AN UNUSUAL PRESENTATION OF MALIGNANCY

NECROTIZING PNEUMONIA SECONDARY TO CANDIDA INFECTION IN A PATIENT WITH HISTORY OF ALCOHOL ABUSE REQUIRING LOBECTOMY AND ANTIFUNGAL THERAPY

BLAST VS MASS: USE OF FLEXIBLE BRONCHOSCOPY AND ENDOBRONCHIAL ULTRASOUND IN THE MEDICAL ICU

SINGLE CAVITARY LUNG LESION IN A HEALTHY YOUNG MALE

Introduction: Despite supporting evidence, cryobiopsy remains underutilized for obtaining lung tissue. We present a case of a lung mass that was negative for malignancy using ultrasound-guided transbronchial needle aspiration (TBNA) but was consistent with metastatic renal cell carcinoma using cryobiopsy in the same procedure. Case: An 87-year-old male with a history of renal cell carcinoma (RCC) status post left nephrectomy presented for evaluation of a right-sided infrahilar lung mass. He initially presented with a 15 lb weight loss, prompting a CT of the chest. A right lower lobe infrahilar mass measuring 4.4x4.6 cm was identified, and the patient was referred for an endobronchial ultrasound (EBUS) biopsy. Multiple transbronchial needle aspirations from the bronchus intermedius into the mass evaluated by rapid on-site diagnostics were inconclusive. A 1.1mm cryobiopsy probe was then inserted into the mass via the working channel of the EBUS bronchoscope after a pilot hole was created with TBNA. The probe could be seen in real time, via ultrasound, inside the mass when obtaining samples. Final pathology for the cryobiopsy was consistent with metastatic renal cell carcinoma, but negative on TBNA. Discussion: In 2021, Zhang et al. published a randomized control trial involving 197 patients comparing the diagnostic yield of transbronchial needle aspiration to cryobiopsy of mediastinal lymph nodes with results in favor of cryobiopsy due to improved diagnostic yield. A recent prospective publication from Spain followed 50 cases where TBNA and cryobiopsy were utilized to evaluate peripheral tumors in a single procedure. Again, the results of this study showed improved diagnostic yield with cryobiopsy, mainly attributed to larger biopsy size. Additionally, the large tissue sample will certainly produce more tissue for next generation sequencing. As seen in this case, cryobiopsy is a safe and valuable tool for cases, especially when rapid on site TBNA is inconclusive. Conclusion: EBUS TBNA is currently the standard diagnostic tool for central mass evaluation. However, TBNA samples can have lower diagnostic yield, particularly when larger biopsy samples are required for diagnostic certainty. Recent articles have demonstrated the effectiveness and safety of cryobiopsy through the working channel of an EBUS bronchoscope for mediastinal lymph nodes. Alternatively, we have documented the same technique can be used for central lung masses outside of the mediastinum viewable by EBUS. Cryobiopsy continues to prove itself a safe and reliable tool for pulmonary tumor evaluation and should be further explored as a conjunctive first-line tool alongside TBNA.

