3/28/17 Resident Morning Report – Eosinophilia, Eosinophilic Pneumonia

CC: dyspnea

ID: 40 yo female presents with 7 weeks of progressively worsening dyspnea and non-productive cough that have persisted despite a course of azithromycin.  She was found to have diminished breath sounds bilaterally and a CBC with WBC of 20.3 and 43% eosinophils.  She denied any recent travels, but admits to frequent “purification rundown” treatments with the Church of Scientology.  She underwent a BAL that showed predominant eosinophils and a thoracentesis with 85% eosinophils.  She was ultimately diagnosed with chronic eosinophilic pneumonia, thought to be secondary to her purification treatments (high doses of niacin).  She was started on steroids with improvement in symptoms; however, each time she stopped steroid therapy and got more purification treatments, her symptoms would flare up.

Don’t forget:

The causes for peripheral eosinophilia can be broadly categorized into 2 mnemonics: CHINA or NAACP.

  • C – connective tissue disease
  • H – helminthic disease
  • I – idiopathic/iatrogenic
  • N – neoplastic
  • A – allergic/asthma
  • N – neoplastic
  • A – allergic
  • A – asthma/atopic
  • C – connective tissue disease
  • P – parasites

Pearls from morning report:

  • An absolute eosinophil count (AEC) > 20,000 should raise suspicion for malignancy.
  • Bacterial infections very rarely cause eosinophilia.
  • > 25% eosinophils on BAL is suggestive of a diagnosis of acute eosinophilic pneumonia, and > 40% for chronic eosinophilic pneumonia.
  • Chronic eosinophilic pneumonia may appear on CXR as ‘photographic negative of pulmonary edema’ and is considered pathognomonic for the disease.

Random trivia:

Purification rundown treatments were developed by the Church of Scientology founder L. Ron Hubbard.  The goal goal was designed to remove LSD from the body using a restricted diet and large doses of vitamins.


Want to read more?

Eosinophilia (The New England Journal of Medicine)
Eosinophilic Lung Disease (Clinical Chest Medicine)


References: 

Weller PF, Klion AD, Mahoney DH, Bochner BS, Rosmarin AG, Feldweg AM. Approach to the patient with unexplained eosinophilia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2017)

Klion AD, Weller PF, Bochner BS, Hollingsworth H. Causes of pulmoanry eosinophilia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2017)

3/1/17 Resident Morning Report – Diffuse Alveolar Hemorrhage, ANCA Vasculitis

CC: shortness of breath

ID: 59 yo female with HTN initially presents with joint swelling and extremity swelling.  She was diagnosed with p-ANCA vasculitis and was started on pulse steroids, rituximab and plasmaphresis.  Her hospital course was complicated by melena (she was found to have multiple small gastric ulcers, a large duodenal ulcer, and candida esophagitis on EGD) and shortness of breath (TTE and coronary angiogram was demonstrated Takotsubo’s cardiomyopathy with symptom improvement with therapy).  She again began to feel short of breath on HD #24 with symptoms of lightheadedness and weakness.  Exam was notable for decreased breath sounds to bilateral bases and CXR performed at the time revealed bilateral patchy disease.  An ABG performed revealed pH 7.47, pCO2 24, pO2 50, HCO3  18 with an anion gap of 15.  Bronchoscopy was performed with serial lavages and findings were consistent with diffuse alveolar hemorrhage.

Don’t forget:

  • There are many, many causes of DAH, but think of the main etiologies of DAH in 5 broad categories:
    1. vasculitidies (ex: MPA, GPA, EGPA)
    2. other autoimmune disorders, esp pulmonary-renal syndromes (ex: Goodpasture’s)
    3. medications (ex: PTU, anticoagulants)
    4. infections (ex: endocarditis, leptospirosis)
    5. idiopathic pulmonary hemosiderosis/pulmonary endometriosis

Pearls from morning report:

  • 30% of patients with DAH will NOT present with hemoptysis.
  • The diagnostic yield of bronchoscopy in DAH is higher if performed within the first 48 hours of symptoms .
  • A DLCO > 100% predicted is a sensitive marker for DAH, though impractical as patients are likely too unstable to get a pulmonary function test.

Random trivia:

Cocaine laced with levamisole can induce vasculitis and diffuse alveolar hemorrhage.  It is estimated that up to 70-80% of cocaine entering the United States since 2005 is adulterated with levamisole.


Want to read more?

Diffuse Alveolar Hemorrhage (Chest)


References: 

Ioachimescu OC, Stoller JK. Diffuse alveolar hemorrhage: diagnosing it and finding the cause. Cleve Clin J Med. 2008;75(4):258, 260, 264-5.

Schwarz MI, King TE, Hollingsworth H. The diffuse alveolar hemorrhage syndromes. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 1, 2017)

 

11/4/16 Intern Morning Report – Mediastinal Mass

CC: 3 weeks of chest pain and dry cough

ID: 56 yo female with migraines and uterine cyst presents with sharp, non-exertional chest pain and dry cough for the past 3 weeks.  She was found to have a mediastinal mass on CXR and 6% peripheral blasts.  Bone marrow biopsy revealed B-lymphoblastic leukemia/lymphoma.

cxr

ct

Don’t forget:

  • To evaluate whether a mass on an upright CXR arises from the mediastinum or the lung, consider the following:
    • does the mass seem to touch the mediastinum or heart border?
    • are the borders of the mass smooth and sharp (instead of spiculated)?
    • are the angles at which the mass meets the mediastinum obtuse?
    • are the borders of the mass smooth (instead of lobulated or undulating)?

If the above answers are “yes,” it suggests that the mass is mediastinal rather than from the lung.

  • The anterior, middle, and posterior mediastinal compartments are theoretical – there are no surgical or anatomical planes that create a clear division (hence, different radiology groups define each compartment a little differently).  Therefore, a mediastinal mass can be found in more than one compartment.

mediastinal-mass

Mediastinal Masses (PDF)


Pearls from morning report:

  • Lymphomas encase, but do not compress adjacent structures.
  • Not all malignancies will result in tumor lysis syndrome (TLS).  TLS is seen most frequently in high grade lymphomas, acute leukemia, and rapidly proliferating tumors
  • Indications for HD in TLS include hyperphosphatemia-induced symptomatic hypocalcemia, persistent hyperkalemia, and severe oliguria or anuria.

Random trivia:

Wilhelm Röntgen, a German physicist and mechanical engineer, produced and detected X-rays in 1895.  X-rays are named as such to signify an unknown quantity.  They are also known as roentgenograms (röntgenograms) – named in his honor.


Want to read more?

The Tumor Lysis Syndrome (New England Journal of Medicine)


References: 

Whitten CR, Khan S, Munneke GJ, Grubnic, S. A diagnostic approach to mediastinal abnormalities. Radiographics. 2007;27(3):657-71.