PURPOSE:Clinicians choose to start Mycobacterium tuberculosis (TB) therapy based on microbiologic data (smear and culture), clinical presentation and radiologic findings, but diagnostic suspicion for TB is lower in areas with a low prevalence of TB and this may delay treatment initiation.While chest CT scans have a high sensitivity and specificity for TB, radiologist suspicion for TB is likely lower in areas of low prevalence.The purpose of this study was to determine if a radiologist specifically raising concern for TB in a CT scan report altered the time to treatment initiation of TB therapy. METHODS:All patients with positive TB cultures in the last 20 years at our tertiary care medical center were retrospectively identified.Patients with an abnormal chest CT scan as part of their initial evaluation were included.Patients without a CT scan and those with exclusively extrapulmonary TB were excluded.Radiology reports were reviewed and characterized into 2 groups.Patients were considered ''High Suspicion for TB (HighSTB)'' if they included any of the following words: "Mycobacterium," "TB," "Tuberculosis," or "Mtb."All other patients were considered "Not High Suspicion for Tuberculosis (LowSTB)''.Statistical analysis with Kaplan Meier and Cox Proportional-Hazard models was performed with SPSS.RESULTS: Patients were 42% female and 58% male.Average age was 55.3 AE 17.0.25% of patients were Asian, 33% Black/African, 21% Caucasian, 17% Hispanic/Latinx, and 4% unknown.The median time to treatment for the HighSTB group was 3.0 AE 0.8 days compared to 12.0 AE 5.2 days for the LowSTB group.The means for HighSTB and LowSTB groups were 7.0 AE 2.1 days and 20.9 AE 3.7 days respectively [X 2 (1, N ¼ 48) ¼ 11.2, p < 0.001].Age, gender and ethnicity did not affect time to start treatment, but Acid-Fast Bacilli (AFB) smear status did.Even after adjusting for TB smear status with cox hazard-proportional model, the HighSTB group was still significantly associated with increased chance of earlier treatment initiation (HR ¼ 1.4, 95% CI ¼ 1.1-1.9p < 0.05).CONCLUSIONS: Specifically reporting high suspicion for TB in radiologic reports significantly correlates with earlier treatment initiation times.CLINICAL IMPLICATIONS: Physicians practicing in areas with a low TB prevalence need to maintain a high level of suspicion for TB to enhance care and treatment initiation.

