Sidra Bonner is a general surgery resident at Michigan Medicine. She completed her undergraduate education at Cornell University and medical education at the University of California-San Francisco. Sidra also has a Master’s in Public Health focused in Health Policy from Harvard and a Master’s in Science Health and Healthcare Research from the University of Michigan. She is interested in pursuing a career in general thoracic surgery with a research focus aimed at addressing the multi-level contributors to racial and ethnic inequities in access, quality, and outcomes of surgical care for patients with lung and esophageal cancer.
Tom Valley is an Associate Professor in the Division of Pulmonary and Critical Care Medicine at the University of Michigan. He completed his IM residency and chief residency at the University of Texas-Southwestern/Parkland Memorial Hospital and then joined the University of Michigan as a pulmonary and critical care fellow in 2013 and stayed on for faculty and is the physician-lead for the University of Michigan Schwartz Rounds for Compassionate Care. Tom’s research aims to understand and improve medical decision making in the intensive care unit.
We are thrilled to be back with another episode in our Top Consults series. We are talking about Solitary Pulmonary Nodules, which is something every pulmonologist will encounter in the clinic and on in-patient consults. We go through a number of cases and provide a framework for approaching these cases.
Meet our guests
Dr. Jessica Wang Memoli is board certified in pulmonary disease, critical care medicine and internal medicine. She is the Director of Bronchoscopy and Interventional Pulmonary, as well as the Associate Fellowship Program Director for Pulmonary Critical Care Medicine at the MedStar Washington Hospital Center. Dr. Wang Memoli received her medical degree from the University of Miami Miller School of Medicine. She completed her residency at MedStar Washington Hospital Center and her fellowship training at the Medical University of South Carolina in Charleston.
Dr. Nick Ghionni works at Union Memorial, Good Samaritan, and Franklin Square as an Intensivist and Pulmonologist. He completed his Internal Medicine residency at Mercy Catholic Medical Center in PA serving as Chief Internal Medicine resident. He was a fellow at MedStar Washington Hospital Center where he was the Chief Pulmonary Critical Care Fellow. His specific interests include mechanical ventilation, POCUS, and medical education.
Case Presentations
Case 1:
33 year old woman who came to the emergency department with acute onset of shortness of breath. She states that she had been in her normal state of health until this morning when she developed shortness of breath at rest, and chest pain. She does report a non-productive cough over the last few weeks which she feels may be contributing to her chest pain. She does report a history of asthma during childhood but without any exacerbations or maintenance therapies needed during her adulthood. She does report wheezing when she is sick with a cold but this is infrequent. The ED team sent off an initial work-up including a D-Dimer which was elevated, and she underwent a CTA of the chest for concern for possible PE. On the CT scan, there was no PE but the radiologist did call a “2 mm indeterminate right upper lobe pulmonary nodule.”
Case 2:
We have a 67-year-old male with a past medical history of ischemic cardiomyopathy, chronic systolic heart failure (LVEF 10-15%), s/p AICD, diabetes mellitus type 2, hyperlipidemia, hypertension, chronic kidney disease stage III, prostate cancer s/p seed implantation that was over 15 years ago who presented with acute decompensation of his heart failure and cardiogenic shock. He was successfully managed for that and is now being worked up by advanced HF and as a part of that workup got a chest CT, which found a RUL 6 mm nodule.
Case 3:
We have a 66-year-old male with a past medical history of HTN and drug abuse who presented to the ED with acute SOB, likely a COPD exacerbation. He was given bronchodilator and steroids as well as being started on Bipap. He eventually was able to be weaned off Bipap and was able to tolerate nasal cannula. As a part of his initial work up, the patient underwent CT scan for possible PE which demonstrated a new LUL spiculated nodule that is 1.3cm that is new since 2019.
Key Learning Points
Approaching Pulmonary Nodules:
A structured approach is essential due to the complexities of diagnosing pulmonary nodules.
Patient history, including risk factors, past interventions, and imaging, plays a vital role.
Nodules’ appearance, such as location, shape, or characteristics like calcification or spiculation, can provide diagnostic clues.
The nodules history on serial imaging is a key predictive risk factor for determining the likelihood that the nodule represents cancer
Tools like the Mayo Risk Calculator and Fleishner Society guidelines assist in risk assessment and guidance.
It’s essential to assess patient risk, and nodule risk, and prioritize patient concerns and education. Periodic monitoring or follow-up might be necessary based on the nodule’s risk and size.
