Successful Rituximab Treatment in a Patient With ANCA-Negative Granulomatosis With Polyangitis: A Case Report

Abstract A 68-year-old woman was referred to our hospital for further evaluation of fever, nasal congestion, deafness, and multiple pulmonary nodules refractory to antibiotic use. Despite negative findings of antineutrophil cytoplasmic antibodies, she was diagnosed with granulomatosis with polyangiitis based on the analysis of biopsy specimens of pulmonary nodules. The administrations of oral prednisolone and six intravenous cyclophosphamide (IVCY) resulted in the prompt relief of symptoms and disappearance of pulmonary nodules. However, 3 months after the completion of IVCY therapy, nasal congestion and deafness flared up with an increase in the C-reactive protein level; a repeat computed tomography revealed a left lung nodule. Consequently, she underwent remission induction and maintenance therapy with rituximab (RTX), which resulted in the symptomatic improvement and disappearance of pulmonary nodule after 6 months. The patient remained in remission thereafter. Therefore, RTX may be an effective therapeutic option even in the absence of detectable autoantibodies.

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Cavitating pulmonary metastases from a renal cell carcinoma

Clinics and Practice ◽

10.4081/cp.2020.1234 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Kulothungan Gunasekaran ◽

Berty Baskaran ◽

Mandeep Singh Rahi ◽

Daniel Rudolph ◽

Jay Parekh

Keyword(s):

Computed Tomography ◽

Renal Cell Carcinoma ◽

Cell Carcinoma ◽

Renal Cell ◽

Lung Nodule ◽

Left Lung ◽

Pulmonary Nodules ◽

Papillary Renal Cell Carcinoma ◽

Metastatic Carcinoma ◽

Diagnostic Challenge

Cavitary lung lesions are quite common findings on chest imaging and often pose a diagnostic challenge to the clinicians. We describe a case of a 75-year-old male who presented to the emergency room with hemoptysis. Computed tomography of the chest demonstrated multiple cavitary pulmonary nodules with peripheral groundglass opacities. Bronchoscopy did not reveal any active bleeding source, and washings were negative for malignancy and infectious cause. Computed Tomography guided biopsy of the left lung nodule showed metastatic carcinoma consistent with papillary renal cell carcinoma. This case highlights the unusual presentation of metastatic renal cell carcinoma.

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Open Treatment of Osteochondral Lesions of the Talus With Bone Grafting and Particulated Juvenile Cartilage Allografting

Foot & Ankle Specialist ◽

10.1177/19386400211009732 ◽

2021 ◽

pp. 193864002110097

Author(s):

Suhas P. Dasari ◽

Thomas M. Langer ◽

Derek Parshall ◽

Brian Law

Keyword(s):

Therapeutic Option ◽

Symptomatic Improvement ◽

Pain Scale ◽

Osteochondral Lesions ◽

Outcome Scores ◽

Scale Scores ◽

Open Treatment ◽

Bone Autograft

Background: Large cystic osteochondral lesions of the talus (OLT) are challenging pathological conditions to treat, but particulated juvenile cartilage allografts (PJCAs) supplemented with bone grafts are a promising therapeutic option. The purpose of this project was to further elucidate the role of PJCA with concomitant bone autografts for treating large cystic OLTs with extensive subchondral bone involvement (greater than 150 mm2 in area and/or deeper than 5 mm). Methods: We identified 6 patients with a mean OLT area of 307.2 ± 252.4 mm2 and a mean lesion depth of 10.85 ± 6.10 mm who underwent DeNovo PJCA with bone autografting between 2013 and 2017. Postoperative outcomes were assessed with radiographs, Foot and Ankle Outcome Scores (FAOS), and visual pain scale scores. Results: At final follow-up (27.0 ± 12.59 weeks), all patients had symptomatic improvement and incorporation of the graft on radiographs. At an average of 62 ± 20.88 months postoperatively, no patients required a revision surgery. All patients contacted by phone in 2018 and 2020 reported they would do the procedure again in retrospect and reported an improvement in their symptoms relative to their preoperative state, especially with pain and in the FAOS activities of daily living subsection (91.93 ± 9.04 in 2018, 74.63 ± 26.86 in 2020). Conclusion: PJCA with concomitant bone autograft is a viable treatment option for patients with large cystic OLTs. Levels of Evidence: Level IV

