Chest Case Conference March 1, 2017

Dr. Jayanth H. Keshavamurthy. M.B.B.S.

Case 1

CXR- 30 yr old male acute shortness of breath

CT CHEST

IMPRESSION:

• 1. Severe diffuse alveolitis and inflammatory nodules consistent with pulmonary parenchymal inhalational injury. No pneumothorax.

•2. Trachea and central bronchi are patent.

FINDINGS

• Ground glass centri lobular nodules.• Apical predominance• So likely route of exposure via airway

Silo-fillers disease

Case 2 A

33 year old female acute shortness of breath

CT chest with contrast

IMPRESSION:

•1. Diffuse bilateral groundglass opacities with peribronchial thickening concerning for interstitial edema which may be cardiogenic (correlate with BNP) versus atypical pneumonia versus acute noxious injury .2. Trace pericardial effusion.3. No CT evidence for pulmonary embolism or aortic dissection.

Better

• 1. Is there Cardiogenic pulmonary edema.• 2. Is there PH?• 3. Is there centrilobular nodules?• 4. Is there pleural effusion, etc or other signs of

pulmonary edema?

Case 2 B

53 year old male -acute shortness of breath

CT chest with contrast

IMPRESSION:

1. Bilateral segmental and subsegmental pulmonary embolism with left lobar pulmonary embolism. There is straightening of the intraventricular septum, consistent with right heart strain. Mild cardiomegaly.2. Diffuse bilateral airspace opacities with bilateral crazy paving and subpleural sparing. Findings are highly concerning for bilateral multifocal pneumonia.3. Reactive hilar lymphadenopathy.

How could you have done better ?

Marijuana induced acute necrotizing bronchiolitis- unfortunately first patient succumbed to her illness.

Ivan A. Morales, Caralee J. Forseen, Paul W. Biddinger, Jayanth H. Keshavamurthy, Norman B. Thomson, Thomas FortsonMedical College of Georgia at Augusta University

Augusta, GA

• Use of marijuana for recreational and medicinal purposes has been prevalent for thousands of years in many cultures

• Advent prior to 2700 BCE in China• Recent data shows trends of increased use

worldwide• Lifetime use in the U.S. reached a prevalence of

42.8%• Marijuana's safety is brought into question

• Here we describe a case necrotizing bronchiolitis after marijuana use

• With other etiologies ruled out, this case was an example of necrotizing bronchiolitis secondary to inhalation of noxious stimuli likely from the marijuana from a new dealer

• Marijuana has been shown to have a wide variety of beneficial uses, but the question remains, is it safe?

• Inhalation of the smoke produced by igniting marijuana is the most common route for use

• Combustion of marijuana emits hundreds of compounds, including the primary psychoactive ingredient THC and over 100 other cannabinoids

• Marijuana smoke also deposits tar and an array of noxious chemicals including NH3, HCN, NOx, aromatic amines, and polycyclic aromatic hydrocarbons at equal or higher concentrations than tobacco smoke

• Respiratory symptoms including chronic cough, bronchitis, and wheezing were reported at similar percentages for marijuana and tobacco smokers

• Analysis of respiratory mucosa biopsies in marijuana smokers show extensive airway inflammation comparable to tobacco smokers, which is likely responsible for the increased respiratory symptoms

1. United Nations Office on Drugs and Crime. World Drug Report 2014. United Nations publication, Sales No. E.14.XI.7.

2. Joshi M, et al. Marijuana and Lung Diseases. Curr Opin Pulm Med. 2014; 20(2): 173-9. 3. Moir D, et al. A comparison of mainstream and sidestream marijuana and tobacco cigarette

smoke produced under two machine smoking conditions. Chem Res Toxicol. 2008; 21(2):494-502.4. Moore, BA et al. Respiratory Effects of Marijuana and Tobacco Use in a U.S. Sample. J Gen Intern

Med. 2005; 20(1): 33–37.5. Tetrault, JT, et al. Effects of Marijuana Smoking on Pulmonary Function and Respiratory

Complications: A Systematic Review . Arch Intern Med. 2007; 167(3): 221–228.

