Faculty Bibliography

While most teratomas are asymptomatic, intrathoracic teratomas can rarely rupture spontaneously causing more alarming symptoms. Ruptured teratoma is a serious clinical entity, and early recognition is crucial for avoidance of further complications and preparation of proper surgical approach. We present a case of ruptured anterior mediastinal teratoma with radiologic, pathologic, and bronchoscopic correlation. This case uniquely illustrates a patient presenting with signs of infection and progressively worsening symptoms, thus emphasizing the need for early diagnosis and the importance of imaging.

A wide variety of pathologic processes, both benign and malignant, affect the central airways. These processes may be classified into 4 distinct groups: anatomic variants, lesions that result in focal or diffuse airway narrowing, and those that result in multinodular airway disorder. Key to the accurate assessment of the central airways is meticulous imaging technique, especially the routine acquisition of contiguous high-resolution, 1-mm to 1.5-mm images. These images enable high-definition axial, coronal, and sagittal reconstructions, as well as advanced imaging techniques, including minimum intensity projection images and virtual bronchoscopy. Current indications most commonly include patients presenting with signs and symptoms of possible central airway obstruction, with or without hemoptysis. In addition to diagnosing airway abnormalities, computed tomography (CT) also serves a critical complementary role to current bronchoscopic techniques for both diagnosing and treating airway lesions. Advantages of CT include noninvasive visualization of the extraluminal extent of lesions, as well as visualization of airways distal to central airways obstructions. As discussed and illustrated later, thorough knowledge of current bronchoscopic approaches to central airway disease is essential for optimal correlative CT interpretation.

Alveolo-pleural fistula is a common complication of severe pulmonary infection. Some patients require long-term placement of chest tubes until spontaneous closure of the fistula takes place, whereas others require surgical intervention. We report a case of a patient with alveolo-pleural fistula secondary to Pneumocystis jirovecii pneumonia who was successfully treated with the use of intrabronchial unidirectional valves inserted using flexible bronchoscopy.

OBJECTIVE: To determine whether linezolid is safe and well tolerated in the treatment of extensively drug-resistant tuberculosis (XDR-TB). MATERIALS AND METHODS: The was conducted in a specialized tuberculosis ward for multidrug-resistant tuberculosis (MDR-TB) on the Chest Service of Bellevue Hospital Center, which is a 768-bed public hospital in New York City. Seven patients with confirmed MDR-TB or XDR-TB who were still culture positive despite appropriate directly observed therapy were treated with a regimen containing linezolid and at least one other active agent. RESULTS: The linezolid-containing regimen led to sustained negative conversion of sputum cultures and radiographic improvement in all patients. Long-term therapy (longest duration of therapy, 28 months) was well tolerated in most patients. Neutropenia developed in three patients, but was reversible, and peripheral neuropathy developed in two patients. CONCLUSIONS: Linezolid remains a promising possible addition to our therapeutic armamentarium against XDR-TB. Linezolid is associated with side effects that can be adequately managed. Further studies to define the mechanism of action and optimum dose should be performed

Propylthiouracil (PTU) has been held responsible for diffuse alveolar hemorrhage (DAH) with positive antineutrophil cytoplasmic antibody (ANCA) and capillaritis. We describe a case of a 23-year-old pregnant female with Grave's disease treated with PTU who presented with flu-like symptoms and progressive dyspnea. Open lung biopsy showed DAH without evidence of capillaritis. All serologies were negative. Five days after PTU withdrawal and intravenous steroid therapy, the patient improved dramatically. She remained symptom free without relapse 9 months after the episode. To the best of our knowledge, this is the first reported case of PTU-related alveolar hemorrhage with negative serologic markers and without capillaritis.

Transbronchial needle aspiration is a safe procedure with a complication rate under 1%. Aseptic pericarditis and mediastinal hematoma are rare complications. We present a case of a 40-year-old patient who underwent left paratracheal lymph node biopsy with a 21-g needle who sustained both aseptic pericarditis and a mediastinal hematoma. His symptoms of pericarditis were treated with ibuprofen, whereas the hematoma resolved spontaneously.

In 1977, Cunningham et al reported a 45% risk of hemorrhage in azotemic patients undergoing flexible bronchoscopy (FB) with biopsy. There have been no recent studies evaluating renal insufficiency as a relative contraindication to biopsy. We reviewed all charts of Bellevue Hospital bronchoscopies from October 1997 to October 2002 for blood urea nitrogen (BUN), creatinine (Cr), hemogram, and coagulation studies as well as the type of biopsy performed, pretreatment medications, and complications from the FB. Patients were included if they had a BUN >=30 mg/dL and/or a Cr >=2 mg/dL. Seventy-two patients met criteria. Twenty-five of 72 (35%) patients had bronchoscopic biopsy. Seven of 25 (28%) were hemodialysis (HD) patients and 18 of 25 (72%) were nondialysis (ND) patients. All HD patients received FB within 24 hours after HD and were given desmopressin (DDAVP) prebronchoscopy. One patient with coagulopathy also received platelets and fresh-frozen plasma. Six of 7 HD patients had forceps biopsy (BX) (BUN range 31-65; Cr range 5.2-18.7) and 1 had transbronchial needle aspiration (TBNA) (BUN 32; Cr 4.3). Twelve of 18 ND patients had BX (BUN 20-69; Cr 0.9-2.5), 4 had TBNA (BUN 20-62; Cr 1.1-4.5), and 2 had BX and TBNA (BUN 30-35; Cr 1.4-1.5). One of 25 (4%) ND patients had a major complication of massive bleeding that required intervention. One of 25 (4%) ND patients had minor bleeding. There were no complications in the HD group. These findings suggest a low complication rate of bleeding in patients undergoing biopsy during FB if screened for coagulation abnormalities and, if receiving HD, done after HD with prebronchoscopy DDAVP. Our hemorrhagic complication rate was much lower than that reported in 1977. These data advocate further studies to evaluate whether bronchoscopic biopsy should be considered a relative contraindication in patients with renal insufficiency.

BACKGROUND: Asbestos bodies (AB) in BAL cells are specific markers of asbestos exposure. METHODS: We retrospectively reviewed BAL cytocentrifuge slides of 30 utility workers with a history of asbestos exposure and 30 normal volunteers. BAL cytocentrifuge slides were blinded and scanned under 40 x light microscope. RESULTS: AB were found more frequently in subjects with a history of asbestos exposure compared to normal volunteers (10 of 30 subjects, 33%, vs 0 of 30 subjects). The mean number of AB seen in the AB-positive group was 2.7 per slide. Demographic data were comparable including age, gender, and smoking. Exposure histories were also similar: duration > 20 years, onset > 30 years ago, and time since last exposure > 7 years. More AB-positive patients reported respiratory symptoms (70% vs 26%, p < 0.05). High-resolution CT scans of AB-positive patients revealed a higher prevalence of parenchymal disease (70% vs 26%, p < 0.05). AB-positive subjects had reduced pulmonary function compared to AB-negative subjects: FVC (86% vs 97% predicted), FEV(1) (77% vs 92% predicted, p < 0.05), and diffusion capacity of the lung for carbon monoxide (76% vs 104% predicted, p < 0.01). CONCLUSION: In individuals with a history of asbestos exposure, the presence of AB in BAL cells is associated with higher prevalence of parenchymal abnormalities, respiratory symptoms, and reduced pulmonary function