SESSION TITLE: Diffuse Lung Disease Case Report Posters 13 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Granulomatous and lymphocytic interstitial lung disease (GL-ILD) is a distinct clinic-radio-pathologic form of ILD occurring in patients with common variable immunodeficiency (CVID) that results in long-term lung damage and respiratory impairment associated with poor clinical outcomes. Herein is described the case of a patient with CVID with progressive pulmonary infiltrates consistent with GL-ILD. CASE PRESENTATION: A 33-year-old male with a past medical history significant for CVID with recurrent sinopulmonary infections and sepsis presented with persistent fevers, chills, and headaches. Chest imaging revealed innumerable ground glass and nodular centrilobular opacities bilaterally, which had increased in size and number since their initial discovery 2 years prior. Bronchoscopy with bronchoalveolar lavage was performed to evaluate for nontuberculous mycobacterial disease with negative results. Empiric antibiotic therapy resulted in clinical improvement and the patient was planned for outpatient evaluation. PFTs showed mild restriction with moderate diffusion defect. 6-minute walk test noted mild desaturation with ambulation. Serial CT imaging revealed increasing multifocal ground-glass and solid nodules throughout the lung fields with persistent mediastinal and hilar lymphadenopathy and splenomegaly. Transbronchial needle biopsy of the left upper lung lobe and a hilar lymph node was sent to a CVID center for evaluation where pathology identified peribronchial lymphocytic infiltrate with histiocytes. The patient was diagnosed with GL-ILD based on clinical, radiologic, and pathology findings. Treatment with rituximab and azathioprine resulted in symptomatic improvement and PFT stability. DISCUSSION: Up to 90% of patients with CVID may be affected by diffuse parenchymal lung complications including infection, hypersensitivity pneumonitis, immune-mediated disease, malignancies, or GL-ILD amongst other processes. GL-ILD is a rare, severe non-infectious complication that is recognized with increasing frequency. The natural course and optimal treatment of GL-ILD are yet to be fully understood, however literature suggests that GL-ILD is a progressive lung disease, and that early recognition and treatment can impact the disease progression. In this patient with recurrent and progressive respiratory symptoms, exhaustive testing for alternate explanations and consultation with a CVID center aided in the diagnosis of GL-ILD. A thorough evaluation of respiratory symptoms and maintaining a suspicion of GL-ILD is crucial to comprehensive care of patients with CVID. CONCLUSIONS: Given the lack of well-defined clinical, laboratory, and radiological diagnostic parameters that may identify patients suffering from or at risk for development of GL-ILD, this case adds to a growing body of literature. A better understanding of GL-ILD may lead to earlier diagnosis and therapy for patients with CVID. REFERENCE #1: Verbsky JW, Hintermeyer MK, Simpson PM, et al. Rituximab and antimetabolite treatment of granulomatous and lymphocytic interstitial lung disease in common variable immunodeficiency. J Allergy Clin Immunol. 2021;147(2):704-712.e17. doi:10.1016/j.jaci.2020.07.021 REFERENCE #2: van de Ven AAJM, Alfaro TM, Robinson A, et al. Managing Granulomatous-Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency Disorders: e-GLILDnet International Clinicians Survey. Front Immunol. 2020;11:606333. doi:10.3389/fimmu.2020.606333 REFERENCE #3: Cinetto F, Scarpa R, Carrabba M, et al. Granulomatous Lymphocytic Interstitial Lung Disease (GLILD) in Common Variable Immunodeficiency (CVID): A Multicenter Retrospective Study of Patients From Italian PID Referral Centers. Front Immunol. 2021;12:627423. doi: 10.3389/fimmu.2021.627423 DISCLOSURES: No relevant relationships by Daniel Baram No relevant relationships by Maryssa Miller No relevant relationships by Ivana Milojevic No relevant relationships by Christopher Walker