Marijuana: Is It Safe? A Case of Fatal Necrotizing Bronchiolitis

• 31-year-old female presented to the emergency department (ED) with shortness of breath, cough, and chest pain for 2 weeks

• Diagnosed with an upper respiratory infection at an urgent care clinic 4 days prior and prescribed a steroid taper and azithromycin with no improvement

• History of cigarette smoking 1 pack/day and smoking marijuana• In the ED she has a pulse of 110 bpm, a respiratory rate of 24 breaths/min, and a SaO2 of 77% on room air. • Lungs clear to auscultation• Laboratory findings showed ↑ WBC count, ↑ BNP of 223, and ↑ troponin of 0.24. • Portable CXR demonstrated nodular changes bilaterally (below)• Echocardiogram revealed no abnormalities• CTA revealed no evidence of pulmonary embolism but showed severe diffuse bilateral groundglass

opacification with diffuse centrilobular nodules (below)• Treatment for pneumonia was initiated• Lung biopsies revealed necrotizing bronchiolitis associated with diffuse interstitial and intralveolar pneumonia• The samples were negative for fungi, acid-fast bacilli, bacteria, HSV 1/2, and CMV• Inhalation of a toxic substance was suspected• Patient admitted to smoking marijuana from a new dealer 2 weeks ago when the symptoms began• Unfortunately, she succumbed to her illness due to diminished gas exchange from severe acute necrotizing

bronchiolitis.

Conclusion

Discussion

References

Introduction Clinical Presentation

AP Portable Chest X-Ray: Demonstrated nodular changes bilaterally with no consolidation

CT Angiogram:Revealed no evidence of pulmonary embolismShowed severe diffuse bilateral groundglass opacification with diffuse centrilobular nodules, bronchiolar thickening, and interspersed parenchymal blebs.

A. Diffuse effacement of lung architecture and bronchiole containing necrotic cell debri, macrophages, and lymphocytes

B. Bronchiole showing squamous metaplasia, necrotic cell debris; intralveolar inflammatory exudate

A. B.

Case 3

39 year old female acute shortness of breath

IMPRESSION

1. Centrally distributed groundglass opacity involving all lobespossibly representing pulmonary edema, but multilobar infection is a concern given leukocytosis. Specifically, there are no cavitary lesions to suggest septic emboli.2. Mild centrilobular emphysema with 6 mm right lower lobe pulmonary nodule.3. Likely reactive prominent mediastinal and hilar lymph nodes.4. Multivessel coronary artery calcifications advanced for thepatient's age.

How could you have done better ?

Non cardiogenic pulmonary edema likely from acute methadone lung injury.

Case 4

39 year old female acute shortness of breath

Echo• Compared to prior echo done

The left ventricle is mildly dilated with normal wall thickness.There are multiple wall motion abnormalities; the anteroapical area appearsmore hypokinetic than on previous echo 11/2014.

• Left ventricular systolic function is moderately to severelyreduced;ejection fraction is 31% by the biplane method of disks.The left ventricular filling pattern is pseudonormal.

Cardiogenic pulmonary edema.

Case 5

2 days later

• Neurogenic pulmonary edema.• Alveolar edema more than interstitial edema.

Case 6

CLINICAL STATEMENT: "desatting and rales post op,concern for pulm edema"

Negative pressure edema

Case 7

57 year old with APML and recently started treatment

Old name retinoic acid syndrome, now differentiation syndrome

http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=117520&ti=379439&si=1166&searchkey=#poster

Case 8

27 year old

Pulmonary alveolar proteinosis

Case 9

Day1

Day 3

After treatment

Alveolar hemorrhage from pulmonary renal hemorrhagic syndrome

Case 10

CT lung screening MIP

RB -ILD

Case 11

58 year old smoker and restrictive lung disease

Case 12

31 year old male smoker

http://pubs.rsna.org/doi/full/10.1148/rg.285075223

Case 13

TS with LAM

http://thoracicrad.org/assets/index/2015/Case_of_the_Month/cardio/10-2015/index.htm

Case 14

41 year old with fever and cough

Did you identify all the support devices correctly?

Severe pneumonia needing a VV ECMO catheter placement

2 years later