Rabih Maroun

The use of the PleurX catheter in the management of non-malignant pleural effusions:

Purpose: To evaluate the effectiveness of the PleurX catheter in the management of recurrent non-malignant pleural effusions. Methods: All subjects who underwent a PleurX catheter placement between 2003 and 2009 were evaluated. General demographic data, time to pleurodesis, complications, and a satisfaction questionnaire were collected. The subjects were divided into two groups. Group I included patients with non-malignant effusions and group II included patients with malignant effusions. Results: A total of 64 subjects were included in the final data analysis. A total of 23 subjects were included in group I and 41 subjects were included in group II. The diagnoses in group I included congestive heart failure (CHF; 13), hepatic hydrothorax (8), traumatic bloody (1), and idiopathic exudative (1). The diagnoses in group II included lung cancer (20), breast cancer (11), colon cancer (5), prostate cancer (2), B-cell lymphoma (2), and mesothelioma (1). The time to pleurodesis was 36 ± 12 days for group II compared to 110.8 ± 41 days for group I (p < 0.0001). The mean satisfaction score was similar in both groups (3.8 ± 0.4). Time to pleurodesis was significantly shorter in hepatic hydrothorax compared to CHF (73.6 ± 9 days vs. 113 ± 36 days, p = 0.006). There was one case of exit site infection in a patient with hepatic hydrothorax. Among subjects who were alive at 3 months after the catheter removal, none had recurrence of their pleural effusion. Conclusion: The Denver catheter was effective in achieving pleurodesis in non-malignant pleural effusions. The complication rate was low and patient satisfaction was high.

Lipoid pneumonia: a challenging diagnosis.

Lipoid pneumonia is a rare medical condition, and is usually classified into two groups, ie, exogenous or endogenous, depending on the source of lipids found in the lungs. Exogenous lipoid pneumonia may result from the aspiration of food and lipids. Although most cases are asymptomatic, common symptoms include cough, dyspnea, chest pain, pleural effusions, fever, and hemoptysis. Radiologically, lipoid pneumonia can manifest as consolidations, pulmonary nodules, or soft-tissue densities. These presentations involve a wide differential diagnosis, including lung cancer. Other rare causes of fatty pulmonary lesions include hamartomas, lipomas, and liposarcomas. The avoidance of further exposures and the use of corticosteroids, antibiotics, and lavage comprise the mainstays of treatment. The exclusion of mycobacterial infections is important during diagnosis, in view of their known association. Generally, acute presentations run a benign course, if promptly treated. Chronic cases are more persistent and difficult to treat. Although the radiologic and pathologic diagnosis is fairly reliable, more research is needed to clarify the optimal treatment and expected outcomes. We report on a 54-year-old man presenting with progressively worsening cough, hemoptysis, and dyspnea over a few weeks. The patient underwent multiple computed tomographies of the chest and bronchoscopies. All failed to diagnose lipoid pneumonia. The diagnosis was finally established using video-assisted thoracoscopic surgery. Most of the paraffinoma was resected during this surgery. He was treated with antibiotics and steroids, and discharged from the hospital in stable condition.

Endotracheal tube exchangers: Should we look for safer alternatives?

Endotracheal tube exchange is considered a simple procedure, performed in cases of endotracheal tube malfunction. It usually involves the use of airway exchange catheters (AECs). The procedure, however, can lead to major complications that require prompt intervention for optimal outcomes. We report on a case of endotracheal tube exchange with AECs complicated by pneumothorax, without evidence of tracheal or bronchial injury demonstrable via bronchoscopy. Increasing rates of AEC-related complications highlight the need for alternative methods to exchange malfunctioning endotracheal tubes safely.

Comparison of cytologic accuracy of endobronchial ultrasound transbronchial needle aspiration using needle suction versus no suction

Background and Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new procedure initially used for lung cancer diagnosis, staging and re-staging and extended to benign diseases such as sarcoidosis and other mediastinal lesions. Previously, multiple studies evaluated the use of needle biopsy with no aspiration that did not change the diagnostic accuracy compared with needle biopsy aspiration. Materials and Methods: All adult subjects who were scheduled to undergo EBUS-TBNA to sample mediastinal lesions were eligible. We evaluated two methods of sampling mediastinal lesions. The first method was the application of negative pressure syringe for needle suction aspiration. The second was with no suction. For every patient and every biopsy site in the same patient, we had two samples using each method. Results: Among the 26 participants, 24 patients had adequate tissue using both methods (92.3%, P = 1.00). Among the 24 patients with adequate tissue using both methods, 14 patients (58.3%) had benign pathology using both methods, whereas ten patients (41.7%) had malignant pathology using both methods (P = 1.00). Among the 32 sites that were sampled, 30 sites had adequate tissue using both methods (93.8%, P = 1.00). Among the thirty sites with adequate tissue using both methods, 17 (56.7%) had benign pathology using both methods; 12 (40.0%) had malignant pathology using both methods; and one site (3.3%) had malignant pathology using suction, but benign pathology using no suction (P = 1.00). Conclusion: In patients undergoing EBUS-TBNA to sample mediastinal lesions, the diagnostic yield with the application of suction to needle biopsy was not statistically significant compared to no suction.