SESSION TITLE: Infectious Complications with Obstructions and ConnectionsSESSION TYPE: Case ReportsPRESENTED ON: 10/17/2022 03:15 pm - 04:15 pmINTRODUCTION: Invasive pulmonary fungal infections are a challenge for diagnosis. One of the most common types is Invasive pulmonary aspergillosis. It occurs usually among immunocompromised patients [1], so an early diagnosis is warranted for potential better outcome. Evidence of calcium oxalate can be an early diagnostic tool for such an infection. The presence of calcium oxalate crystals can be detected within 24 hours under polarized light in the microbiology labs. We present this case to highlight the potential importance of pulmonary oxalosis in diagnosing pulmonary aspergillosis.CASE PRESENTATION: A 62-year-old-woman with limited breast cancer was admitted to the hospital seven days after her last cycle of docetaxel and cyclophosphamide with COVID-19 pneumonia and hypoxemic respiratory failure. She was not neutropenic. She received a full course of dexamethasone and remdesivir. Sputum cultures subsequently grew Klebsiella aerogenes for which she was treated with antibiotics but failed to significantly improve over four weeks. Repeat chest computed tomography (CT) showed progressive multifocal airspace opacities with new areas of cavitation. Patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy. Transbronchial biopsy specimen from the right upper lobe showed bronchial mucosa and lung parenchyma with calcium oxalate crystals and no organisms. Biopsy specimen from the right middle lobe showed fungal organisms consistent with Aspergillus invading bronchial mucosa and lung parenchyma.Several days later, serum beta-D-glucan returned within normal limits, serum galactomannan was significantly elevated, and BAL culture grew Aspergillus niger. Patient improved with antifungal therapy.DISCUSSION: Fungal pneumonia has high morbidity and mortality. It is essential to start antifungal therapy as soon as possible. Pulmonary oxalosis or calcium oxalate has been seen among Aspergillus Fumigatus and Aspergillus Niger [2-3]. It is a combination of oxalic acid which is produced by Aspergillus spp. and calcium from blood supply of an invaded tissue. Further progression of lesions can be due to calcium oxalate toxicity itself [4-5]. In our case, clinical suspicion for pulmonary aspergillosis was high and we were able to document fungal invasion of lung parenchyma on one of the lung specimens. Though fungal culture is very sensitive and specific, it can take several days to result. Tissue staining for crystals can be performed quickly and provide more timely information when deciding about starting anti-fungal therapy.CONCLUSIONS: Pulmonary oxalosis, calcium oxalate deposition, can be seen in aspergillus infection and should be considered as an early diagnostic tool for invasive pulmonary aspergillosis.Reference #1: Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011; 20(121): 156–174, doi: 10.1183/09059180.00001011Reference #2: U. Pabuccuoglu, Aspects of oxalosis associated with aspergillosis in pathology specimens, Pathol. Res. Pract. 201 (2005) 363–368Reference #3: Osholowu OS, Kak V, Singh H. Pulmonary oxalosis in pulmonary aspergillosis syndrome. Adv Respir Med. 2020;88(2):153-156. doi: 10.5603/ARM.2020.0090. PMID: 32383468.DISCLOSURES: No relevant relationships by Mohammed AlsaggafNo relevant relationships by Daniel BaramNo relevant relationships by Ivana Milojevic SESSION TITLE: Infectious Complications with Obstructions and Connections SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: Invasive pulmonary fungal infections are a challenge for diagnosis. One of the most common types is Invasive pulmonary aspergillosis. It occurs usually among immunocompromised patients [1], so an early diagnosis is warranted for potential better outcome. Evidence of calcium oxalate can be an early diagnostic tool for such an infection. The presence of calcium oxalate crystals can be detected within 24 hours under polarized light in the microbiology labs. We present this case to highlight the potential importance of pulmonary oxalosis in diagnosing pulmonary aspergillosis. CASE PRESENTATION: A 62-year-old-woman with limited breast cancer was admitted to the hospital seven days after her last cycle of docetaxel and cyclophosphamide with COVID-19 pneumonia and hypoxemic respiratory failure. She was not neutropenic. She received a full course of dexamethasone and remdesivir. Sputum cultures subsequently grew Klebsiella aerogenes for which she was treated with antibiotics but failed to significantly improve over four weeks. Repeat chest computed tomography (CT) showed progressive multifocal airspace opacities with new areas of cavitation. Patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy. Transbronchial biopsy specimen from the right upper lobe showed bronchial mucosa and lung parenchyma with calcium oxalate crystals and no organisms. Biopsy specimen from the right middle lobe showed fungal organisms consistent with Aspergillus invading bronchial mucosa and lung parenchyma. Several days later, serum beta-D-glucan returned within normal limits, serum galactomannan was significantly elevated, and BAL culture grew Aspergillus niger. Patient improved with antifungal therapy. DISCUSSION: Fungal pneumonia has high morbidity and mortality. It is essential to start antifungal therapy as soon as possible. Pulmonary oxalosis or calcium oxalate has been seen among Aspergillus Fumigatus and Aspergillus Niger [2-3]. It is a combination of oxalic acid which is produced by Aspergillus spp. and calcium from blood supply of an invaded tissue. Further progression of lesions can be due to calcium oxalate toxicity itself [4-5]. In our case, clinical suspicion for pulmonary aspergillosis was high and we were able to document fungal invasion of lung parenchyma on one of the lung specimens. Though fungal culture is very sensitive and specific, it can take several days to result. Tissue staining for crystals can be performed quickly and provide more timely information when deciding about starting anti-fungal therapy. CONCLUSIONS: Pulmonary oxalosis, calcium oxalate deposition, can be seen in aspergillus infection and should be considered as an early diagnostic tool for invasive pulmonary aspergillosis. Reference #1: Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011; 20(121): 156–174, doi: 10.1183/09059180.00001011 Reference #2: U. Pabuccuoglu, Aspects of oxalosis associated with aspergillosis in pathology specimens, Pathol. Res. Pract. 201 (2005) 363–368 Reference #3: Osholowu OS, Kak V, Singh H. Pulmonary oxalosis in pulmonary aspergillosis syndrome. Adv Respir Med. 2020;88(2):153-156. doi: 10.5603/ARM.2020.0090. PMID: 32383468. DISCLOSURES: No relevant relationships by Mohammed Alsaggaf No relevant relationships by Daniel Baram No relevant relationships by Ivana Milojevic

