This is a 22 year old female with no prior respiratory complaints.  She devloped a bronchitis in February and May, 2008 and had a CXR that suggested bullous disease in the RUL.  PFT’s showed normal spirometry and the diffusion capacity was 89% predicted.  She had no respiratory illness as an infant.

Her CT scan showed the following

Which of the following would you recommend?

1) Leave the bulla alone, no Rx recommended, inform to go to ED with SOB or pain

2) Recommend Scuba diving lessons to utilize hyperbaric conditions to shrink the bulla

3) Refer for an experimental endobronchial valve to deflate the bulla

4) Refer to thoracic surgery for surgical bullectomy

5) Insert a Heimlich valve to permit deflation of the bulla through chest wall

I include a reference regarding 1 way valves:valve

This 49 year old male had been healthy but presented with increasing SOB. Below are the radiographs in the first 6 days in the hospital

This 34 year old female presented for evaluation with 2 months of increasing shortness of breath, chest tightness and cough.  There was minimal sputum production, but she is uncomfortable at night and had to sleep with 2 pillows.  Wheezing had been present but she did not respond to steroids, albuterol or Symbicort. Her lab data was normal except for a positive mono test.  She was not exposed to any aerosols.  She is a non-smoking, non-drug using female with 2 children living in a rural enviroment.

The CT images are shown:

What are possible diagnoses and how would proceed at this time

This patient arrives with hypoxia despite supplemental oxygen and this radiograph.  Why do you think the film is abnormal and what is the diagnosis?

clinical-practice-essay

The ground glass infilitrates were caused by alveolarseptal amyloidosis.  The CT showed a uniformity of ground glass infiltrates, without a mosaic pattern.  The pathology images above include H&E, congo red and crystal violet stains which are typically used to confirm the diagnosis.  The fibrils were also  birefringent but this could not be photographed.  These were samples obtained by transbronchial biopsy.

 This case was used as a clinical vignette for the 2nd year medical students.  Above is the paper written by Nicholas Braus (click on the clinical-practice-essay icon) which is an excellent review of the pathophysiology of this disorder.  I invite you to read it.

This patient is a 67 year old female who had a chronic right pleural effusion.  A thoracentesis in March did not reveal a cause.  She presented in May to HH with a pain in her left chest and increased sputum production for 2 weeks. A CT scan was done.  What do you think was responsible for the air in the pleural space?

This is a 57 year old black female who had been a smoker but stopped 1 yr ago . She complained of increasing shortness of breath over 1 year.  She had undergone PFT’s that showed reduced FVC (59%) predicted and FEV1 (72% predicted).  Her total lung capacity was 71 % predicted.  She was unable to do a diffusion capacity.  The intial chest radiograph was read as normal.  Representative images from her CT scan are above

Do you think this is an abnormal scan? Would you perform a diagnositic procedure? If abnormal, suggest a diagnosis compatible with the CT scan.

This is a 55 year old female who has sustained 2 pneumothoracies and had bilateral pleurodesis.  Otherwise she is mildly short of breath.  PFT’s show an FEV1 of 69% predicted an FEV1/FVC ratio of .50.  Her DlCO is 79% of predicted.  She has not smoked and the alpha-1 level is normal

Please offer a differential diagnosis

The prior benign nodule case was nodular amyloidosis.  Please read about the risk of bleeding and nodular amyloidosis under the case comments.  One of the DDx was an AVM  I include a recent patient with an AVM that was diagnosed many years ago and embolized recently.  The patient had some TIA’s which is a risk as is brain abscess.

Can one of the fellows write a brief review of sclerosing hemangiomas and find an image for me to publish? That was another popular dx.  LL had nodular amyloidosis in her DDx.

This is a 35 year old EMT who presented to HH with severe SOB and hypoxia.  He was feeling well, but the day before admission applied waterproofing aerosol to his boots outside in a well ventilated area for 20 minutes.  The next day he was SOB and came to the emergency room.  He was a smoker but did no elicit drugs.  He revovered over the next 24 hours.  He has no known systemic disorder

What is the cause of the lung injury?