A multidisciplinary approach involving various specialists ensures comprehensive care.
Key Discussion Points:
PET Scans:
Useful in gauging a nodule or tumor’s metabolic activity.
Large, hypermetabolic nodules are suspicious.
Not every positive PET result means malignancy; other causes like inflammation or scars can produce positive results.
Evaluating Nodules:
Consideration of nodule size, characteristics, patient history, and risk calculators is crucial.
Tumor boards provide a collaborative expertise approach.
Tissue Sampling & Testing:
The method of tissue sampling depends on resources and expertise.
CT-guided biopsy offers a high diagnostic yield but with a risk of pneumothorax.
Bronchoscopic biopsy provides a lower diagnostic yield than CT-guided biopsy but has a significantly reduced risk of complications.
Advanced diseases now often require molecular testing on tissue samples.
Ground Glass Nodules:
Different from solid nodules due to their slow growth rate.
Monitoring is crucial due to the potential for transformations raising cancer suspicions.
The approach for ground glass nodules typically involves more extended monitoring intervals than for solid nodules.
Holistic Evaluation:
Consider the nodule’s characteristics, the patient’s history, and clinical intuition.
Individualized patient assessment is as vital as evidence-based guidelines and clinical expertise.
See the infographic for a summary of key learning points:
References and further reading
Loverdos K, Fotiadis A, Kontogianni C, Iliopoulou M, Gaga M. Lung nodules: A comprehensive review on current approach and management. Ann Thorac Med. 2019 Oct-Dec;14(4):226-238. doi: 10.4103/atm.ATM_110_19. PMID: 31620206; PMCID: PMC6784443.
Mazzone PJ, Lam L. Evaluating the Patient With a Pulmonary Nodule: A Review. JAMA. 2022 Jan 18;327(3):264-273. doi: 10.1001/jama.2021.24287. PMID: 35040882.
MacMahon H, Naidich DP, Goo JM, Lee KS, Leung ANC, Mayo JR, Mehta AC, Ohno Y, Powell CA, Prokop M, Rubin GD, Schaefer-Prokop CM, Travis WD, Van Schil PE, Bankier AA. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243. doi: 10.1148/radiol.2017161659. Epub 2017 Feb 23. PMID: 28240562.
Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC; American College of Chest Physicians. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):94S-107S. doi: 10.1378/chest.07-1352. PMID: 17873163.
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.
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.
We’re excited to be back with another episode in our Pulm PEEPs Fellows’ Case Files series! This is a particularly exciting case since it is our first episode where some intrepid fellows reached out to us with an interesting case they had encountered. If you have a great case, please let us know and you can follow in their footsteps! Pack your bags, and let’s head to Mississippi to learn about another great pulmonary and critical care case.
Meet our Guests
Meredith Sloan is a pulmonary and critical care fellow at the University of Mississippi. She completed her medical school at the Medical University of South Carolina College of Medicine, and her residency at the University of Mississippi.
Kevin Kinloch is a senior fellow at the University of Mississippi Medical Center where he also completed his internal medicine residency. He completed medical school at Meharry Medical College.
Jessie Harvey is an Associate professor of Medicine at the University of Mississippi and is the Pulmonary and Critical Care Program Director. She is also the Director of the MICU, and has been at MMC since medical school. She is a dedicated educator and leads the POCUS curriculum for IM residents and PCCM fellows
Patient Presentation
A 65-year-old man presented to the ED with worsening hemoptysis over the last several days after a recent lung biopsy. The patient is an active smoker with at least a 50-pack-year history, and he had been having a cough with small-volume hemoptysis. He ultimately had a chest CT that revealed a large LUL mass (10.3 x 6.4 cm). Given this suspicious mass, three days prior to his ED presentation, he was taken for bronchoscopy with BAL, transbronchial biopsies, endobronchial biopsy, EBUS guided TBNA of 11L, along with TBNA, brushing and radial EBUS TBNA of his left upper lobe mass.
Key Learning Points
**Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at these points.
Staging procedures for masses
Enough tissue so we can make a diagnosis and do molecular testing
Highest staging when getting your biopsy
POCUS for respiratory failure
Absence of lung slidings
Especially post procedure
The presence of a new pleural effusion after a procedure could indicate hemothorax
Hematocrit sign – an echogenic layering of material in an effusion
New B-lines, especially if prior there were only A-lines
Cardiogenic or non-cardiogenic pulmonary edema, alveolar hemorrhage, or infection
