Diagnostic approach to a cardiac mass: a case report of misdiagnosed cardiac synovial sarcoma

Background Cardiac synovial sarcoma (CSS) is an extremely rare malignant tumour with a poor prognosis. We report the case of a 31-year-old woman who presented with a CSS in the right atrium and was initially misdiagnosed with a tuberculoma. The aim of this article is to focus on the importance of having broad differential diagnoses including rare entities. Case summary A 31-year-old White woman, with a close contact with a relative having pulmonary tuberculosis, presented to the emergency unit with severe dyspnoea. Chest radiography and echocardiography showed a large pericardial effusion with a mass in the right atrium. Pericardiocentesis removed bloody exudative fluid with adenosine desaminase at 17 UI/L and no malignant cells in the cytological study. Cardiac magnetic resonance revealed a tuberculoma of the right atrium. Intraoperatively, the mass was only biopsied because of the local invasion. Histological study concluded to a CSS. The patient died 3 days later. Discussion This case highlights the importance of having broad differential diagnoses including rare entities. Histology was the key investigation for the diagnosis of CSS which has no clinical nor laboratory or imaging pathognomonic signs.

Dyspnoea and Symptom Burden in Mild-Moderate COPD: the Canadian Cohort Obstructive Lung Disease Study

RationaleStudies assessing dyspnoea and health-related quality of life (HRQoL) in chronic obstructive pulmonary disease (COPD) have focused on patients in clinical settings, not the general population.ObjectivesCompare the prevalence and severity of dyspnoea and impaired HRQoL in individuals with and without COPD from the general population, focusing on mild-moderate COPD.MethodsAnalysis of the 3-year Canadian Cohort Obstructive Lung Disease (CanCOLD) study included four subgroups: mild-COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] 1); moderate-COPD (GOLD 2); non-COPD smokers; and non-COPD never-smokers. The primary outcome was dyspnoea (Medical Research Council [MRC] scale), and the secondary outcome was HRQoL (COPD Assessment Test [CAT] score; Saint George's Respiratory Questionnaire [SGRQ] score). Subgroups were analysed by sex, physician-diagnosed COPD status, and exacerbations.Results1443 participants (mild-COPD [n=397]; moderate-COPD [n=262]; smokers [n=449], and never-smokers [n=335]) were studied. People with mild-COPD were more likely to report more severe dyspnoea (MRC 2 versus 1 [MRC2 versus 1]) than those without COPD (OR [95%CI]: 1.42 [1.05,1.91]), and non-COPD never-smokers (OR [95%CI]: 1.64 [1.07,2.52]). Among people with mild-COPD, more severe dyspnoea was reported in women versus men (MRC2 versus 1; OR [95%CI]: 3.70 [2.23,6.14]); people with, versus without, physician-diagnosed COPD (MRC2 versus 1; OR [95%CI]: 3.27 [1.71,6.23]), and people with, versus without, recent exacerbations (MRC2 versus 1; ≥2 versus 0 exacerbations: OR [95%CI]: 3.62 [1.02,12.86]; MRC≥3 versus 1 [MRC≥3 versuss 1]; 1 versus 0 exacerbation: OR [95%CI]: 9.24 [2.01,42.42]). Similar between-group differences were obtained for CAT and SGRQ scores.ConclusionsCareful assessment of dyspnoea and HRQoL could help identify individuals for earlier diagnosis and treatment.

Case Report: Fatal myocarditis after combination of immune checkpoint inhibitor and platinum doublet chemotherapy

Myocarditis is a rare but feared adverse event of treatment with immune checkpoint inhibitors. The incidence is about 1%, while the mortality rate is up to 50%. Many physicians treating lung cancer do not have experience with this serious adverse event, and few hospitals in Scandinavia have routines for baseline assessments that may help detect early signs of inflammation of the myocard. Early onset of anti-inflammatory treatment is associated with favourable outcome. We present a case report of fatal myocarditis after treatment with check-point inhibitor. The patient was admitted with severe dyspnoea, general body ache, weakness, dysphagia, palpitations and diplopia two weeks after her second infusion of systemic treatment combining chemotherapy and immunotherapy. She had presented vague symptoms at time of the second infusion that were not identified as related to myocarditis/myositis. Upon aggressive treatment with methylprednisolone, mycophenolate mofetil, abatacept and plasmapheresis, her troponins and pro-BNP were reduced, but clinically she deteriorated and her life could not be saved. We present this case report to increase awareness of the condition and to raise discussion about the role of routine baseline assessments to aid early diagnosis and anti-inflammatory treatment to prevent treatment-related deaths.