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural fibrosis results in adhesions between the visceral and parietal pleura, obliterating the pleural cavity. Severe cases can lead to restrictive lung disease, hypercapnic respiratory failure, and death. Known etiologies include asbestosis, neoplasms, hemothorax, connective tissue diseases, radiation, trauma, drugs, and infection [1]; unexplained cases are deemed cryptogenic. CASE PRESENTATION: A 48-year-old female presented with chronic dyspnea. Past surgical history: March 2004 at age 31 she underwent right thoracotomy for fibrothorax; January 2005 she underwent decortication of left thorax; pathology from both surgeries: fibrosis without specific diagnosis or etiology. Past medical history: hypertension, Human Immunodeficiency Virus (HIV) on Highly Active Antiretroviral Therapy (HAART). Vital Signs: afebrile, pulse 110, BP 140/93, SpO2 was 91%. Physical exam: elevated jugular venous pressure and markedly diminished breath sounds bilaterally. Arterial blood gas 7.38/61/65/36. Chest x-ray and CT: chronic bilateral pleural thickening. Pulmonary Function Tests (PFTs): restrictive pattern with TLC 41%, DLCO 47% predicted.Extensive workup for etiology of the pleural fibrosis in 2004 and 2005 was negative; young age argues against occupational exposure; even after many years of follow up, she never developed connective tissue disorders. She has been HIV positive since before 2004, but had no opportunistic infections and remained well controlled on HAART. Right heart catheterization in 2014 showed mean PA pressure of 27. DISCUSSION: Given extensive negative workup, we diagnosed the patient with cryptogenic fibrosing pleuritis. HIV has not been described to lead to fibrosing pleurisy in the absence of infection. Prior case reports of patients with similar symptomatology are generally in older smokers or ex-smokers; in one case report, three improved with pleural decortication and one had a good response to corticosteroids [2]. A case was described in 26-year-old male with cryptogenic fibrosing pleuritis for whom decortication was unsuccessful [3]. Our case adds to the published literature by providing many years of follow up including PFTs and imaging. She showed no progression in the pleural disease, no development of fibrosis in other areas, and stability in pulmonary function testing. Bilateral decortication did improve her PFT and functional status, though she remains severely restricted with chronic hypoxemic respiratory failure and pulmonary hypertension. CONCLUSIONS: The cause and optimal treatment for cryptogenic fibrosing pleuritis remains unclear. REFERENCE #1: Huggins JT, Sahn SA. Causes and management of pleural fibrosis. Respirology. 2004;9:441–7. doi: 10.1111/j.1440-1843.2004.00630.x. REFERENCE #2: Buchanan DR, Johnston ID, Kerr IH, Hetzel MR, Corrin B, Turner-Warwick M. Cryptogenic bilateral fibrosing pleuritis. Br J Dis Chest. 1988 Apr;82(2):186-93. doi: 10.1016/0007-0971(88)90042-3. PMID: 3166932. REFERENCE #3: Verweel E, Noble Jl, Zoelen CG, Maat A, Thijsse W, Gerritsen P, Bakker J. Failure to wean caused by cryptogenic fibrosing pleuritis and bilateral lung trapping: case report. Rev Bras Ter Intensiva. 2007 Dec;19(4):504-8. English. doi: 10.1590/s0103-507x2007000400018. PMID: 25310172. DISCLOSURES: No relevant relationships by Ammar Alhaddad, source=Web Response No relevant relationships by Daniel Baram, source=Web Response No relevant relationships by Prasantha Vemu, source=Web Response

