Pulmonary & Critical Care Division Newsletter

A 76 y.o. W with a past medical history of type 2 diabetes and essential hypertension, presented to hospital with a progressively worsening shortness of breath and dry cough for three weeks, which started while she was on a cruise. She had an associated rash localized to both hands, for which she was prescribed antibiotics, with improvement. She is retired from desk work and is a lifetime non-smoker. Chest xray revealed bilateral airspace disease, predominantly lower lobes, with representative CT chest above. She had a new oxygen requirement of 2L. WBC was 14.7, neutrophil predominant, absolute eosinophil count 0. Respiratory failure continued to worsen despite antibiotics. Bronchoscopy with BAL was performed, with a neutrophil-predominant cell count, normal eosinophils, and low colony count Pseudomonas aeruginosa. ANA, rheumatoid factor, anti-CCP, and DsDNA were negative. She has normal renal function. Histoplasma and blastomycosis Ab are negative. Clinical status worsens despite antipseudomonal coverage, steroids for pneumonia, and diuresis for newly diagnosed cardiomyopathy with an ejection fraction of 35%. She develops renal failure with reduced urine output, with normal urine sediment. She requires mechanical ventilation with PEEP 14, FiO2 100%. What is the next best step to establish a diagnosis?

A. Perform repeat bronchoscopy with transbronchial biopsy
B. Perform bronchoscopy with serial aliquots
C. Obtain myositis antibody panel
D. Evaluate exposures and obtain hypersensitivity panel


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Answer to last month's quiz:


Thoracic splenosis is an uncommon condition that arises as a complication of trauma to the spleen and diaphragm. It complicates up to 18% of splenic rupture, particularly following penetrating trauma. Median time from trauma to diagnosis is 18.8 years. Abdominal splenic implants are more common than thoracic implants but when involved, thoracic splenosis tends to be on the left side of the chest. Rarely patients can have pleurisy or hemoptysis related to thoracic splenosis. Clues to diagnosis include a history of trauma and an absent spleen on imaging. Nuclear medicine scans with technetium-99 tagged RBCs or technetium-99 labeled sulfur colloid imaging can confirm the presence of splenic tissue [choice D is correct]. If thoracic splenosis is on the differential diagnosis, imaging should be considered prior to biopsy as splenic tissue is very vascular, risking significant hemorrhage [choice B is incorrect]. The splenic tissue should not be resected as it is functional and thought to prevent post splenic sepsis. One study demonstrated auto transplantation of splenic tissue post splenectomy was more effective at clearing pneumococcal bacteremia than native spleen. A PET-CT scan was performed for this patient with no FDG uptake in the pleural mass. Ultimately a technetium-99 sulfur colloid scan confirmed thoracic splenosis and a biopsy was avoided.



Biopsy and resection should be reserved for cases where malignancy is suspected. This pleural mass should not be biopsied bronchoscopically as it would cross the pleural border [choice A is incorrect]. While the mass abutted the mediastinum, it did not extend into the mediastinum, thus mediastinoscopy would not be able to successfully sample the pleural mass [choice C is incorrect]. Pulmonary function testing can be useful prior to lung resection surgery to assess for the safety of resection. Lung nodules or lung masses with a very high likelihood of malignancy may be best managed by surgical risk assessment and initial lung resection which is not the case for this patient [choice E is incorrect]. BRCA-associated protein 1 [BAP1] mutational analysis will not aid diagnosis. Over half of the malignant mesothelioma cases with onset under the age of 50 are associated with BAP1 mutations. Multiple malignancies are associated with BAP1 mutations. Identifying a mutation could aid in identifying malignancies for the patient and family members but this is done after a diagnosis of malignant mesothelioma is made. Our patient is over the age of 50 and a negative BAP1 mutation does not exclude malignant mesothelioma [choice F is incorrect].