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AUTOMATIC LUNG NODULE DETECTION BASED ON STATISTICAL REGION MERGING AND SUPPORT VECTOR MACHINES

Image Analysis & Stereology ◽

10.5566/ias.1679 ◽

2017 ◽

Vol 36 (2) ◽

pp. 65 ◽

Cited By ~ 7

Author(s):

Elaheh Aghabalaei Khordehchi ◽

Ahmad Ayatollahi ◽

Mohammad Reza Daliri

Keyword(s):

Lung Nodule ◽

Three Dimensional ◽

Pulmonary Nodules ◽

Ct Images ◽

Support Vector ◽

Svm Classifier ◽

Region Merging ◽

Three Dimensional Objects ◽

Ct Data ◽

Statistical Region Merging

Lung cancer is one of the most common diseases in the world that can be treated if the lung nodules are detected in their early stages of growth. This study develops a new framework for computer-aided detection of pulmonary nodules thorough a fully-automatic analysis of Computed Tomography (CT) images. In the present work, the multi-layer CT data is fed into a pre-processing step that exploits an adaptive diffusion-based smoothing algorithm in which the parameters are automatically tuned using an adaptation technique. After multiple levels of morphological filtering, the Regions of Interest (ROIs) are extracted from the smoothed images. The Statistical Region Merging (SRM) algorithm is applied to the ROIs in order to segment each layer of the CT data. Extracted segments in consecutive layers are then analyzed in such a way that if they intersect at more than a predefined number of pixels, they are labeled with a similar index. The boundaries of the segments in adjacent layers which have the same indices are then connected together to form three-dimensional objects as the nodule candidates. After extracting four spectral, one morphological, and one textural feature from all candidates, they are finally classified into nodules and non-nodules using the Support Vector Machine (SVM) classifier. The proposed framework has been applied to two sets of lung CT images and its performance has been compared to that of nine other competing state-of-the-art methods. The considerable efficiency of the proposed approach has been proved quantitatively and validated by clinical experts as well.

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Insulin Autoimmune Syndrome Treated with Plasmapharesis

Global Journal of Medical Research ◽

10.34257/gjmrkvol20is1pg25 ◽

2020 ◽

pp. 25-26

Author(s):

Dr. Kavya Jonnalagadda ◽

Dr. Praveen. V. Pavithran

Keyword(s):

Low Dose ◽

Serum Insulin ◽

Oral Prednisolone ◽

Symptomatic Improvement ◽

Insulin Antibody ◽

Autoimmune Syndrome ◽

Dose Oral ◽

High Insulin ◽

History Of ◽

Antibody Titers

A 66-year male with a history of Central Serous Retinopathy presented with recurrent episodes of hypoglycemia. On evaluation, he was found to have insulin-mediated hypoglycemia with serum insulin of 300uIU/ml, C peptide 27.51ng/ml, when the blood glucose was 46mg/dl. High insulin levels above 100uIU/ml, led to suspicion of Autoimmune hypoglycemia and were confirmed by a high anti-insulin antibody titer of 300U/ml. Imaging was negative for Insulinoma. The patient was started on low dose oral prednisolone under ophthalmological monitoring, but as there was no symptomatic improvement, the dose was increased following which there was a flare-up of CSR. The patient was initiated on plasmapheresis following which his hypoglycemia improved with drop in anti-insulin antibody titers to 29U/ml. The patient was maintained on low dose steroids, which were tapered and stopped over the next six months with complete resolution of hypoglycemia and normalization of anti-insulin antibody titers.

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Comparison of chest radiographic findings among HIV positive and negative adults with smear positive Pulmonary Tuberculosis in Dar-es-salaam

Tanzania Medical Journal ◽

10.4314/tmj.v31i1.336 ◽

2020 ◽

Vol 31 (1) ◽

pp. 48-65

Author(s):

Balowa M. Baraka ◽

Mboka Jacob ◽

Ramadhani Kazema ◽

Tumaini Nagu ◽

Emmanuel Suluba ◽

...