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pneumocystis jirovecii (PJP) can cause a life-threatening opportunistic infection in patients with HIV, especially in those not treated with HAART and a CD4 count less than 200 cells/mcL. Diagnosis of PJP in HIV patients is typically made with bronchoscopy with a very high diagnostic yield of bronchoalveolar lavage (BAL). IRIS describes the paradoxical worsening of a preexisting infection following HAART initiation (1). We present a case of an HIV patient with PJP-related IRIS who presented with an atypical chest radiograph and a negative BAL. CASE PRESENTATION: A 48-year-old man with HIV presented to the ED for a 2-week history of subjective fevers, chills, poor appetite, progressively worsening dyspnea, non-productive cough, and pleuritic chest pain associated with intermittent myalgias. He had recently started HAART (bictegravir, emtricitabine, and tenofovir alafenamide) ten days prior after presenting with oropharyngeal candidiasis; at that time his chest radiograph (xray) was normal and he denied respiratory symptoms. He had been prescribed prophylactic trimethoprim-sulfamethoxazole for PJP prophylaxis but was non-compliant. The patient was hemodynamically stable on presentation, temperature was 39°C, and oxygen saturation of 95% on room air. He was tachypneic with a respiratory rate of 26, and his lungs were clear. Initial workup showed a WBC of 4.6*10^3 /mcL (78% neutrophils, 17% lymphocytes) with absolute lymphopenia of 0.75*10^3 /mcL. His CD4 count was 85 cells/mcL with a viral load of 3360 copies/mcL. LDH was elevated at 1281 units/L. His initial blood gas was 7.52/22/58 showing respiratory alkalosis and hypoxemia. Chest xray showed bilateral coalescing upper lung opacities. He was started on trimethoprim-sulfamethoxazole and prednisone for suspected PJP pneumonia along with antibiotic coverage of community-acquired pneumonia. Bronchoscopy showed normal bronchial mucosa with minimal secretions. BAL specimens were negative for bacterial, fungal, and mycobacterial growths. Transbronchial biopsies (TBBx) of the left upper lobe revealed PJP on GMS stain. DISCUSSION: We present a case of an HIV patient who developed acute hypoxemic respiratory failure from PJP soon after starting HAART despite a normal chest x-ray 2 weeks prior. The rapid worsening after initiation of HAART is consistent with IRIS. A Spanish observational study showed that PJP-related IRIS is uncommon involving only six cases of IRIS out of 123 (4.9%) (2).Our patient's chest radiograph atypically showed bilateral coalescing upper lung opacities. Typical chest radiographs in PCP show bilateral diffuse or perihilar symmetric interstitial changes that can be reticular, ground glass, or granular (3). CONCLUSIONS: Given the high yield of BAL in HIV patients, many physicians defer TBBx in these patients. The negative BAL in our patient may suggest a need for performing TBBx in patients with HIV presenting with IRIS. REFERENCE #1: Müller M, Wandel S, Colebunders R, et al. Immune reconstitution inflammatory syndrome in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10(4):251-261. doi:10.1016/S1473-3099(10)70026-8 REFERENCE #2: Roade Tato L, Burgos Cibrian J, Curran Fábregas A, et al. Immune reconstitution inflammatory syndrome in HIV-infected patients with Pneumocystis jirovecii pneumonia. Enferm Infecc Microbiol Clin. 2018;36(10):621-626. doi:10.1016/j.eimc.2017.11.002 REFERENCE #3: Boiselle PM, Crans CA Jr, Kaplan MA. The changing face of Pneumocystis carinii pneumonia in AIDS patients. AJR Am J Roentgenol. 1999;172(5):1301-1309. doi:10.2214/ajr.172.5.10227507 DISCLOSURES: No relevant relationships by Reem Al Shabeeb, source=Web Response No relevant relationships by Daniel Baram, source=Web Response No relevant relationships by Sandrine Hanna, source=Web Response

