Respiratory Medicine CME RSS feed: Current Issue. Respiratory Medicine CME publishes articles relevant to the continuing medical and professional development of researchers and practitioners with an interest in adult and paediatric medicine, epidemiology, immunology and cell biology, physiology, occupational disorders, and the role of allergens and pollutants. Respiratory Medicine CME publishes commissioned CME related articles and Case Reports . The journal is published online only on a quarterly basis. Access the journal online at http://www.resmedcme.com/ Click here to take a CME test . Respiratory Medicine CME tests are accredited by The European Board for Accreditation in Pneumology (EBAP).http://www.resmedcme.com/?rss=yesElsevier Inc.en © 2010 Elsevier Ltd. All rights reserved. Respiratory Medicine CME1755-0017312010 © 2010 Elsevier Ltd. All rights reserved. healthpermissions@elsevier.comhttp://www.resmedcme.com/article/PIIS1755001710000023/abstract?rss=yesAbstract: Most cases of pulmonary arterial hypertension (PAH) are not idiopathic, but rather are attributable to other disorders. This fact has become increasingly apparent following the recent establishment of centralised PAH registries in several countries. Yet, this “secondary” PAH has been the subject of even less research than idiopathic PAH, itself an orphan disease par excellence. Secondary PAH is heterogeneous: prognosis and response to vasodilator therapy differs substantially between various forms of secondary PAH, partly as a function of underlying pathophysiology, and cannot simply be extrapolated from data derived from idiopathic PAH.This article reviews the commonest secondary causes of PAH, focusing on epidemiology, risk factors, clinical presentation, treatment options, prognosis, and the role of screening. PAH secondary to chronic hypoxia, congenital heart disease, connective tissue disorders, liver disease, appetite suppressants and stimulants, and HIV infection are all considered. Strengths and limitations of available screening tests for PAH are discussed.Secondary pulmonary hypertensionPaul Sexton, Margaret L. Wilsher10.1016/j.rmedc.2010.01.001Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1CME Articles19http://www.resmedcme.com/article/PIIS1755001709000852/abstract?rss=yesAbstract: Systemic sclerosis is a fascinating, although uncommon condition. However, fibrosing alveolitis in systemic sclerosis patients is common and is associated with significant morbidity and mortality. Investigations assist, not only with diagnosis, but also with assessment of disease severity and assessment of the likelihood of disease progression, thus helping to identify those requiring closer medical supervision. Treatment of fibrosing alveolitis in systemic sclerosis is complex, as the risks of some therapies may outweigh the potential benefits, and for those with advanced disease there is a lack of donor organs available for transplantation. Great strides continue to be made in unravelling the mysteries of the immunopathogenesis of fibrosing alveolitis in systemic sclerosis, and this should eventually lead to the development of more rational and targeted pharmacological therapies.Pulmonary fibrosis in systemic sclerosis: Diagnosis & managementHoward M. Branley10.1016/j.rmedc.2009.09.016Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1CME Articles1014http://www.resmedcme.com/article/PIIS1755001709000293/abstract?rss=yesAbstract: The thymus is a lymphoid organ located in the antero-superior mediastinum and composed of heterogeneous admixture of lymphoid and epithelial elements. Thymic tumors are dominated by thymoma; lymhomas are uncommon involving the gland secondary to adenopathies. Primary thymic lymphomas are exceptional.We report a 25-year-old man referred to us because of chest pain and irritating cough since 2 months. Physical examination was normal and no lymph nodes were palpable. Chest radiography showed an anterior mediastinal mass. Computed tomography (CT) examination of the chest revealed a homogeneous tissular mass occupying the anterior mediastinum in its upper and medium stage, extending to the infundibulum without lymph node enlargement. Thymectomy and wedge were performed via a median sternotomy. Pathologic diagnosis was nodular sclerosis Hodgkin's disease of the thymus. The patient received 6 cycles of ABVD (Adriamycin [doxorubicin], bleomycin, vinblastin and dacarbazine) and mediastinal radiotherapy. Currently, tow years after diagnosis, he is well and free of disease.Primary thymic Hodgkin's lymphoma is a rare entity which should be included in the differential diagnosis of anterior mediastinal mass especially in young patients.Primary Hodgkin's disease of the thymusKetata Wajdi, Msaad Sameh, Fouzi Salma, Abid Tarek, Ayadi Hajer, Ayoub Abdelkader10.1016/j.rmedc.2009.02.006Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports1517http://www.resmedcme.com/article/PIIS175500170900027X/abstract?rss=yesAbstract: Combination of Shwachman-Diamond syndrome genetic mutations and cystic fibrosis carrier mutations can account for severe morbidity and early mortality in