Tag Archives: Infectious Disease

Infectious disease

92. Journal Club with BMJ Thorax – COPD and Emphysema

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Today is our second episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to lung health, COPD, and emphysema.

Meet Our Guests

Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

 Ewan Mackay is a Respiratory Clinical Research Fellow who has started his PhD in London. His research focus is on chronic cough and in the development of new patient-reported outcome measures as well as respiratory physiology, particularly in relation to exercise and disease.

Journal Club Papers

To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk


To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

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85. Journal Club with BMJ Thorax – Airway Disease

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We are extremely excited today to announce a new collaboration with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. We hope you enjoy!

Meet Our Guests

Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

 Imran Howell is an Asthma Fellow at the Nuffield Department of Medicine, University of Oxford

Journal Club Papers

To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk


To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

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Radiology Rounds – 3/12/24

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A #RadiologyRounds case with 3 different imaging modalities! A 65+ year old man never smoker, former marathoner has had 2-3 years of progressive non-productive, incessant cough with decreasing exercise tolerance. Some select CT scan slices are below

You are considering multiple etiologies including airway bleeding, pneumothorax, and hemothorax. You grab an ultrasound and perform a lung / pleural POCUS. Here is what you see

The long POCUS shows an area of lung sliding and an area without any lung sliding. This is called lung point and is diagnostic of a pneumothorax. To get a better look at this, you can use M-mode.

A CXR confirmed the finding of a pneumo. He was trialed on 100% oxygen but repeat CXR showed the pneumothorax was expanding. He had a chest tube placed with re-expansion of his lung and no air leak. It was able to be removed the next morning without incident

Here is our algorithm for pneumothorax!

Both BAL and tbbx returned positive for MAI complex. He was HIV neagative. Given his persistent and bothersome symptoms, he was started on treatment for pulmonary MAC with a macrolide, ethambutol and a rifamycin with plan for 6 months of therapy. He improved with this

67. Fellows’ Case Files: Northwestern University

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Listen in today to another stop on our Fellows’ Case Files journey. We’re at Northwestern University for another great case presentation. Tune in, check out our associated infographic, and let us know what you think!

Meet Our Guests

Jamie Rowell is a first-year clinical fellow in the Northwestern PCCM program. She completed medical school at the Medical University of South Carolina and her internal medicine residency and Chief Residency at the University of Vermont Medical Center.

Cathy Gao is an Instructor of Medicine at Northwestern and completed her PCCM fellowship there last year. Her research focuses on using machine learning applied to ICU EHR data to characterize patient trajectories and identify potential interventions to improve outcomes.

Clara Schroedl is an Associate Professor of Medicine in Pulmonary and Critical Care and Medical Education. She is the program director of the Northwestern PCCM fellowship program, with an interest in medical education and simulation.

Case Presentation

A 25-year-old previously healthy woman presents with recurrent episodes of right chest pain and cough. In October she was treated with antibiotics and felt somewhat better but in December, she presented again with chest pain, and again was treated with antibiotics. The pain improved but she still felt breathless. In February, again she had intense chest pain interfering with life, and was given NSAIDs and took high dose TID without clear benefit.

One month later, she coughed up some bloody mucus, so now she is presenting for evaluation. The chest pain is worse with deep breaths and improves in between these episodes. She only notes it on her right side. At this point, she does sometimes feel short of breath; she used to run 5 miles but is now struggling to run two miles. She denies any unusual exposures. She went to school in central rural Ohio for a while. She has no history of pulmonary infections, no exposure to mold or animals, and no history of vaping.

