Pulmonary Medicine

Kim, W. Y., I. Kugasia, G. Pearson and O. Epelbaum (2021). “Dramatic Ventricular Shunt Complications in Pulmonary and Critical Care Medicine.” Am J Respir Crit Care Med 204(9): e94-e96.

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A 29-year-old man with bilateral ventriculoperitoneal shunts (VPS) underwent left shunt revision with replacement of the valve and distal catheter. On postoperative Day 1, he developed subcutaneous emphysema (SE) from the neck to the scrotum. Chest radiography demonstrated SE without pneumothorax (Figure 1A). Chest computed tomography (CT) (Video 1) showed widespread SE without pneumoperitoneum. The next day, sepsis and progressive SE were noted. Abdominal CT showed the VPS catheter perforating into the small intestine with its tip inside the lumen (Figure 1B). Following emergent laparotomy with resection of the perforated segment, the patient’s truncal SE resolved (Video 2). Despite a prolonged postoperative course, he was ultimately transferred from our institution in stable condition.[No abstract; excerpt from article].

Karime, C., M. Ijaz, I. R. Kugasia, A. Khan and G. S. Schwartz (2021). “A 49-Year-Old Woman With Persistent Bilateral Pleural Effusions.” Chest 160(3): e273-e278.

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A 49-year-old woman presented to the ED with sudden onset abdominal pain, nausea, and vomiting. Her medical history included an uncomplicated gastric lap band surgery 9 years ago and subsequent removal of lap band after 6 years. She had a Roux-en-Y gastric bypass and cholecystectomy 5 months prior to the current presentation. The patient had been diagnosed with asthma and was prescribed an inhaled corticosteroid that she used only as needed. The patient denied smoking and heavy alcohol consumption. She was currently employed as a scrub technician in a local surgical center.

Reininger, K.A., Sam, T., Patel, R.S., Grazia, T.J., Naik, C.A., Ausloos, K.A., Rosenblatt, R.L. and Lam, I.L.L. (2021). “A retrospective analysis of the safety and efficacy of apixaban use after lung transplant.” Clin Transplant: e14327.

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Direct acting oral anticoagulants (DOACs) have become the mainstay of treatment for patients requiring anticoagulation for atrial arrhythmias and venous thromboembolism (VTE) but safety and efficacy has not been established in lung transplantation. This is a retrospective review of 28 adult lung transplant patients who were prescribed apixaban for stroke prevention in atrial arrhythmias or treatment of VTE between October 15, 2015 and December 31, 2018. The primary outcome was a composite of efficacy and safety measured by recurrence or breakthrough of stroke or thromboembolism and bleeding events. Seven patients were treated for atrial arrhythmias and 21 treated for VTE. Fifteen patients received CYP3A4 or P-gp inhibitors at initiation of anticoagulation, and 4 of these patients received strong CYP3A4 inhibitors. During the follow-up period, one breakthrough DVT and one clinically relevant non-major bleed were observed. These data suggest that apixaban may be safe to use for lung transplant patients, and larger studies are warranted to assess long-term outcomes as well as safety and efficacy of alternative DOACs.

Steiger, D., Siddiqi, M.F., Yip, R., Yankelevitz, D.F., Henschke, C.I. and I-ELCAP investigators (2021). “The importance of low-dose CT screening to identify emphysema in asymptomatic participants with and without a prior diagnosis of COPD.” Clin Imaging 78: 136-141.

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PURPOSE: Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis, small airways disease, and emphysema. Diagnosis of COPD requires spirometric evidence and may be normal even when small airways disease or emphysema is present. Emphysema increases the risk of exacerbations, and is associated with all-cause mortality and increased risk of lung cancer. We evaluated the prevalence of emphysema in participants with and without a prior history of COPD. METHODS: We reviewed a prospective cohort of 52,726 subjects who underwent baseline low dose CT screening for lung cancer from 2003 to 2016 in the International Early Lung Cancer Action Program. RESULTS: Of 52,726 participants, 23.8%(12,542) had CT evidence of emphysema. Of these 12,542 participants with emphysema, 76.5%(9595/12,542) had no prior COPD diagnosis even though 23.6% (2258/9595) had moderate or severe emphysema. Among 12,542 participants, significant predictors of no prior COPD diagnosis were: male (OR = 1.47, p < 0.0001), younger age (OR(age10) = 0.72, p < 0.0001), lower pack-years of smoking (OR(10pack-years) = 0.90, p < 0.0001), completed college or higher (OR = 1.54, p < 0.0001), no family history of lung cancer (OR = 1.12, p = 0.04), no self-reported cardiac disease (OR = 0.76, p = 0.0003) or hypertension (OR = 0.74, p < 0.0001). The severity of emphysema was significantly lower among the 9595 participants with no prior COPD diagnosis, the OR for moderate emphysema was OR(moderate) = 0.58(p = 0.0007) and for severe emphysema, it was OR(severe) = 0.23(p < 0.0001). CONCLUSION: Emphysema was identified in 23.8% participants undergoing LDCT and was unsuspected in 76.5%. LDCT provides an opportunity to identify emphysema, and recommend smoking cessation.

Miranda, L., Kugasia, I., Han, L., Chandy, D. and Epelbaum, O. (2021). “Tuberculous placenta: a rare bird but not extinct.” Postgrad Med J Mar 15;postgradmedj-2021-139902. [Epub ahead of print].

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A 26-year-old woman from Pakistan presented to our institution in New York with episodic right-sided weakness and expressive aphasia. She was at 36 weeks’ gestation of an uncomplicated third pregnancy. On presentation, the patient appeared well, had normal vital signs and was afebrile. Her neurological examination was normal between recurrences. The patient reported usual fetal movement, and fetal monitoring displayed a reassuring tracing. MRI of the brain without gadolinium revealed numerous ring-like hyperintense lesions most consistent with an inflammatory or infectious aetiology (figure 1A). CT of the chest demonstrated multiple bilateral lung nodules with areas of coalescence (figure 1B). The patient denied respiratory symptoms. HIV and vasculitis testing was negative. Interferon gamma release assay had been positive earlier in the pregnancy. Lumbar puncture was performed: there was an elevated opening pressure, lymphocytic pleocytosis, low glucose and high protein. [No abstract; excerpt from article].