Keyword(s):

Pulmonary Tuberculosis ◽

Imaging Modality ◽

Left Lung ◽

Pulmonary Nodules ◽

Hiv Positive ◽

P Value ◽

Lung Field ◽

Tuberculosis Case ◽

Radiographic Findings ◽

Severe Immunosuppression

Background: Chest X-ray radiography is a widely available and cheap imaging modality used for identification of pulmonary tuberculosis (PTB) in suspected patients. Knowledge of discriminatory features of PTB among HIV infected patient is of utmost importance to improve tuberculosis case detection and consequently reduce morbidity and mortality associated with TB among HIV infected individuals. We aimed to describe chest radiographic findings among PTB patients and their association with HIV co-infection and CD4 levels among HIV positive patients.Methodology: A total of 170 newly diagnosed consented smear positive PTB patients underwent postero-anterior Chest radiographs (PA - CXR) and HIV testing. Determination of CD4 count was performed among HIV positive patients. The radiographs were interpreted using glossary of terms for thoracic radiology by two independent radiologists who were blinded to HIV diagnosis.Results: Study participants included 100 (58.9%) males and 70 (41.1%) females. Among these 54 (31.8%) had HIV/PTB co-infection. The pattern of radiographic findings among patients with PTB/HIV compared to PTB only were: pulmonary cavities 44.4% vs 61.2%, (p=0.04), alveolar consolidation 64.9% vs 81.7%, (p=0.04), upper zone consolidation 40.7% vs 57.8%, (p=0.039), middle zone consolidation 25.9% vs 44.8%, (p=0.019) and typical PTB 40.7% vs 57.8%, (p=0.039), respectively. Therefore, lesions were less likely to be observed among PTB/HIV compared to PTB only and the differences were statistically significant. When compared to PTB patients only HIV/PTB co-infected patients had more nodules on the left lung field 85.2% vs 60.9% (p=0.023); on each left lung zone upper 59.3% vs 34.4% (p=0.028); mid 77.8% vs 54.7% (p-value=0.039); lower 66.7% vs 34.4% (p=0.005) and miliary nodules 44.4% vs 15.6% (p=0.003), respectively. HIV/PTB co-infected patients with CD4 > 200 cells/μL had more mid zone consolidation (42.9% vs 15.2%, p=0.024).Conclusion: The commonest chest radiographic findings in HIV/PTB co-infected patients were pulmonary cavities and alveolar consolidation are associated with HIV negative status. HIV/PTB co-infected patients with severe immunosuppression had mid zone consolidation. Patients with severe immunosuppression showed less chest radiographic findings. HIV/PTB co-infection was highly associated with mid and lower zone pulmonary nodules and miliary nodules. Key words: PTB, HIV, CXR

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Pulmonary Nodule in a Patient with Oral and Lung Cancer: Cryptococcus Infection

Dentistry Journal ◽

10.3390/dj7040102 ◽

2019 ◽

Vol 7 (4) ◽

pp. 102

Author(s):

Yamagata ◽

Hirano ◽

Kanno ◽

Uchida ◽

Fukuzawa ◽

...

Keyword(s):

Lung Cancer ◽

Mediastinal Lymph Node ◽

Left Lung ◽

Pulmonary Nodules ◽

Pulmonary Cryptococcosis ◽

Thoracoscopic Resection ◽

Inferior Lobe ◽

Primary Lung Tumors ◽

Oral Cancer Patients ◽

The Right

Pulmonary nodules are frequently considered to be a metastatic disease or primary lung tumors in oral cancer patients. We present a case of pulmonary cryptococcosis in a 68-year-old man with oral and lung cancer. This lung cancer was treated with thoracoscopic resection of the right inferior lobe and mediastinal lymph node dissection. Lower gingival cancer was treated with a mandibulectomy, neck dissection, and reconstruction after chemoradiotherapy. A 20 mm cavitary nodule appeared at the left lung S6 one-month after surgery, during post-operative computed tomography. Thoracoscopic partial resection of the left inferior lobe was performed under the suspicion of lung metastasis. Pathology results revealed a pseudo-epithelial granuloma with necrosis and many yeast-shaped fungi with capsules. A pathological diagnosis of Cryptococcus infection was made. The patient was prescribed the antifungal agent fosfluconazole, which was administered intravenously for 1 week and intraoral fluconazole for 12 months. No recurrence of the Cryptococcus infection has been noted after 1.5 years.