The relationship between sleep quality and dyspnoea severity in patients with COPD

Objectives: This study aimed to determine sleep quality, frequency and severity of dyspnoea in COPD patients and to eval- uate the relationship between dyspnoea severity and sleep quality. Method: The sample of the study consisted of 110 patients admitted to the Chest Diseases polyclinic of a private hospital and diagnosed as COPD for at least one year. The data of the study were collected using the "Individual Information Form", "COPD and Asthma Sleep Scale (CASIS)" and "Medical Research Council (MRC) Dyspnoea Scale”. Results: It was found that 6.4% of the patients did not experience dyspnoea, 34.5% had mild, 40.9% had moderate, and 18.2% had severe dyspnoea. The mean CASIS score of the patients without dyspnoea was 29.08±7.83, with mild dyspnoea was 40.22±9.30, with moderate dyspnoea was 50.31±8.97 and with severe dyspnoea was 56.96±13.13. There was a statisti- cally significant difference between dyspnoea severity and mean CASIS score (p=0.001). Correlation analysis between MRC dyspnoea scale and CASIS score showed a significant positive correlation (r=0.61 p=0.001). Conclusion: It was concluded that the majority of COPD patients had moderate or poor sleep quality and dyspnoea. As dyspnoea severity increases, sleep quality decreases. Keywords: Dyspnoea; COPD; Sleep.

ALENDRONATE-INDUCED RESPIRATORY DISTRESS

Respiratory distress is a rare adverse effect of alendronate that is typically associated with severe dyspnoea and wheezing and typically requires hospitalization. The patient with a history of dyspnoea and wheezing during the strenuous workload was treated promptly with alendronate for newly diagnosed osteoporosis. After 2 days, respiratory distress complications were restarted and we accurately reported the patient with basophilia, elevated immunoglobulin E (with a blood test), and allergic bronchopulmonary aspergillosis (with computed tomography scan image). The prospective patient was adequately understood as alendronate-induced respiratory distress with an unfortunate rechallenge method. Although there is no direct causal relationship from this adverse case report, the possible mechanism has discussed typically based on peer-reviewed literature.

Ticagrelor-Related Severe Dyspnoea: Mechanisms, Characteristic Features, Differential Diagnosis and Treatment

With a growing number of patients on ticagrelor therapy after stent implantation, we observe many cases of side effects of the drug, mostly dyspnoea and bradycardia. In our article we present 2 patients, in which the symptoms were particularly severe. Then we describe possible mechanisms of these complications, explain how to carry out differential diagnosis, discuss when to switch ticagrelor to other antiplatelet drug and finally we present the way to deal with the symptoms.

CPFE Syndrome: A Case Report

Combined pulmonary fibrosis and emphysema syndrome (CPFE syndrome) is the co-existence of emphysema and pulmonary fibrosis in individuals. The syndrome was first described by Cottin et al., in 2005 and is characterised by upper lobe emphysema and lower lobe interstitial fibrosis. Patients with CPFE show severe dyspnoea and hypoxemia with exercise. Lung function tests (LFT) reveal a mixed pattern with relatively preserved lung volumes and severely low diffusing capacity for carbon monoxide (DLCO). CPFE is prevalent in heavy male smokers and have a high probability of developing pulmonary hypertension, acute lung injury and lung cancer

Intravenous leiomyomatosis manifesting as saddle embolism

A 51-year-old, otherwise well woman, presented with progressive severe dyspnoea. CT pulmonary angiogram (CTPA) demonstrated a large filling defect within the right main pulmonary artery with evidence of right heart strain. She was anticoagulated and discharged home; however, was readmitted with progression of symptoms and hypotension within 1 month. Repeat CTPA demonstrated progression of the filling defect. Formal surgical thrombectomy was performed with removal of an unusual cream-coloured, rubber-like material. Histological analysis revealed intravenous leiomyomatosis (IVL). IVL is a rare benign neoplasm, characterised by smooth muscle cell proliferation in vascular structures that can act aggressively. This case describes the workup, recognition and management of IVL.

Internal Laryngocele: Unusual onset in a 91-year-old female patient

While internal laryngoceles rarely cause major clinical complaints, they may lead to airway obstruction and require emergency intervention on rare occasions. We report a 91-year-old patient who was referred to the Ear, Nose & Throat Clinic of the Policlinico Santa Maria alle Scotte, Siena, Italy, in 2017 due to recurrent episodes of severe dyspnoea. A flexible nasopharyngolaryngoscopic examination revealed an internal laryngocele of approximately 1.5 cm in diameter that moved up and down the glottic plane, occasionally invading the subglottic space during inspiration and impeding airflow. This caused cyanosis and dyspnoea so severe that an emergency tracheotomy was considered. Luckily, after considerable effort, the patient was able to cough, causing the mass to move above the vocal plane and allowing normal breathing. The laryngocele was subsequently removed via laryngomicrosurgery. Although the incidence of internal laryngoceles is quite rare, physicians should consider this potentially life-threatening condition among patients with dyspnoea.