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 © 2011 Elsevier Ltd. All rights reserved. Respiratory Medicine CME1755-0017442011 © 2011 Elsevier Ltd. All rights reserved. healthpermissions@elsevier.comhttp://www.resmedcme.com/article/PIIS175500171100042X/abstract?rss=yesAbstract: A 32 year old male presented to our services with severe, progressive breathlessness. Following a detailed clinical work-up he was found to have severe pulmonary arterial hypertension due to chronic thromboembolic disease. No risk factor for venous thromboembolism,was identified at this time. Vasculitic screen including anti-neutrophil cytoplasmic antibody (ANCA) was normal. He was referred for pulmonary artery endarterectomy which was performed successfully and with good initial improvement in his symptom complex. He represented with breathlessness four months later. He was diagnosed with necrotizing granulomatous vasculitis (known formerly as Wegner's Granulomatosis). While an association between necrotizing granulomatous vasculitis and venous thromboembolic disease is well described, to our knowledge this is the first case of a patient with chronic thromboembolic pulmonary hypertensive disease subsequently developing fulminant necrotizing granulomatous vasculitis.Chronic thromboembolic disease and necrotizing granulomatous vasculitis – A case reportDonall G. Forde, Brian McCullagh, Michael T. Henry, Sean P. Gaine, Desmond M. Murphy10.1016/j.rmedc.2011.07.003Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports149150http://www.resmedcme.com/article/PIIS175500171100039X/abstract?rss=yesAbstract: Malignant fibrous histiocytoma (MFH), also known as undifferentiated high grade pleomorphic sarcoma, accounts for 20–24% of all soft tissue sarcomas in the US. Peak incidence is in the fifth and sixth decades of life, with a 2:1 male to female distribution. MFH is usually seen in the soft tissues of the extremity and involvement of the lung is rare. We report a case of pleural MFH in a patient with previous pleuro-pulmonary tuberculosis for which he had a lobectomy.A 42-year-old man with progressive dyspnea and a rapidly growing massJinesh P. Mehta, Juan Guardiola10.1016/j.rmedc.2011.05.002Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports151153http://www.resmedcme.com/article/PIIS1755001711000388/abstract?rss=yesAbstract: Behcet’s disease is a rare systemic disorder which is associated with an underlying vasculitis. Most cases of BD occur in Asia and North American cases are rare. Patients often present with aphthous ulcers and have a number of other clinical findings including genital lesions, skin lesions (folliculitis, erythema nodosum, and acne), and uveitis. Hemoptysis and cough in BD may be a sign of pulmonary involvement with include pulmonary artery aneurysms (PAA). Intracardiac thrombus is another rare occurrence in BD but should be suspected if there is a right heart mass detected on imaging. We present a case of suspected BD who presented with hemoptysis and was diagnosed with PAA and intracardiac thrombus. His aphthous ulcers were not diagnoses until subsequent hospitalization for hemoptysis. Clinicians should be aware of unusual presentations of BD because of the associated high mortality.Intracardiac thrombus in Behcet’s disease: A rare case in the United StatesSwapna Gopathi, Ryan T. Hurt, Juan Guardiola10.1016/j.rmedc.2011.07.001Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports154156http://www.resmedcme.com/article/PIIS1755001711000376/abstract?rss=yesAbstract: A pulmonary abscess is defined as necrosis of the pulmonary parenchym caused by microbial infections. The most common organisms are anaerobe bacteria. Local conditions, host resistance and infecting agents all play a role in the formation of pulmonary abscesses. An underlying endobronchial obstructing lung cancer predisposes for the development of a pulmonary abscess. The diagnosis of lung cancer can often be made with computed tomography (CT) of the chest combined with bronchoscopy and cytological analysis of the abscess fluid. We present two patients with a pulmonary abscess caused by an underlying lung cancer. Although in both cases the differential diagnosis was malignancy at first presentation, the diagnosis could not be made definitively prior to surgery, despite intensive investigations with even CT guided biopsies and mediastinoscopy.A pulmonary abscess, beware of lung cancer!L.E.L. Hendriks, M.M.H. Hochstenbag, U.C. Lalji, A.-M.C. Dingemans10.1016/j.rmedc.2011.05.001Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports157159http://www.resmedcme.com/article/PIIS1755001711000364/abstract?rss=yesAbstract: A young 19 year old boy reported to the emergency with complaints of productive cough and mild haemoptysis over three days duration. Initial investigations were within normal limits. Symptoms suddenly aggravated and his condition deteriorated severely before further sophisticated investigations could be carried out. Urgent diagnostic bronchoscopy indicated it to be a case of spontaneously ruptured micro-vascular Pulmonary Arterio-Venous Malformation (PAVM) which was further confirmed on performing pulmonary angiography. Diameter of the feeding vessel was narrow causing difficulty in negotiating for coil embolotherapy. Occlusion of the bleeding artery was finally achieved by pushing in gel foam particles through the vessel. The boy recovered completely and remained asymptomatic one month after the intervention. PAVM is a relatively rare medical emergency where timely diagnosis and therapeutic embolization of the feeding vessel can be lifesaving as indicated in this case report.Bronchial artery embolization: Managing ruptured pulmonary artery venous malformation – A case reportDharitri Goswami, Shantanu Das, Ashok Parida, Joy Sanyal10.1016/j.rmedc.2011.04.006Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports160163http://www.resmedcme.com/article/PIIS1755001711000352/abstract?rss=yesAbstract: Cryptogenic organizing pneumonia (COP) is a rare, potentially serious respiratory