Today we’re visiting the University of New Mexico for another interesting entry in our Fellows’ Case Files.
Meet Our Guests
Neel Vahil is a second-year internal medicine resident at the University of New Mexico. He completed medical school at New York Medical College and is planning on applying to pulmonary critical care fellowship programs.
Ishan Patel is a third year PCCM fellow at the University of New Mexico and will be pursuing a second fellowship in clinical informatics this year. He completed medical school and residency in Internal Medicine at Oregon Health & Science University. His fellowship research has focused on clinical outcomes of intensivist-led ECMO programs.
Dr. Lucie Griffin completed her internal medicine residency and PCCM fellowship at the University of New Mexico and is currently the Director of the Albuquerque VA medical intensive care unit.
Case Presentation
A 69 year old male veteran who presents with 6 weeks of weight loss, cough, and malaise. He has ongoing tobacco use, and history of rheumatoid arthritis on HCQ and weekly MTX with etanercept, which he had stopped taking in the three prior months. Vitals: Afebrile, mildly tachycardic to 101, BP of 93/59, saturating appropriately on room air without any signs of respiratory distress
Key Learning Points
References and Further Reading
Komarla A, Yu GH, Shahane A. Pleural effusion, pneumothorax, and lung entrapment in rheumatoid arthritis. J Clin Rheumatol. 2015;21(4):211-215.
Boddington MM, Spriggs AI, Morton JA, Mowat AG. Cytodiagnosis of rheumatoid pleural effusions. J Clin Pathol. 1971;24(2):95-106.
Balbir-Gurman A, Yigla M, Nahir AM, Braun-Moscovici Y. Rheumatoid pleural effusion. Semin Arthritis Rheum. 2006;35(6):368-378
Time for another Radiology Round by our Associate Editor Tess Litchman!
We have an older-aged woman found to have gastric and duodenal ulcers requiring multiple abdominal surgeries and transhepatic biliary drainage presenting with respiratory distress
She underwent pleural fluid drainage with the following pleural fluid studies
She ultimately had a right chest tube placed with 1.6 liters of green pleural fluid was drained
Given concern for a bilothorax, a pleural and serum bilirubin test were added. Her pleural bilirubin level was 17.2 and her serum bilirubin level was 0.5. Her chest tube was maintained, IV antibiotics were started and multi-disciplinary meetings occurred to determine next steps.
We’re diving back into some pleural fluid today (okay that is kind of gross to think about and we apologize). If you haven’t listened to our prior pleural effusion episodes and want to start from the top, then check out Episode 36 for a general approach to pleural effusions, and Episode 37 to hear about parapneumonic effusions. Malignant effusions are another common consult question and we’ll talk about everything from detection to monitoring, to definitive management.
Meet Our Guests
Dr. David DiBardino is an Assistant Professor of Medicine at the University of Pennsylvania Medicine and is the Associate Director for Clinical Research within the Section of Interventional Pulmonology. He is also the Program Director for the Interventional Pulmonary Fellowship there.
Dr. Jamie Bessich is an Assistant Professor of Medicine and Cardiothoracic Surgery at NYU Grossman School of Medicine. She is the Section Chief of Interventional Pulmonology and is the Director of Bronchoscopy at Tisch Hospital.
Dr. Van Holden is an Associate Professor of Medicine at the University of Maryland School of Medicine and is the Pulmonary and Critical Care Fellowship Program Director there. She was last on the show for our very first Fellows’ Case Files when we discussed a fascinating case of pulmonary alveolar proteinosis.
Case Presentation
The page: 72M smoker, new effusion, concern for malignancy, tap?
Further history: 72 year old man with PMH of GOLD B COPD, tobacco use (55 pack years), HTN, HLD, and diabetes. He presented to the ED with progressive dyspnea and fatigue. He is on LAMA/LABA for his COPD, and he does not frequently have exacerbations. He has no increased sputum production or wheezing, but he has been feeling progressively fatigued and lethargic. H Over the past few weeks he has had more dyspnea on exertion, and now has it at rest too. It is a bit worse when he lies flat. He has had no weight gain or edema in his legs and has actually lost 10-15 pounds in the last 3 months. In the ED, he is newly requiring 3-4L NC, has decreased breath sounds on the right, and a CXR shows a large right-sided pleural effusion, as well as a large apical nodule with some spiculation, both of which are new from prior.