TO CAVITATE OR NOT TO CAVITATE: ATYPICAL PRESENTATION OF A COMMON PATHOGEN

Introduction: Mycobacterium malmoense is a slow-growing, non-tuberculous mycobacterium which primarily causes pulmonary disease. M. malmoense is acquired through environmental exposure to contaminated soil or water in individuals with impaired cell immunity. M. malmoense infection may cause extrapulmonary manifestations including cervical adenitis, tenosynovitis, and disseminated disease. Our literature search revealed extremely few cases reported on M. malmoense causing cavitary lesions. We present a case of a patient with hemoptysis and worsening bilateral lung cavitary lesions where sputum culture isolated M. malmoense. Case presentation: A 58-year-old male with a past medical history of hypertension, 80-pack-year smoking history, polysubstance abuse with methamphetamine, cannabis, benzodiazepines, hepatitis C, COPD, and chronic cavitary lung lesions was admitted to the hospital secondary to hemoptysis. He had an initial episode of hemoptysis approximately one year ago which self-resolved after six days. He was scheduled to receive outpatient bronchoscopy for his chronic cavitary lesions though missed follow-up. Two days before the current admission, the patient had worsening cough and bloody sputum. He denied chest pain, night sweats, weight loss, fever, or chills. Computerized tomography (CT) chest showed a new right lower lobe cavitary nodule measuring 3.4 cm x 2.8 cm and unchanged bilateral apical cavitary lung lesions. Our patient was started on IV piperacillin-tazobactam and vancomycin. He had approximately 150 ml of hemoptysis in 24 hours therefore received inhaled tranexamic acid. Sputum smear was positive for acid fast bacilli. Quantiferon TB and HIV testing were negative. Sputum cultures grew Mycobacterium malmoense. Unfortunately, the patient refused any further treatment. Discussion: Mycobacterium species are seen in patients with underlying lung disease or immunocompromised states. Infection is diagnosed by clinical, radiological, and microbiological workup. Microbiological workup includes two separate sputum samples or via transbronchial biopsy or bronchial wash. The most common radiological finding include thick-walled cavitary lung lesions in the upper lobes and underlying pulmonary fibrosis. This Mycobacterium species has high antimicrobial resistance. As per the current ATS and IDSA guidelines, multidrug treatment with macrolides, ethambutol, and rifamycin for a duration of 12 months is indicated. Conclusion: Non-TB Mycobacterium infrequently causes disease, though in susceptible or immunocompromised individuals, it can cause serious respiratory infections. M. malmoense infection still carries a high mortality risk, so careful and early diagnosis is important to improve outcomes. It is important to recognize patients with non-resolving radiographic imaging as well as atypical and persistent infections that do not improve with standard treatment.

RARE PRESENTATION OF A THYMOMA AT AN INFREQUENT LOCATION

The present study investigates the diagnostic efficiency of apparent diffusion coefficient (ADC) values in differentiating between malignant and benign cavitary lesions on diffusion-weighted magnetic resonance imaging (DWI). This prospective study included 45 consecutive patients identified with a cavitary lung lesion with a wall thickness of ≥5mm on thoracic computed tomography in our clinic between 2020 and 2022, and who underwent thoracic DWI within 1 week of their original computed tomography. ADC measurements were made on DWI by drawing a region of interest manually from the cavity wall, away from the lung parenchyma in the axial section where the lesion was best demonstrated. The patients were then classified into benign and malignant groups based on the pathology or clinico-radiologic follow-up. The sample included 29 (64.4%) male and 16 (35.6%) female patients, with a mean age of 59.06±17.3 years. Included in the study were 1 patient with 3 and 3 patients with 2 cavitary lesions each, with a total for the sample of 50 cavitary lesions. There were 23 (46%) malignant and 27 (54%) benign cavitary lung lesions. The mean ADC value (×10 -3 mm 2 /s) of the malignant and benign cavitary lesions was 0.977±0.522 (0.511 to 2.872) and 1.383±0.370 (0.930 to 2.213), respectively. The findings were statistically significant using an independent samples t test ( P =0.002). The mean wall thickness of the malignant and benign lesions was 12.47±5.51mm (5 to 25mm) and 10.11±4.65mm (5 to 22mm), respectively. Although malignant cavities had a higher mean wall thickness than benign cavities, the difference was statistically insignificant ( P =0.104). A significant difference was identified between the ADC values measured in DWI of the malignant and benign cavitary lung lesions. DWI, a noninvasive and rapid imaging method, can provide useful information for the differential diagnosis of cavitary lesions and can minimize unnecessary biopsies.

Hodgkin lymphoma (HL), a lymphoid neoplasm characterized by the presence of Reed-Sternberg cells, often presents with painless lymphadenopathy and systemic symptoms. This case report details the diagnostic journey of a 27-year-old non-smoker female with chronic respiratory symptoms, including persistent cough, hemoptysis, and weight loss over two years. Despite multiple treatments for presumed infections and extensive diagnostic procedures, the correct diagnosis of HL was delayed due to atypical pulmonary manifestations, notably necrotizing pneumoniaand multiple cavitary lung lesions. Ultimately, histopathology from a third bronchoscopy confirmed HL, highlighting the complexity of diagnosing HL with unusual presentations. Patients with cavitary lesions have a poor prognosis compared to others with typical pulmonary involvement, as cavitation in HL is likely caused by central ischemia necrosis due to the tumor's rapid growth. This case can be considered a primary pulmonary HL, a rare and hard-to-treat presentation since it does not respond well to radiotherapy. It emphasizes the challenge in diagnosing HL when it presents atypically, making it crucial to consider HL in differential diagnoses to avoid delayed diagnosis and improve patient outcomes.