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Mechanisms of Allergen Immunotherapy in Allergic Rhinitis

Current Allergy and Asthma Reports ◽

10.1007/s11882-020-00977-7 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Gabija Drazdauskaitė ◽

Janice A. Layhadi ◽

Mohamed H. Shamji

Keyword(s):

Allergic Rhinitis ◽

Immune Responses ◽

Allergen Immunotherapy ◽

Therapeutic Option ◽

Nasal Congestion ◽

Work Productivity ◽

Allergic Inflammation ◽

The United States ◽

Adaptive Immune Responses ◽

Adaptive Immune

Abstract Purpose of Review Allergic rhinitis (AR) is a chronic inflammatory immunoglobulin (Ig) E-mediated disease of the nasal mucosa that can be triggered by the inhalation of seasonal or perennial allergens. Typical symptoms include sneezing, rhinorrhea, nasal itching, nasal congestion and symptoms of allergic conjunctivitis. AR affects a quarter of the population in the United States of America and Europe. Recent Findings AR has been shown to reduce work productivity in 36–59% of the patients with 20% reporting deteriorated job attendance. Moreover, 42% of children with AR report reduced at-school productivity and lower grades. Most importantly, AR impacts the patient’s quality of life, due to sleep deprivation. However, a proportion of patients fails to respond to conventional medication and opts for the allergen immunotherapy (AIT), which currently is the only disease-modifying therapeutic option. AIT can be administered by either subcutaneous (SCIT) or sublingual (SLIT) route. Both routes of administration are safe, effective, and can lead to tolerance lasting years after treatment cessation. Both innate and adaptive immune responses that contribute to allergic inflammation are suppressed by AIT. Innate responses are ameliorated by reducing local mast cell, basophil, eosinophil, and circulating group 2 innate lymphoid cell frequencies which is accompanied by decreased basophil sensitivity. Induction of allergen-specific blocking antibodies, immunosuppressive cytokines, and regulatory T and B cell phenotypes are key pro-tolerogenic adaptive immune responses. Conclusion A comprehensive understanding of these mechanisms is necessary for optimal selection of AIT-responsive patients and monitoring treatment efficacy. Moreover, it could inspire novel and more efficient AIT approaches.

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Primary Mammary-Analogue Secretory Carcinoma of the Lung: A Rare Entity With an Unusual Location

International Journal of Surgical Pathology ◽

10.1177/1066896920914975 ◽

2020 ◽

Vol 28 (7) ◽

pp. 775-781

Author(s):

Josean Ramos ◽

Waqas Mahmud ◽

Fernando Alekos Ocampo ◽

Gillian Alex ◽

Paolo Gattuso

Keyword(s):

S100 Protein ◽

Lung Nodule ◽

Left Lung ◽

Secretory Carcinoma ◽

Mammary Analogue Secretory Carcinoma ◽

Unusual Location ◽

Computed Tomographic ◽

Architectural Patterns ◽

Show Evidence ◽

History Of

This is a case of a 55-year-old female with past medical history of tobacco smoking, hypertension, and lupus who presented with a left lung nodule, found on computed tomographic scan of the chest during workup for a recently diagnosed squamous cell carcinoma in a cervical lymph node. Resection of the lung nodule showed a 2.3-cm well-defined pale-tan mass, and histologic examination showed a well-circumscribed lesion with papillary, solid, and gland-like architectural patterns, with eosinophilic secretions, areas of comedonecrosis, and increased mitotic activity. Immunohistochemical stains showed the lesion to be positive for cytokeratin 7, S100 protein, and focally positive for mammaglobin. Fluorescence in situ hybridization studies confirmed rearrangement of the ETV6 gene at 12p13.2. To date, our case is the second reported case of a primary mammary-analogue secretory carcinoma arising in the lung, and the first to show evidence of tumor necrosis: an unusual feature in an unusual location.