SESSION TITLE: Monday Electronic Posters 3 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Sarcoidosis is a disease with heterogeneous pulmonary progression and need for pharmacological therapy. Though serial pulmonary function testing (PFT) is recommended, there is no consensus regarding required frequency and expected spirometric changes. We assessed the variability of PFT frequency in a series of patients with sarcoidosis, to compare practice patterns among pulmonologists. METHODS: We retrospectively reviewed PFTs for patients diagnosed with sarcoidosis between 2001 and 2018 from our institution and an affiliated community clinic. Frequency of monitoring for each patient was defined as number of PFT, including both spirometry and full PFT, performed divided by number of years monitored. A Kruskal Wallis test was utilized to determine if frequency of monitoring was different among 8 pulmonologists. We also compared the frequency of monitoring across different disease severities (mean percent of predicted FEV1: 80) and levels of PFT’s fluctuation (Average of absolute difference in percent of predicted FEV1 across all PFTs separates by tertiles). Dunn’s test for multiple comparison was performed, if Kruskal Wallis finding was significant. Similar analyses were performed for FVC and DLCO. Results are reported as mean (minimum, maximum). RESULTS: There were 3618 PFTs (2280 full PFTs and 1338 spirometries) performed in 643 patients. Monitoring period was 47 months (0, 184); number of PFT was 5.6 (1, 65); testing frequency was 1.4 PFT/year (0.5, 10.5) for the first 2 years of monitoring and 1.52 PFT/year (0.16, 11.45) for the entire period. Frequency of monitoring was different among the eight pulmonologist, χ2(7) = 187.215, p < 0.01. The severity of FEV1 impairment did not have an effect on frequency of monitoring, χ2(3) = 0. 947, p = 0.81. Monitoring frequency varied between the three levels of FEV1 fluctuation, χ2(2) = 10.9, p<.01; however, the group with most FEV1 fluctuation underwent less PFT when individually compared to the other two groups of lower fluctuation. Analyses with FVC and DLCO demonstrated similar results. CONCLUSIONS: Frequency of PFT testing in patients with sarcoidosis significantly varied among providers; this variation is not explained by increased disease severity or greater fluctuations in spirometric changes. CLINICAL IMPLICATIONS: Providers’ variability in interpreting changes in PFTs and practice preference may affect the number of PFT ordered. Additional longitudinal studies aimed at assessing changes in pulmonary function over disease course may improve the use PFT in predicting disease progression and aid in treatment decision making. DISCLOSURES: No relevant relationships by Daniel Baram, source=Web Response Scientific Medical Advisor relationship with AstraZeneca Please note: $20001 - $100000 Added 03/13/2019 by Guillermo Gutierrez, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Sunovion Please note: $5001 - $20000 Added 03/13/2019 by Guillermo Gutierrez, source=Web Response, value=Honoraria No relevant relationships by Jeffrey Williams, source=Web Response No relevant relationships by Kendrew Wong, source=Web Response

Rationale: Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy.Objectives: To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations.Methods: We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions.Measurements and Main Results: Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16).Conclusions: Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

Purpose: This study aimed to assess the imaging findings in patients with pathologically proven carcinoid tumors and determine if SUV can help to differentiate typical from atypical (more aggressive) pulmonary carcinoid tumors.Patients and Methods: A retrospective review of patients with a biopsy-proven diagnosis of a pulmonary carcinoid tumor at our institution from 2002 to 2010 that had a preoperative PET scan was performed after institutional review board approval was obtained. PET results, including SUV uptake and location, were recorded as well as all data from pathology reports. Carcinoids were considered to be more aggressive if they showed pathological diagnosis consistent with atypical carcinoid, lymph node invasion, poor histological grade (poorly differentiated), or evidence of systemic metastases. Atypical carcinoid pathology consisted of focal necrosis or a higher mitotic index (2-10 per square millimeter) with features of nests, trabeculae, pleomorphic cells, or dense hyperchromasia. SUV uptake was then evaluated and compared between the typical and atypical carcinoid groups using nonparametric statistical methods.Results: We identified 29 patients from 2002 to 2010 at our institution with a pathological diagnosis of pulmonary carcinoid. Twenty-three were histopathologically typical, and the other 6 showed atypia. Mean (SD) nodule size was 2.4 (1.3) cm in the typical group versus 5.0 (3.2) cm in the atypical group (P = 0.065). Mean (SD) SUV uptake in the typical carcinoid group was 2.7 (1.6) and in the atypical group the SUV was 8.1 (4.1) (P < 0.01). A cutoff SUV of 6 or greater is predictive of malignancy (odds ratio, 23.6; P < 0.01), as well as a nodule size of 3.5 cm or greater (odds ratio, 5.1; P = 0.024).Conclusions: Preoperative PET imaging result is frequently positive in carcinoid tumors, and the biological behavior correlates well with SUV; however, size is not as strong of a predictor of malignancy. Size of 3.5 cm or greater and SUVof 6 or greater have a predictive value of greater than 95% for malignant histology.