Key Learning Points

1.Making the diagnosis of Fibrosing Mediastinitis :

–Etiologies: histoplasmosis, sarcoidosis, tuberculosis, IgG4, Behcet, ANCA vasculitis

–Imaging modalities: CT chest, perfusion studies, pulmonary angiogram

–Imaging characteristics:  infiltrative, heterogeneous, fibrotic process that crosses fat planes and encroaches on nearby structures causing airway or vascular stenoses  

2. Management strategies:

–No curative therapies. Goal to relieve symptom burden

–Airway stents

–Vascular stents

–Rituximab

–Antifungals, steroids generally not considered effective

References and Further Reading

Kern et al. Bronchoscopic Management of Airway Compression due to Fibrosing Mediastinitis. Annals of the American Thoracic Society 2017. 14: 1235-1359 

Welby JP, Fender EA, Peikert T, Holmes DR Jr, Bjarnason H, Knavel-Koepsel EM. Evaluation of Outcomes Following Pulmonary Artery Stenting in Fibrosing Mediastinitis. Cardiovasc Intervent Radiol. 2021 Mar;44(3):384-391. doi: 10.1007/s00270-020-02714-z. Epub 2020 Nov 17. PMID: 33205295.

Westerly, BD Targeting B Lymphocytes in Progressive Fibrosing Mediastinitis. Am J Respir Crit Care Med. 2014 Nov 1; 190(9): 1069–1071.

https://rarediseases.org/rare-diseases/fibrosing-mediastinitis/#complete-report

https://pubmed.ncbi.nlm.nih.gov/21422386/

https://academic.oup.com/cid/article/30/4/688/421789

https://pubmed.ncbi.nlm.nih.gov/22033450/

https://www.sciencedirect.com/science/article/pii/S2352906715300087

https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201610-782RL

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Radiology Rounds – 1/16/24

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We are back with another #RadiologyRounds for 2024 featuring high-yield imaging findings and teaching points for you to review

In this immunosuppressed patient, you find a reverse halo sign, right pleural effusion and left lower lobe consolidation.

Serum fungal markers are negative but given the reverse halo sign, you empirically start Amphotericin B given concern for pulmonary mucormycosis.

Given the profound neutropenia, the patient was predisposed and mucor was identified on lung tissue biopsy and IV Amphotericin-B was continued.

Radiology Rounds – 11/21/23

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We’re back with another #RadiologyRounds by Pulm PEEPs Associate Editor Tess Litchman. An immunosuppressed 65-year-old man presents with neutropenic fever. He is started on empiric broad-spectrum antibiotics with vancomycin and zosyn. Serum beta-D-glucan is positive.

Further, workup reveals a positive serum galactomannan and a BAL PCR that is positive for Aspergillus. The patient is diagnosed with invasive aspergillosis and started on voriconazole. A repeat CT is obtained in 3 weeks. What do you think of the evolving findings?

Radiology Rounds – 9/5/23

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Tuesday is time for another #RadiologyRounds! Time for some CXR reading and a differential diagnosis mnemonic Two women presented to the hospital with similar presentations. They are both in their 80s with multiple weeks of cough, fever, and fatigue. Here are the CXRs

The CXRs both showed cavities. They are thick-walled (>4mm) and gas-filled. Cavitary lung lesions are seen within infiltrates, nodules, or masses. There can be an air-fluid level within the cavity. Cysts have thinner walls. The findings were confirmed on CT scan

Cavitary lung lesions can have a broad differential so it is helpful to have a systematic approach. To make it easy, when you see this just remember: CAVITY

Bonus points to anyone who can fill in the Y

Both patients were ultimately diagnosed with pulmonary abscesses which improved with prolonged courses of antibiotics with anaerobic and gram-negative coverage.

52. Fellows’ Case Files: University of Pittsburgh

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We’re excited to be back with another Fellows’ Case Files. Today, we’re visiting the University of Pittsburgh to meet a fantastic fellow and a dedicated educator, and to hear about a fascinating case. Let us know if you’ve ever had a similar case, and share your interesting cases with us!

Meet Our Guests

Rachel Wojcik obtained her B.S. in Biology from Mercyhurst University and a Master’s in Liberal Studies from the University of Denver in Global Affairs with a focus on Healthcare. She completed her MD at the University of Colorado before completing her residency and chief resident year at the University of Pittsburgh and has continued her training at Pitt for PCCM fellowship.