A renal angiomyolipoma with extension to the renal vein and asymptomatic fat pulmonary embolus.

Renal angiomyolipoma (AML) is a rare benign tumor that can extend into the renal vein, inferior vena cava and the right atrium. AML is a mesenchymal tumor composed of smooth muscle, fat and vascular elements. In rare instances, the tumor may release a fatty tissue to the pulmonary vasculature, which can lead to cardiopulmonary collapse and death. Only four cases of fat pulmonary embolism secondary to AML have been reported in the literature but our case was the first to present as asymptomatic. Our patient had left renal AML extending to the renal vein that was associated with fat pulmonary embolus. The patient underwent uncomplicated radical nephrectomy and was discharged home on no anticoagulation. Follow-up chest computed tomography showed no extension of the pulmonary embolism. Whether embolectomy or anticoagulation is necessary in asymptomatic pulmonary embolism secondary to renal AML is unclear. Although controversial, some surgeons prefer to place an inferior vena cava filter prior to radical nephrectomy to prevent dislodgement of new intraoperative emboli, which can lead to catastrophic outcome.

Unusual Presentation of Pneumocystis Pneumonia in an Immunocompetent Patient Diagnosed by Open Lung Biopsy

Pneumocystis pneumonia (PCP) is the most common opportunistic infection in acquired immune deficiency syndrome (AIDS) patients. It is a fungal infection with Pneumocystis jiroveci which can be isolated from bronchoalveolar lavage of healthy subjects. The infection occurs mainly in HIV patients; with CD4 lymphocyte count drop to less than 200 cells/μL. PCP has been reported in non-HIV patients with other risk factors such as immunosuppressive medications, malignancies, and other inflammatory conditions. PCP has been rarely reported in immunocompetent subjects. However, in most of these patients, PCP occurred after a period of acute illness with bacterial pneumonia and antibiotic therapy. In this report, we describe a case of PCP in an immunocompetent patient with nonreactive HIV and no immunosuppressive risk factors. The patient had large pulmonary nodules discovered incidentally on chest film as preoperative evaluation for hip surgery. Bronchoalveolar lavage, transbronchial biopsies (TBB), and computed tomography (CT) guided needle biopsy were all negative for P. jiroveci. PCP diagnosis was made after open lung biopsy and wedge resection. To our knowledge, this is the first case of PCP in immunocompetent patient with negative BAL, TBB and CT guided biopsy. The diagnosis of PCP required open lung biopsy and the patient recovered without complications.

Bronchopleural fistula after robotic-assisted pulmonary lobectomy.

http://tar.sagepub.com 309 Bronchopleural fistula (BPF) is defined as a communication between a lobar or segmental pulmonary bronchi and the pleural space. It can be a late as well as early postlobectomy or postpneumonectomy complication. The incidence of BPF is 0.5% postlobectomy and can be up to 28% post pneumonectomy. It is more frequent on the right side (13.2%) compared with the left (5%) [McManigle et al. 1990; Cerfolio, 2001; Darling et al. 2005]. Moreover, the mortality is higher on the right (44%) compared with the left side (33%) [Darling et al. 2005]. The risk factors for BPF include right-sided pneumonectomy, infectious complications, radiation or chemotherapy, leaving residual tumor, long stump and surgeon inexperience, among others [Darling et al. 2005, Sato et al. 1989]. The clinical presentation ranges from acute dyspnea, fever and cough to hemoptysis, subcutaneous emphysema and persistent air leak. In some instances, BPF can lead to life threatening tension pneumothorax with cardiovascular collapse and death. In some cases, patients with BPF can present chronically with wasting, malaise and relapsing fever [Lois and Noppen, 2005]. The diagnosis of BPF is usually suggested with persistent leak through the chest tube. Chest radiographs frequently demonstrate a new or multiple air–liquid levels in the postpneumonectomy space, or a change in a preexisting air–liquid level. BPF can be confirmed by bronchoscopy; however it can be falsely negative in cases of small distal fistulas and the use of various bronchoscopic techniques such as bronchography, methylene blue instillation, capnography and balloon-tipped catheter reliably make the diagnosis [Sarkar et al. 2010]. If the location of the BPF remains in doubt, ventilation scintigraphy can be performed with high sensitivity and specificity [Raja et al. 1999]. The initial step in managing patients with BPF is hemodynamic stabilization, such as insertion of a chest tube in the presence of tension pneumothorax or drainage of an infected pleural space. The next step is the closure of the BPF, which can be done surgically as well as bronchoscopically. Surgical options are usually successful (95%) and consist of direct stump closure with or without intercostal muscle reinforcement, omental flap, thoracoplasty and chronic open drainage [Stamatis et al. 1994]. Bronchoscopically, different sealing compounds can be applied, such as tissue glue, lead shot, ethanol, watersoluble polyethylene glycol-based gel, cyanoacrylate glue, fibrin glue, albumin-glutaraldehyde tissue adhesive, gel foam, coils, balloon catheter occlusion, stent and others.