Tracheal insufflation is useful during bronchoscopy to improve oxygenation. A 75-year-old woman developed seizure during bronchoscopy resulting in desaturation. Oxygen was insufflated into the trachea; however, jaw clenching and tongue swelling limited her ability to exhale resulting in bilateral pneumothoraces. Pneumothorax owing to insufflation has been reported in children and during mechanical ventilation, especially during targeted bronchial maneuver. Bronchoscopists need to be aware that seizure can compromise exhalation sufficiently to make insufflation dangerous.

Purpose of review Though lobectomy remains the standard of care for resection of nonsmall cell lung cancer, a number of studies have been published in the last 24 months exploring the role of sublobar resection in the treatment of stage I nonsmall cell lung cancer. Recent findings Large retrospective studies comparing lobar and sublobar resection show similar overall and disease-free survival. Survival and local control for sublobar resections are best for tumors smaller than 2 cm and with margins greater than 2 cm. Importantly, sublobar resections commonly have less thorough nodal dissection and incomplete pathologic staging; this may have important therapeutic consequences. No formal comparison of segmentectomy to wedge resection has been performed although bias towards segmentectomy resulting in better outcomes than nonanatomic wedge resection continues. Sublobar resection is especially interesting for patients with prior resection, bronchoalveolar carcinoma, and the elderly. Radiologic criteria for selecting candidates appropriate for sublobar resection are evolving. Summary Sublobar resection is an alternative therapy for stage I nonsmall cell lung cancer for patients with physiologic impairment unable to undergo lobectomy. The literature also suggests a role for patients with prior lung resection, bronchoalveolar carcinoma, peripheral tumors less than 2 cm, and for the elderly.

This review summarizes recent clinical data examining the use of aerosolized antimicrobial therapy for the treatment of respiratory tract infections in mechanically ventilated patients in the intensive care unit. Aerosolized antibiotics provide high concentrations of drug in the lung without the systemic toxicity associated with the intravenous antibiotics. First introduced in the 1960s as a treatment of tracheobronchitis and bronchopneumonia caused by Pseudomonas aeruginosa, now, more than 40 years later, there is a resurgence of interest in using this mode of delivery as a primary therapy for ventilator-associated tracheobronchitis and an adjunctive therapy for ventilator-associated pneumonia.

Objective To evaluate the performance of APR-DRG (All Patient Refined—Diagnosis Related Group) Risk of Mortality (ROM) score as a mortality risk adjustor in the intensive care unit (ICU). Design Retrospective analysis of hospital mortality. Setting Medical ICU in a university hospital located in metropolitan New York. Patients 1213 patients admitted between February 2004 and March 2006. Main results Mortality rate correlated significantly with increasing APR-DRG ROM scores (p < 0.0001). Multiple logistic regression analysis demonstrated that, after adjusting for patient age and disease group, APR-DRG ROM was significantly associated with mortality risk in patients, with a one unit increase in APR-DRG ROM associated with a 3-fold increase in mortality. Conclusions APR-DRG ROM correlates closely with ICU mortality. Already available for many hospitalized patients around the world, it may provide a readily available means for severity-adjustment when physiologic scoring is not available.

BACKGROUND:This study assesses the accuracy and interaction of clinical suspicion and positron emission tomography (PET) scans in diagnosis of suspected thoracic malignancy.MATERIAL/METHODS:313 patients evaluated in a University Hospital lung cancer evaluation center who underwent PET scanning and subsequently had tissue confirmation or a course of stability by CT scans over a period of two years. At the time of the initial visit, clinical suspicion based on history, physical exam and computerized tomography (CT) characteristics was assigned as low, intermediate or high probability of malignancy. Subsequently PET results were classified as negative, intermediate or positive, based on standardized uptake value [SUV] of 0, between 0 and 2.5, greater than 2.5 respectively.RESULTS:ROC analysis showed similar results for clinical suspicion (0.762) and PET (0.779). High clinical suspicion and positive PET had a PPV of 96.6%; low clinical suspicion and negative PET had a NPV of 100%. When PET and clinical suspicion were fully discordant, clinical suspicion was accurate in 80%, PET in 20%. When PET scan or clinical suspicion was intermediate, 35% were malignant.CONCLUSIONS:Clinical suspicion and PET are both accurate in diagnosing thoracic malignancy. When suspicion and PET are concordant, diagnostic accuracy is very high; when discordant, clinical suspicion was more accurate. When clinical suspicion or PET were intermediate, there is a significant likelihood for cancer.