a patient with Shwachman-Diamond syndrome.Severe Shwachman-Diamond syndrome and associated CF carrier mutationsFauziya Hassan, Craig Byersdorfer, Samya Nasr10.1016/j.rmedc.2009.02.001Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports1819http://www.resmedcme.com/article/PIIS1755001709000268/abstract?rss=yesAbstract: This is the first report of alveolar hemorrhage due to erlotinib. This patient had received four courses of carboplatin and paclitaxel as first line chemotherapy. Six months later,the level of serum CEA was increased. As cancer cells detected in right bloody pleural effusion indicated an adenocarcinoma showing in frame deletion in exon 19 (E746-A750 del) of epidermal growth factor receptor (EGFR) mutation, gefitinib was administered. The level of serum CEA was decreased for three months. However, the level of serum CEA increased again. Therefore, she was hospitalized to begin erlotinib treatment as third line chemotherapy. She did not respond to erlotinib, but severe alveolar hemorrhage did occur and was suspected to have been a resul of erlotinib administration We should consider that there may be a risk of alveolar hemorrhage due to erlotinib administration in non-small-cell lung cancer resistant to gefitinib.Alveolar hemorrhage due to erlotinib in non-small-cell lung cancer resistant to gefitinibYano Shuichi10.1016/j.rmedc.2009.02.010Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports2022http://www.resmedcme.com/article/PIIS1755001709000256/abstract?rss=yesWe report a case of pneumonia due to Tsukamurella pulmonis in a 76-year-old immunocompetent woman with chronic pulmonary disease. Microbiological diagnosis was made by bacteriological and molecular means and infection was cured by empirical antibiotic treatment. This work highlights the potential role of Tsukamurella in pathogenesis of pneumonia in immunocompetent patients.First case of Tsukamurella pulmonis infection in an immunocompetent patientRiccardo Inchingolo, Ilaria Nardi, Fabrizio Chiappini, Giuseppe Macis, Fausta Ardito, Michela Sali, Stefania Bani, Giovanni Delogu, Salvatore Valente10.1016/j.rmedc.2009.02.004Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports2325http://www.resmedcme.com/article/PIIS1755001709000244/abstract?rss=yesAbstract: Budd–Chiari syndrome secondary to lung cancer is very rare. The clinical features of this disease have not been well described, as only a few cases have been reported in the past 3 decades. We analyzed 5 such cases, including the present case, and have identified certain features of lung cancer that may play a role in this syndrome. All cases had cancers originating in the right lung, and 4 cases were patients with non-small cell lung cancers. Because of the rapid progression of liver failure, the prognosis for this syndrome is very poor, and the effects of chemotherapy and/or radiotherapy are limited. Recently, however, new treatments, such as stent placement therapy, have been shown to relieve pain and prolong life. We describe a rare case of acute Budd–Chiari syndrome caused by tumor thrombus of the inferior vena cava secondary to lung cancer. In addition, we discuss similar cases reported in the past 3 decades and the effectiveness of stent placement therapy.Acute Budd–Chiari syndrome caused by tumor thrombus of the inferior vena cava secondary to non-small cell lung cancerKohei Fujita, Young Hak Kim, Mitsuru Yoshino, Masataka Ichikawa, Tadashi Mio, Michiaki Mishima10.1016/j.rmedc.2009.02.003Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports2628http://www.resmedcme.com/article/PIIS1755001709000232/abstract?rss=yesAbstract: Aspergilloma is a saprophytic infection that consists of masses of fungal mycelium that occurs in pre-existing cavities usually due to tuberculosis, bronchestasis or pulmonary infraction. However, few cases of aspergilloma within hydatid cyst have been reported in literature.We describe two patients with aspergilloma formed within cyst hydatid. Both patients consulted because of recurrent hemoptysis. In a 52-year-old woman, diagnosis was established by a transthoracic CT biopsy. Treatment consisted of postero-lateral thracotomy with wedge resection of tow aspergilloma in the left upper lobe. In a 56-year-old man, thoracotomy with lower right lobectomy was performed at emergency because of massive hemoptysis. In both cases, patients progressed favourably without antifungal therapy.Aspergilloma is an unusual complication of hydatid cyst. It results from the deterioration of local defence against opportunistic infections. Prognosis appears to be better than aspergilloma within tuberculosis cavities.Aspergilloma in a hydatid cavitySameh M'saad, Lobna Ayedi, Mohamed Abdennader, Najla Bahloul, Abdessalem Hentati, Chouki Dabbech, Imed Frikha, Tahia Boudawara, Abdelkhader Ayoub10.1016/j.rmedc.2009.02.002Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports2932http://www.resmedcme.com/article/PIIS1755001709000190/abstract?rss=yesAbstract: A 24-year-old women presented with unresolved right upper lobe consolidation. Her medical history was notable for asthma, coronary artery disease, cerebrovascular