). Snoring, restless legs symptoms, hypertension, atrial fibrillation, and prior overnight oximetry testing were more prevalent in 2004 than in 2003 (P = .05, P = .01, P < .001, P = .003, P = .02, respectively). In contrast, insomnia and parasomnia complaints were less common in 2004 (P < .001). The mean apnea-hypopnea index, minimum oxygen saturation, and percentage of time with oxygen saturation less than 90% were all more severe in 2004 (P = .01, P = .001, P < .001, respectively). Sleep-related breathing disorders were more commonly diagnosed in 2004 (83.2% vs 67.2%; P = .02), whereas the diagnoses of nonbreathing disorders declined. CONCLUSION The insurance policy changes that resulted in larger employee co-payments shifted the spectrum of diagnoses seen at the Sleep Disorders Center toward more symptomatic patients, with more associated comorbidities, and patients who had more severe sleep-related breathing disorders. Total utilization did not decrease.

Synchronous Bilateral Lung Carcinoid Tumors Diagnosed by Flexible Bronchoscopy

A 60-year-old African-American man was evaluated for a right upper lobe pulmonary nodule. Bronchoscopy revealed a vascular endobronchial lesion in the posterior segment of the right upper lobe. Unexpectedly, a similar lesion was identified in the anterior segment of the left upper lobe. Histologic e