Bortezomib, a chemotherapeutic agent used in the treatment of hematologic malignancies, has been associated with multiple forms of lung injury including diffuse alveolar hemorrhage (DAH). We present the first reported case of bortezomib-induced DAH in a patient with plasma cell leukemia. This 59-year-old female developed hemoptysis, severe cough, and diffuse bilateral ground glass opacities on CT scan of the chest after receiving one dose of bortezomib, with DAH subsequently confirmed on bronchoalveolar lavage. Unlike most previously reported cases, she did not develop respiratory failure requiring high dose corticosteroids, and in fact did not require any supplemental oxygen. We also provide a comparative summary of all reports of bortezomib-induced DAH in the literature to date. This case provides additional insight into the spectrum of disease severity observed in DAH secondary to bortezomib therapy.

Background: A positive response to indirect airway challenges (eg, mannitol) that cause release of mast cell mediators causes refractoriness to a repeat exposure to the same or different indirect stimulus that lasts for at least several hours. Allergen challenge causes increased response to methacholine measured at 3 hours.Objective: To compare allergen-induced changes in airway response to methacholine and mannitol 3 hours after completion of an allergen challenge.Methods: Ten atopic patients with asthma completed a randomized clinical trial. The provocation concentration of methacholine causing a 20% decrease in forced expiratory volume in 1 second (FEV1) was measured 24 hours before and 3 hours after a standard allergen challenge. The provocation dose of mannitol causing a 15% decrease in FEV1 was also measured 24 hours before and 3 hours after allergen challenge. The allergen challenges were separated by 7 to 14 days.Results: The allergen-induced early responses, expressed as the maximum (SD) percent decrease in FEV1, were 29.7% (11.1%) and 27.8% (7.6%) on the methacholine and mannitol days, respectively. Airway response to methacholine increased significantly after allergen challenge (P = .02). By contrast, the airway response to mannitol was reduced by almost a doubling dose (P = .02) after allergen.Conclusion: Three hours after allergen challenge at a time when the airways are more responsive to methacholine, there is a significant refractoriness to the indirect stimulus mannitol. (C) 2013 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

The methacholine challenge is commonly used to measure airway responsiveness. Two doubling concentration methods have been outlined by the American Thoracic Society: the tidal breathing method and the dosimeter method. 1 Crapo R.O. Casaburi R. Coates A.L. et al. Guidelines for methacholine and exercise challenge testing 1999. Am J Respir Crit Care Med. 2000; 161: 309-329 Crossref PubMed Scopus (2187) Google Scholar Quadrupling concentrations are an option with the dosimeter method as a time-saving measure. 1 Crapo R.O. Casaburi R. Coates A.L. et al. Guidelines for methacholine and exercise challenge testing 1999. Am J Respir Crit Care Med. 2000; 161: 309-329 Crossref PubMed Scopus (2187) Google Scholar We reasoned that the tidal volume method could also be performed with quadrupling concentrations and performed a study to compare doubling and quadrupling concentrations.

INTRODUCTION: There are many causes of hypercalcemia including malignancy associated hypercalcemia. A review of the medical literature reveals three previously reported cases of ST elevation due to increased calcium mimicking acute myocardial infarction (AMI). Two of them were due to hyperparathyroidism and the other with vitamin D intoxication. This case is the first report of this phenomenon due to multiple myeloma induced hypercalcemia.

INTRODUCTION: Adult Langerhans' Cell Histiocytosis (LCH) is a rare interstitial lung disease most commonly of smokers in their 3rd and 4th decade. Clinical presentation is often one of non specific respiratory complaints and constitutional symptoms with cysts and nodules in the upper lung zones on chest radiography. Twenty percent of patients present asymptomatically with incidental findings on a chest film. Pulmonary complications of LCH include spontaneous pneumothorax, pulmonary arteriopathy and veno-occlusive disease, and pulmonary hypertension. Extrapulmonary manifestations include central diabetes insipidus (DI), skeletal, mucocuteanous, hepatic, splenic, lymph node, or marrow involvement. Although adult LCH is often considered a pulmonary disease, it can present with only extrapulmonic manifestations. We describe the case of an adult male with preexisting 'idiopathic' central DI and a new occipital skull lesion.

PURPOSE: Quadrupling dose step-up for methacholine inhalation has been recommended as a time saving measure over the usual doubling method but has not been assessed. We undertook a study to compare doubling and quadrupling concentration step-up using the tidal volume methacholine challenge.