Key Learning Points
Causes of malignant pleural effusion
–Lung cancer is the most common in men
–Breast cancer is the most common cause in women
–Lung and breast cancer account for > 50% of all malignant pleural effusions
–Other less common causes are lymphoma, GU or GI tract cancer
–Remember to consider mesothelioma
Prognosis of MPE
–Malignant pleural effusion means the cancer is advanced and stage 4 by definition
–The average life expectancy after a diagnosis of MPE is 3-12 months, depending on the patient and the malignancy
Imaging and MPE
–Make sure to get a CT scan after drainage so no lesions are missed
–Ultrasound can be helpful to look for disruptions of the pleural line, loculated fluid, or pleural nodules
Pleural fluid analysis
–Make sure to send common labs (gram stain, culture, pH)
–Cell count is very important as most MPE are lymphocyte-predominant
–Triglycerides can be helpful as well (more on chylothorax in future episodes)
–Cytology is essential and makes the diagnosis. The sensitivity is 65 – 75 percent so repeat taps may be needed and you need to send at least 60 cc of fluid (often more)
–If you have high suspicion and no diagnosis after two taps, pleuroscopy and pleural biopsy is warranted
Management of MPE
–First you need to determine if the MPE is recurrent. This requires drainage and then monitoring
— The main options are repeat thoracenteses, pleurodesis, or indwelling pleural catheter. A combination can often be used, and shared decision making is essential to the determining the best option
–The three things to consider with recurrent malignant pleural effusion are:
Did the patient feel better after drainage?
Did the lung fully re-expand?
What is the best option for this specific patient to optimize quality of life and time outside of the hospital?
–In AMPLE, pleural cetehters and talc pleurodesis were compared, and both are reasonable options with equivalent outcomes on quality of life; although pleural catehters had fewer hospital days overall.
Today’s #RadiologyRounds is a reminder that pulmonary care extends beyond the lungs! Although we’ll have a CT chest too
A 70-year-old woman with a diagnosis of seronegative RA presents with progressive dyspnea. PFTs show a moderate restrictive defect and moderately reduced DLCO. Here is the CT scan:
The CT was interpreted as indeterminate for UIP / fibrosing NSIP. The basilar and subpleural fibrosis and honeycombing are consistent with UIP, but with reticular nodular infiltrates and pleural effusions that are less consistent. In reviewing her history: RF, CCP, and anti-SCL70 were all negative. On hand exam, she had MCP enlargement, some PIP synovitis, and slight R hand ulnar deviation. She did not have clear telangiectasias. She had a history of GERD. She denied Raynauds. She had significant skin thickening over her legs and limited ankle mobility. X-rays were obtained:
This showed severe dystrophic calcifications and no bony erosions. This degree of extensive dystrophic calcifications is consistent with scleroderma and the patient was felt to have limited scleroderma, and possibly an overlap syndrome
The patient was started on MMF as the initial agent based on the Scleroderma Lung Study II (SLSII): https://pubmed.ncbi.nlm.nih.gov/27469583/ Glucocorticoids were avoided given the risk of scleroderma renal crisis with steroids. An anti-fibrotic was also considered but not started as 1st line.
It is Tuesday #RadiologyRounds time! We are in a pleural state of mind here at Pulm PEEPs. This is another great case authored by rockstar-associate editor @TessLitchman
A 65-year-old man with cirrhosis presents to the ED with progressive shortness of breath:
The CXR has a right lower opacity decreasing in density that is silhouetting the right hemi-diaphragm without signs of volume loss on the right concerning for pleural effusion. There is also associated atelectasis adjacent to the effusion
What is your next step for this patient?