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The effect of bronchial thermoplasty on airway volume measured 12 months post-procedure

ERJ Open Research ◽

10.1183/23120541.00300-2020 ◽

2020 ◽

Vol 6 (4) ◽

pp. 00300-2020

Author(s):

David Langton ◽

Ceri Banks ◽

Peter B. Noble ◽

Virginia Plummer ◽

Francis Thien ◽

...

Keyword(s):

Left Lung ◽

Muscle Layer ◽

Symptomatic Improvement ◽

Forced Expiratory Volume ◽

Middle Lobe ◽

Oral Steroid ◽

Asthma Control Questionnaire ◽

Post Procedure ◽

Bronchial Thermoplasty ◽

Residual Capacity

Bronchial thermoplasty induces atrophy of the airway smooth muscle layer, but the mechanism whereby this improves patient health is unclear. In this study, we use computed tomography (CT) to evaluate the effects of bronchial thermoplasty on airway volume 12 months post-procedure.10 consecutive patients with severe asthma were evaluated at baseline by the Asthma Control Questionnaire (ACQ), and high-resolution CT at total lung capacity (TLC) and functional residual capacity (FRC). The CT protocol was repeated 4 weeks after the left lung had been treated by bronchial thermoplasty, but prior to right lung treatment, and then again 12 months after both lungs were treated. The CT data were also used to model the implications of including the right middle lobe (RML) in the treatment field.The mean patient age was 62.7±7.7 years and forced expiratory volume in 1 s (FEV1) 42.9±11.5% predicted. 12 months post-bronchial-thermoplasty, the ACQ improved, from 3.4±1.0 to 1.5±0.9 (p=0.001), as did the frequency of oral steroid-requiring exacerbations (p=0.008).The total airway volume increased 12 months after bronchial thermoplasty in both the TLC (p=0.03) and the FRC scans (p=0.02). No change in airway volume was observed in the untreated central airways. In the bronchial thermoplasty-treated distal airways, increases in airway volume of 38.4±31.8% at TLC (p=0.03) and 30.0±24.8% at FRC (p=0.01) were observed. The change in distal airway volume was correlated with the improvement in ACQ (r=−0.71, p=0.02). Modelling outputs demonstrated that treating the RML conferred no additional benefit.Bronchial thermoplasty induces long-term increases in airway volume, which correlate with symptomatic improvement.

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Flip flop fungus sign: an FDG PET sign of benign pulmonary nodules

BMJ Case Reports ◽

10.1136/bcr-2020-236231 ◽

2020 ◽

Vol 13 (11) ◽

pp. e236231

Author(s):

Valeri Kraskovsky ◽

Brianne MacKenzie ◽

Ayesha Arshad ◽

Martin Jeffery Mador

Keyword(s):

Fdg Pet ◽

Histoplasma Capsulatum ◽

Clinical Course ◽

Lung Nodule ◽

Pulmonary Nodules ◽

Lymph Node Biopsy ◽

Endobronchial Ultrasound ◽

Flip Flop ◽

Node Biopsy ◽

Mediastinal Adenopathy

A 71-year-old man was referred to pulmonary clinic for incidental findings of hypermetabolic lung nodule and mediastinal adenopathy on CT FDG PET performed for evaluation of cough. The patient underwent bronchoscopy with endobronchial ultrasound that was non-diagnostic. The patient was subsequently sent for video-assisted thoracoscopic lymph node biopsy notable for confluent caseating granulomas due to chronic infection by Histoplasma capsulatum. Review of previous PDG PET was notable for the flip flop fungus sign—a PDG PET finding that could have altered the patients’ clinical course by potentially avoiding the need for invasive surgical tissue diagnosis.

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