PURPOSE: Sputum microscopy and culture for acid fast bacilli (AFB) remains the first diagnostic test for pulmonary tuberculosis (TB). However sputum smear is only 50% sensitive for diagnosing active pulmonary disease. Current guidelines recommend initiation of TB therapy pending AFB culture and further diagnostic work-up when there is high clinical suspicion. In hospitals with a low prevalence of disease, clinicians may have difficulty identifying appropriate patients in whom to begin therapy. We evaluated the management of smear negative TB at our hospital, a suburban hospital in the New York metropolitan area with a low prevalence of TB.

A 48-year-old female presented with worsening rightsided chest pain and a complex pleural process 3 months after undergoing ovarian dermoid cyst removal. Extensive preoperative workup was nondiagnostic except for radiographic imaging suggestive of a pleural lipoma given the presence of fat within the lesion. Thoracotomy with decortications demonstrated granulomatous inflammation without infection or a neoplastic process. We suspect spilled material during the dermoid removal likely crossed through the diaphragm into the pleural space and caused the reaction. Operative technique and proper position of the patient should reduce this risk of contaminating pleural space during dermoid cystectomy. Clinicians should use vigilance for a possibility of abdominal pathology causing pleural diseases. Similar to pleural effusions due to cirrhosis of liver, ovarian tumors, peritonitis, and hepatic abscess, intraoperative spillage from a dermoid cyst can lead to significant pleural disease.

Background: Visualization of a posterior junction line (PJL) on chest x-ray is evidence for emphysema. The correlation between the assessment of the PJL on computed tomography (CT) and emphysema is less clear.Methods: One hundred thirty-seven patients were identified with CT and pulmonary function tests (PFTs) performed within 3 months of each other in a University hospital. The width of the PJL was measured at 2 levels by a blinded investigator: superiorly at the superior border of the aorta and inferiorly 2 cm below the aortic arch. This was correlated to clinical and PFT data and to CT evidence of emphysema.Results: Narrowness of the junction line showed poor Correlation with PFT findings of emphysema as assessed by forced expiratory volume in 1 second forced vital capacity ratio and diffusing capacity of the lung for carbon monoxide percent predicted. The PJL also correlated weakly to CT emphysema severity scoring (r(2) = 0.06; P < 0.002). The area under the receiver operator characteristic curve was 0.652, with maximum accuracy at a width of 1.3 cm.Conclusions: Our data suggest that despite statistical correlation between the narrowness of the PJL and emphysema, its clinical use is limited.

A 32-year-old man presented with a 2-month history of worsening fever, chills, and cough despite therapy with oral antibiotics. Chest radiographs demonstrated migrating, peripheral upper lobe infiltrates. A CBC count demonstrated significant eosinophilia. At bronchoscopy, eosinophil-rich mucus was seen impacted throughout his bronchi. A transbronchial biopsy confirmed the diagnosis of eosinophilic pneumonia. Symptoms, eosinophilia, and radiographic abnormalities were reversed with cessation of duloxetine. This case report briefly reviews the diagnosis of drug-induced pulmonary infiltrates with eosinophilia (PIEs) and eosinophilic pneumonia. To our knowledge, this is the first reported case of PIEs due to duloxetine.

BACKGROUND:Pulmonary histoplasmosis is a mycotic infection that often resembles pulmonary malignancy and continues to complicate the evaluation of pulmonary nodules.CASE PRESENTATION:We report a case of an immunocompetent patient who, despite adequate treatment for known histoplasmosis lung infection, presented with radiological and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) findings mimicking primary lung malignancy which eventually required surgical resection.CONCLUSION:Histoplasmosis infection may radiologically resemble pulmonary malignancy, often causing a diagnostic dilemma. PET imaging is currently used for and considered accurate in the evaluation of pulmonary nodules. However, overlap in PET standardized uptake value (SUV) between granulomatous and malignant lesions decreases the accuracy of PET as a diagnostic modality. Future advances in PET imaging are needed to improve its accuracy in the evaluation of pulmonary nodules in areas where histoplasmosis is endemic.