This patient had a bedside POCUS revealing a simple pleural effusion and abdominal ascites. He also had a CT scan performed:
Based on his imaging and history, the most likely diagnosis on the differential was a hepatic hydrothorax. Here is some more information on hepatic hydrothoraces:
A transudative effusion was confirmed on thoracentesis, and no other clear etiologies were identified The treatment of hepatic hydrothorax should always start with medical management of volume overload in cirrhosis. Pleural procedures can be used for disease that is refractory
Today the PulmPEEPs are joined by two amazing educators as we start off our Top Consult series on Pleural Disease. Join us today as we go through cases to learn a systematic approach for evaluation and management of pleural effusions.
Meet our Guests
Dr. Mira John received her medical degree from Tulane University School of Medicine in New Orleans and completed internal medicine residency at Icahn School of Medicine at Mount Sinai. She is currently a second-year pulmonary and critical fellow at the University of Washington.
Dr. Ylinne Lynch completed her fellowship training at the University of Washington and is currently a Clinical Instructor at the UW. She is a great medical educator and spends her clinical time on the pulmonary consult service as well as in the ICU.
What better way to celebrate Valentine’s Day than with a new #RadiologyRounds?! We think it is time for a Lung-centered holiday, but until then enjoy this case.
The patient’s pneumothorax was managed conservatively with observation and temporary 100% oxygen via a non-rebreather for nitrogen washout. The consolidations and effusion were concerning, so the patient had a CT chest performed.
This week’s #RadiologyRounds and tutorial is authored by Huzaifah Salat, our newest PulmPEEPs contributor! See if you can figure out the case and check out our high-yield points at the end. Follow us on Twitter to answer live polls about the case.
This week’s #RadiologyRounds is brought to you by our newest Contributor, Matthew Tsai! Matt will be continuing to work with us to bring you great cases and images and we are thrilled to have him on the team! Follow us on Twitter and Instagram for our Radiology Rounds, podcast episode releases, and more!
Dave Furfaro, Kristina Montemayor, and Ansa Razzaq are back to tackle another pulmonary case! Listen in and solve the case yourself, and we’ll share some diagnostic pearls along the way. Let us know any additional thoughts on Twitter.
Patient Presentation
The is patient is 57-year-old man with hypertension and asthma who presents with dyspnea and left-sided pleuritic chest pain for 3 weeks. He was in his usual state of health until 3 weeks prior to admission, when he developed dyspnea and sharp left-sided chest pain that worsens with deep breathing. His symptoms are accompanied by unintentional 30-pound weight loss over the past several months as well as an intermittent cough that is nonproductive.
On physical exam, he is mildly tachypneic and saturating well on room air with otherwise normal vital signs. He has decreased breath sounds at the right lung base.
Initial labs
Key Learning Points
**Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below
Physical Exam Pearls
Reasons for decreased breath sounds on physical exam
1. Increased thickness of chest wall
2. Reduced airflow to part of the lung
3. Overinflation to part of the lung
4. Something between the lung and chest wall — air or fluid
Determine bradypnea and tachypnea quickly by matching your breahting rate to the patient’s respiratory rate
1. Is there a compatible presentation (imaging, physical exam)
2. Detection of non-necrotizing granulomatous inflammation in one or more tissue samples
3. Exclusion of other disease that may present similarily
Pulmonary stages of sarcoidosis:
Key to remember that patients don’t always progress through these stages. The system is useful for prognosticating and determining treatment based on the risk for disease progression.
Patients with stage 1, and even many with stage 2, often don’t require treatment
The first-line agent is oral glucocorticoids and the typical starting dose is prednisone 20 – 40 mg by mouth daily. The patient should be evaluated closely, and ideally, this dose can be tapered starting at about 4 – 6 weeks. Following this, the prednisone dose is tapered slowly over 6 months – 1 year while monitoring for symptom recurrence.
Second-line steroid-sparing agents are methotrexate, azathioprine, or mycophenolate. These are often used if the patient relapses, or is on more then 10mg daily for 3 months after the initial taper with intolerance of steroids
