Mourad Ismail

Diffuse pulmonary infiltrates: A guise of adenocarcinoma

Small and non-small cell lung cancer present in a variety of radiologic and clinical patterns, and have been linked to smoking. Primary adenocarcinoma of the lung has been increasingly recognized in females and nonsmokers, often presenting a diagnostic challenge. In the absence of smoking history, these radiographic patterns may be initially misdiagnosed as an infectious or inflammatory condition, often delaying the diagnosis of malignancy. We report two cases of female patients with relatively short or no smoking history presenting with diffuse pulmonary infiltrates not typically seen in primary lung cancer, which created a diagnostic challenge, ultimately diagnosed as primary lung adenocarcinoma. Each case had different subtype patterns of adenocarcinoma. The first case described adenocarcinoma of mostly acinar pattern; while the second case was noted to have adenocarcinoma of micropapillary pattern. Given lung adenocarcinomas nonspecific presentation, which may mimic infectious and diffuse interstitial lung disease, the above cases highlight the importance of entertaining lung adenocarcinoma as part of the differential diagnosis of such presentations.

Pulmonary Mucormycosis - A Disease Against Time

Abstract SESSION TYPE: Infectious Disease Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Pulmonary mucormycosis, a rare fungal infection with a high mortality rate, has been reported in patients with diabetic ketoacidosis, diabetes mellitus, and immunosupression due to chemotherapy, steroids, and hematological malignancies. Without early recognition and management, it can be ultimately fatal. We report a rare case of isolated pulmonary mucormycosis.CASE PRESENTATION: 65-year-old Caucasian male presented with shortness of breath for 2 days associated with chills, nonproductive cough, right upper pleuritic chest pain, and 4 days of polyuria and polydipsia. Patient was recently admitted and discharged on tapering prednisone for COPD exacerbation. Patient had 30 pack year smoking history. On presentation he was febrile, tachycardic, tachypneic and normotensive with physical findings consistent with right upper lobe (RUL) infiltrate. Lab investigations showed leukocytosis. Serum chemistry showed acute kidney injury (AKI) and hyperglycemia with a normal anion gap. Chest x-ray demonstrated RUL infiltrate. Patient was started on IV fluids, insulin drip, and piperacillin-tazobactam, vancomycin and ciprofloxacin. In ICU, patients vitals deteriorated requiring mechanical ventilation. Initially all cultures showed no growth. Ciprofloxacin and vancomycin were changed to moxifloxacin and linezolid with addition of tobramycin. RUL infiltrate steadily worsened with suspicion of cavitation or abscess formation. CT chest showed necrotizing RUL infiltrate. Patient developed multi-organ failure and DIC requiring aggressive management. Bronchoscopy and BAL of the RUL showed mucosal edema and dark brown secretions . Few weeks later BAL results yielded a mold with cultures positive for Rhizopus species. Posaconazole and amphoterocin B were used to treat Rhizopus. Surgery for lobectomy could not be performed due to multilobar involvement. Gradually necrotizing pneumonia resulted in right sided pneumothorax. Chest tube was placed with non-resolving severe air leak. Repeat bronchoscopy showed bronchopleural fistula and necrotizing tissue. After multiple family meetings, comfort care decision was made, after which patient passed away.DISCUSSION: Rhizopus is genus of class Zygomycetes. It can cause tissue infarctions ranging from cutaneous, rhinocerebral, and sinopulmonary to disseminated and frequently fatal infections, especially in immunocompromised hosts. Ischemic necrosis of tissues can prevent delivery of antifungal agents to the foci of infection. Surgical debridement is critical for treatment but is only possible if disease is localized. Combination of posaconazole, amphotericin B and capsofungin is used for medical management.CONCLUSIONS: Pulmonary mucormycosis is a rapidly progressive rare disease that carries a high mortality over a short period of time. Dissemination, multiorgan failure and invariably death follows, if not recognized early.1) Francis Y. Pulmonary Mucormycosis Arch Intern Med. 1999;159:1301-1309DISCLOSURE: The following authors have nothing to disclose: Muhammad Ali, Hasan Zaidi, Aasiya Haroon, Nader Mahmood, Mourad IsmailNo Product/Research Disclosure InformationSt. Josephss Regional Medical Center/Seton Hall Universtiy, Paterson, NJ.