An unusual complication of pigtail catheter insertion

Thoracostomy tubes are indicated for management of air or fluid in the pleural cavity. Pigtail catheters have emerged as an effective and less morbid alternative to traditional large bore chest tubes for evacuation of pleural air or fluid. However, they do not come without complications which commonly include pneumothorax and hemothorax. Rare complications in the literature such as left ventricular penetration, subclavian artery laceration and cerebral air embolism have been reported. We report a case of a 72-year-old male who presented with dyspnea and was found to have a right-sided pleural effusion requiring thoracentesis and subsequent pigtail catheter placement because of re-accumulation of the fluid. After accidental dislodgement of the catheter, it was replaced and the following day a chest X-ray (CXR) demonstrated diffuse subcutaneous emphysema. Computed tomography (CT) scan of the chest demonstrated the pigtail catheter tracking through the right middle and lower lobes reaching the posterior pleural space. We discuss the implications of this occurrence and recommended management based on our experience.

Mediastinal recurrence after curative resection of colon cancer: A case report and review of literature

Colorectal carcinoma is one of the most common and significant causes of cancer-related death. Metastasis to mediastinal lymph nodes and/or pleura without liver or lung involvement is an atypical pattern of colon cancer metastasis. A 70-year-old male underwent curative right side hemicolectomy and omentectomy for ascending colon cancer followed by adjuvant chemotherapy. Around nine months after surgery, the patient was noted to have bilateral large pleural effusions on the restaging computed tomography scan of the chest/abdomen/pelvis. No intraabdominal or intrathoracic mass/metastasis was seen on the imaging. Multiple thoracentesis performed over the course of next few months revealed exudative effusion but failed to demonstrate malignant cells. A few months later, new mediastinal and right hilar lymphadenopathy was noted on the repeat computed tomography scan. A subsequent positron-emission tomography scan revealed multiple sites of fluorodeoxyglucose (FDG)-avid mediastinal lymphadenopathy. The sites of pleural effusion were not fluorodeoxyglucose-avid. Endobronchial ultrasound and biopsy of mediastinal nodes showed adenocarcinoma with signet-ring features. Immunohistochemistry confirmed the diagnosis of metastatic colon cancer. Systemic treatment with chemotherapy was initiated. Our case highlights the importance of mediastinal evaluation by imaging during the follow-up of patients with colorectal carcinoma. The ideal management strategy for mediastinal metastasis of colorectal carcinoma remains a question, two major options being local metastasectomy or systemic chemotherapy.

Primary Pulmonary Lymphoma and Synchronous Cecal Adenocarcinoma: A Rare Occurrence

In the era of extensive imaging and increasing indications for performing PET-CT scans, the recognition of synchronous tumors may be greater than before. However, the majority of these tumors are seen to occur in the same organ system, likely because of sharing similar pathogenic mechanisms. Synchronous lung cancers of similar or differing histologies have been reported. Primary pulmonary lymphoma, which is a rare form of non-Hodgkin’s lymphoma, has also been seen with a synchronous primary lung cancer. However, we report a case of a 56-year-old male diagnosed with primary pulmonary lymphoma and on PET-CT imaging, found to have a cecal lesion, the biopsy of which showed adenocarcinoma. We discuss the incidence of the co-existence of multiple tumors, the pathogenic mechanisms involved, and approaches to the management of these rare clinical scenarios.