A RARE CASE OF SOLITARY FIBROUS TUMOR OF THE LUNG PRESENTING WITH CAVITARY LESION AND THROMBOEMBOLISM

Transbronchial needle aspiration (TBNA) is a 30 year old procedure for diagnosing and staging of lung cancer. There has been renewed interest in TBNA due to the development of a curvilinear array endobronchial ultrasound (EBUS) scope for TBNA. Reports indicate an increased diagnostic yield compared to standard TBNA. In 9 of 11 patients EBUS-TBNA is performed with the second generation Olympus EBUS scope (BF-UC180F) and the ViziShot (NA-201SX-4022) needle in addition to the standard WANG™ TBNA needle. Three punctures were made by the ViziShot needle. The first puncture, the guidewire is partially retracted and without suction the needle is moved back and forth inside the lesion. The second puncture, the guidewire is completely removed and suction is applied during needle movement. The third puncture is without the guidewire but with suction. In five patients with a positive diagnosis of cancer, the first punctures were all positive with a better quality and quantity of tumor cells. Three patients, standard TBNA needle was used, all were positive. Four patients with standard TBNA preceded the EBUS-TBNA were all positive. We conclude, EBUS TBNA is highly effective and dependable and suggest the use of EBUS needle can be simplified. Standard TBNA needle can be used for EBUS-TBNA and standard TBNA in relation to EBUS-TBNA needs to be further investigated.

To demonstrate clinical features and outcomes in patients with cavitary lung lesions and COVID-19 associated pneumonia. A retrospective analysis of electronic medical records of 8261 patients with COVID-19 was performed. We selected 40 patients meeting the inclusion criteria. Sex, age, hospital-stay, lung tissue lesion, comorbidities, treatment, methods of respiratory support, complications and outcomes were evaluated. Cavitary lung lesions were more common in men (67.5%). Age of patients ranged from 28 to 88 (mean 64.9±13.7) years. Hospital-stay in patients with cavitary lung lesions was 9-58 (median 27.5) days. There were 18 complications in 14 (35%) patients. Pneumothorax, isolated pneumomediastinum, pleural empyema, hemoptysis and sigmoid colon perforation were considered as complications of cavitary lung lesions. Nine (22.5%) patients died (5 of them with complications). Three patients died after surgical treatment. Long-term results were analyzed in 8 (25.8%) patients. Patients were followed-up for 3 months after discharge. Shrinkage of lesions occurred after 7-60 (mean 23) days, and complete obliteration of cavities came after 32 (range 14-90) days. Cavitary lung lesions are a rare complication of COVID-19 pneumonia. There was no significant correlation of complications with age, sex, therapy, volume of lung lesions and non-invasive ventilation (NIV). Despite more common fatal outcomes in older patients undergoing NIV, the last one was prescribed exclusively due to disease progression and respiratory failure. Further research on this problem is necessary to identify possible risk factors of cavitary lung lesions.

Pulmonary cystic and cavitary lesions caused by diverse etiologies are commonly encountered in chest imaging. The terms "cyst" and "cavity" are used to describe air-filled regions in the center of a nodule or consolidation of the lung. To date, only radiologic aspects of these lesions have been addressed. The morphologies of pulmonary cystic and cavitary lesions exhibit a broad spectrum, ranging from benign to malignant pulmonary diseases of acquired or congenital origin, including variable infectious diseases. In this review, we summarized the differential diagnosis of pathological entities to provide pathologists and radiologists with an overview of the diseases most commonly associated with pulmonary cystic and cavitary lesions in adults and children. The results showed slightly different patterns in the distribution of the diseases in the two groups. The most common causes of cavitary lesions include malignancy and infection in adults, and congenital malformation in children. Therefore, identification of pathologic entities correlating with the radiologic findings, clinical course, and location of the lesion is important in the evaluation of cystic and cavitary lung lesions in order to avoid unnecessary surgical procedures or delayed treatment.

DISSEMINATED NOCARDIOSIS IDENTIFIED BY MATRIX-ASSISTED LASER DESORPTION/IONIZATION/TIME OF FLIGHT (MALDI-TOF0) MASS SPECTROMETRY

USING LYMPH NODE SIZE AND STANDARDIZED UPTAKE UNITS TO DETERMINE DIAGNOSTIC ACCURACY OF PET-CT IN DETECTING MALIGNANT MEDIASTINAL AND HILAR DISEASE IN A REGION ENDEMIC WITH HISTOPLASMOSIS