accident, and nasal polyposis. Thoracic computed tomography scan revealed total atelectasis in the right upper and middle lobes, and consolidation in the atelectatic regions. A bronchial mucosal biopsy revealed diffuse eosinophilic infiltrates in the interstitium. Clinical presentation and pathological results of bronchoscopy were consistent with Churg–Strauss syndrome. In Churg–Strauss syndrome, radiologic pulmonary manifestations vary and atelectasis is very rare. In this case, mechanism of the lobar atelectasis might be explained by eosinophilic infiltration of airway walls resulting in airway narrowing.Churg–Strauss syndrome diagnosed after lobar atelectasis: Case reportSevinc Sarinc Ulasli, Gaye Ulubay, Asli Gorek Dilektasli, Huseyin Gurkan Tore, Sule Akcay10.1016/j.rmedc.2009.01.017Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports3336http://www.resmedcme.com/article/PIIS1755001709000189/abstract?rss=yesAbstract: Recurrent haemoptysis in pulmonary aspergilloma is an indication for surgical resection of the cavity and removal of the fungus ball, in patients with a sufficient pulmonary function to allow surgery. Use of titanium surgical clips in such cardiothoracic surgical procedures may be the source of unusual complications. We report one such unusual complication of expectoration of a titanium surgical clip through a right lobectomy stump, the procedure having been performed six years previously for a symptomatic aspergilloma. We believe this to be first instance of metalloptysis in a case of pulmonary aspergilloma, following lobectomy.Asymptomatic metalloptysis complicating lobectomy in pulmonary aspergilloma – An unusual complicationArshad Altaf Bachh, Inaamul Haq, Rahul Gupta, Hanumant Ganapati Varudkar, RamMohan Boinapally10.1016/j.rmedc.2009.01.016Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports3739http://www.resmedcme.com/article/PIIS1755001709000165/abstract?rss=yesAbstract: In a sixty-seven year old female smoker, a right lower lobe mass, intimately related to the mediastinum, was detected on computed tomography (CT) scanning. Bronchoscopy confirmed non-small cell lung cancer (NSCLC) and a subsequent integrated 18F-FDG Positron Emission Tomography (PET)/CT scan demonstrated a rim of non-FDG avid tissue between the lung tumour and the mediastinum, and no nodal or distant metastases. The patient was pre-operatively staged as cT3N0M0 and proceeded to exploratory thoracotomy.On histological examination of the resected right lower lobe, multiple deposits of bronchioalveolar cell carcinoma (BAC) were found surrounding a central adenocarcinoma, in addition to a small deposit of adenocarcinoma in a right upper lobe wedge resection sample. Neither the BAC deposits nor the upper lobe disease had been detected on integrated FDG-PET/CT scanning.The final pathological staging of this case (pT4N0M1 (stage IV)) is inconsistent with the improved survival rate of patients with multi-focal intrapulmonary NSCLC confined to the lung over other forms of T4 or M1 disease, particularly when the BAC cell type is involved. This case highlights these major limitations of the current TNM classification and discusses the increased risk of false negative results from integrated FDG-PET/CT scanning in the BAC form of NSCLC.The right operation for the wrong reason in multi-focal non-small cell lung cancerK.G. Blyth, S. Rasul, I.W. Colquhoun, F. Roberts, G.W. Chalmers10.1016/j.rmedc.2009.01.014Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports4043http://www.resmedcme.com/article/PIIS1755001709000153/abstract?rss=yesAbstract: Leiomyosarcoma is a rare malignancy with a poor prognosis. It is however one of the commonest pulmonary artery sarcomas and arises from pleuripotent cells found in the intima of the vessel. Its presentation often mimics other conditions such as pulmonary embolism causing a delay in diagnosis.This article describes a unique case of leiomyosarcoma of the pulmonary artery presenting as progressive cavitating lung disease with multi-level vertebral deposits. A presumptive diagnosis of tuberculosis had previously been made with apparent improvement following treatment. However, despite extensive investigation, attempts to secure a tissue diagnosis were unsuccessful and this was made only after post-mortem examination.Leiomyosarcoma of the pulmonary artery masquerading as disseminated tuberculosisAngela Atalla, Sarah A. Bennett, David L. Smith10.1016/j.rmedc.2009.01.013Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports4447http://www.resmedcme.com/article/PIIS1755001709000141/abstract?rss=yesAbstract: Thromboembolic complications have emerged as a major hazard of the nephrotic syndrome. Thrombosis in both the arterial and venous sides of circulation has been reported. We report a case of a 22-year-old man who suffered pulmonary embolism involving the entire left lung and right ventrobasal segment.Nephrotic syndrome and pulmonary artery thrombosisXin Jiang, Ke Pan, Li Lin, Gui-fang Wang10.1016/j.rmedc.2009.01.012Respiratory Medicine CME 3, 1 (2010)Respiratory Medicine CME31S1755-0017(10)X0002-1Case Reports4850