Dr. Stephanie Maximous is an Assistant Professor of  Medicine at the University of Pittsburgh School of Medicine and is the Clinical Education APD for the Pulmonary and Critical Care Fellowship program. She completed her fellowship at Pitt in addition to obtaining a Master’s Degree in Medical Education there. She teaches in and directs courses throughout the medical school, residency, and fellowship and was recently awarded the 2023 Outstanding Subspecialty Teaching Attending Award from the housestaff.

Case Presentation

Patient: A 70-year-old male with a history of idiopathic thrombocytopenia on chronic prednisone and a history of tobacco use disorder.

Presentation: Came to the hospital with 2-3 days of right-sided weakness and slurred speech.

Findings: MRI showed a moderate-sized left pontine stroke. A CT angiogram of the neck showed no evidence of an occlusion, but a spiculated two-centimeter nodule at the apex of the left lung was found.

Additional Information: He requires a walker for mobility and needs help with activities like taking a shower and dressing. He had an unintentional 20-pound weight loss over six months, increased fatigue, and malaise.

Previous Investigations: A chest x-ray ordered two months prior by his hematologist was unremarkable, and a CT of the abdomen and pelvis showed no masses.

Key Learning Points

Bronchoscopy in Decision Making:

  • The decision to perform bronchoscopy in patients depends on a myriad of factors, including the location of any lesions, accessibility, potential risks, and the potential diagnostic yield.
  • Fiber optic bronchoscopy with BAL can rule out infections, and if no diagnosis is reached, more invasive methods like surgical biopsy might be necessary.
  • Consider the location of consolidated masses; navigational bronchoscopy might be needed for lesions without a clear airway leading into them.

Nocardia Insights:

  • Nocardia is a gram-positive bacterium that stains weakly acid-fast.
  • It can be found in soil and certain water sources and can infect through the skin or by inhalation.
  • Two-thirds of patients with Nocardia are immunocompromised.
  • The dosage of Bactrim given for PJP prophylaxis doesn’t prevent Nocardia infections in immunocompromised individuals.
  • While the lungs are the most common infection site, Nocardia can manifest elsewhere, like the skin or CNS.

Treatment Approach:

  • Bactrim is the mainstay of treatment for Nocardia. If someone is allergic, desensitizing them can be crucial.
  • IV induction phases vary in length depending on the severity of the disease.
  • The overall treatment duration is protracted to prevent relapse.

Takeaway Points:

  • Bactrim for PJP prophylaxis doesn’t necessarily prevent Nocardia infections in immunocompromised individuals.
  • If someone is allergic to Bactrim, consider desensitizing them due to its importance in treating Nocardia.

References and Further Reading:

Menéndez R, Cordero PJ, Santos M, Gobernado M, Marco V. Pulmonary infection with Nocardia species: a report of 10 cases and review. Eur Respir J. 1997 Jul;10(7):1542-6. doi: 10.1183/09031936.97.10071542. PMID: 9230244.

Zia K, Nafees T, Faizan M, Salam O, Asad SI, Khan YA, Altaf A. Ten Year Review of Pulmonary Nocardiosis: A Series of 55 Cases. Cureus. 2019 May 26;11(5):e4759. doi: 10.7759/cureus.4759. PMID: 31363440; PMCID: PMC6663111.

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Radiology Rounds – 7/19/23

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We are back with our first #RadiologyRounds of the new academic year. We have a young, immunocompetent man presenting with fever, weight loss, and abdominal pain.

What abnormalities are seen on his chest imaging?

He was found to have bilateral apical cavitary disease, centrilobular nodules, and tree-in-bud opacities. He developed a productive cough with blood-tinged sputum as well as diarrhea.

Given his apical lung disease, what is on your differential?

When thinking about apical lung disease, remember the mnemonic REACTS to help with your differential.

What are tree-in-bud opacities? They are findings seen on CT chest suggesting bronchial dilation, inflammation, and bronchial filling with fluid, mucus, or pus that can be caused by infections and non-infectious etiologies.

He had sputum and AFB cultures sent and his AFB smear was positive. He was ultimately diagnosed with disseminated TB and started on RIPE therapy.