disease which may be idiopathic or secondary to other conditions. Exceptionally, cases of COP of occupational origin have been reported. We present the case of a laboratory researcher who developed COP after prolonged exposure to ortho-phenylenediamine. The diagnosis was made after a specific inhalation challenge (SIC). After clinical and radiological resolution, the patient has avoided the causal agent and remains asymptomatic.Cryptogenic organizing pneumonia due to ortho-phenylenediamineM. Sanchez-Ortiz, M.J. Cruz, M. Viladrich, F. Morell, X. Muñoz10.1016/j.rmedc.2011.04.005Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports164165http://www.resmedcme.com/article/PIIS1755001711000340/abstract?rss=yesAbstract: Adiaspiromycosis is a world wide airborne infection and is a pulmonary disease in humans caused by the fungus Chrysosporium parvum var crescens (Emmonsia parva). It is caused by inhalation of spores of the saprophytic soil fungus. The spherules induce a granulomatous reaction, in which a single spherule is surrounded by a fibronecrotic and suppurative or fibrous granuloma. The disease can be localized and asymptomatic, or disseminated, occasionally severe, or even fatal. Reticulonodular infiltrates are the most common radiographic manifestations, with localized infiltrates occurring occasionally. We present a case with bilateral diffuse interstitial micronodular infiltration and granulomatous inflammation in the lung. The larvae of adiaspiromycosis visualized in the center of granulomatous inflammation by histopathologic examination of the lung biospy specimens. We aimed to discuss the very rare cause of diffuse interstitial and granulomatous inflammation of lung.Pulmonary adiaspiromycosis: The first reported case in TurkeyMelih Buyuksirin, Sevket Ozkaya, Nur Yucel, Filiz Guldaval, Kenan Ceylan, Gulru Erbay Polat10.1016/j.rmedc.2011.04.004Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports166169http://www.resmedcme.com/article/PIIS1755001711000339/abstract?rss=yesAbstract: Invasive aspergillus infection of the larynx is extremely rare. This report describes the case of a 56-year-old lady with Chronic Obstructive Pulmonary Disease receiving long-term inhaled corticosteroids who presented with a four-week history of progressive hoarseness, dyspnoea and cough. Sputum cultures at the time isolated Aspergillus fumigatus. She was commenced on a trial of Itraconazole for presumed Allergic Bronchopulmonary Aspergillosis. Due to the duration and nature of her symptoms, vocal cord biopsies were taken which revealed abundant colonies of the fungus A. fumigatus infiltrating skeletal muscle. Inhaled corticosteroids were discontinued and the patient was switched to voriconazole. She continues to make a protracted recovery and is being closely monitored.An unusual case of hoarseness of voice related to corticosteroid treatmentR. Naseer, L.J. Buck, M. Small, M. Munavvar10.1016/j.rmedc.2011.03.008Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports170171http://www.resmedcme.com/article/PIIS1755001711000327/abstract?rss=yesAbstract: Constrictive bronchiolitis results in airways obstruction with progressive lung hyperinflation causing dyspnea and eventual respiratory failure. There are many known causes including rheumatic diseases, infections and toxic inhalations. We describe a 58-year-old man with no preexisting lung disease who suffered rapid loss of lung function with hyperinflation over months in association with rapidly progressive radiographic bronchiectasis. Airway cultures grew Mycobacterium kansasii, Pseudomonas aeruginosa and Aspergillus fumigatus; lung biopsy showed constrictive bronchiolitis that was clinically idiopathic. His respiratory symptoms and pulmonary function rapidly improved within a week of high-dose corticosteroid therapy. We suggest that a diagnosis of constrictive bronchiolitis should be considered in patients with a combination of new rapidly progressive lung hyperinflation and worsening bronchiectasis. We hypothesize that the bronchiolitis-associated bronchiectasis may occur from a predisposition for secondary infections known to cause large airway wall damage. Identification and adequate treatment of these infections is critical if concurrent high-dose corticosteroid therapy is attempted to alleviate the constrictive bronchiolitis.Idiopathic constrictive bronchiolitis with rapidly progressive bronchiectasis and Mycobacterium kansasii infectionSandeep Raparla, Eric P. Schmidt, David B. Pearse10.1016/j.rmedc.2011.03.007Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports172174http://www.resmedcme.com/article/PIIS1755001711000315/abstract?rss=yesAbstract: A 60-year-old woman presented with a dry cough without dyspnea or wheezing. Chest CT showed an image of mucoid impactions, which were identified as mucoid impactions by bronchofiberscopy. Aspergillus niger was cultured from her mucus. Her serum total IgE was 5150 IU/ml. Precipitins and IgE specific for Aspergillus were positive. She had no history of asthma and no evidence of bronchoconstriction by pulmonary function tests. Thus, a diagnosis was made of allergic bronchopulmonary aspergillosis without asthma. She refused to take oral corticosteroids, although she improved spontaneously. However, her dry cough persisted. Her cough was relieved by administering an inhaled β-2 agonist; therefore, cough variant asthma was diagnosed. She was treated with an inhaled corticosteroid and her cough resolved completely.Allergic bronchopulmonary aspergillosis presenting with cough variant asthma with spontaneous remissionHirofumi Matsuoka, Towa Uzu, Midori Koyama, Yasuko Koma, Kensuke Fukumitsu, Yoshitaka Kasai, Daiki Masuya, Harukazu Yoshimatsu, Yujiro Suzuki10.1016/j.rmedc.2011.04.003Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports175177http://www.resmedcme.com/article/PIIS1755001711000303/abstract?rss=yesAbstract: We present the case of a 59-year-old lady, who was found to have an incidental finding of a lung lesion on a CxR following percutaneous endoscopic gastroscopy tube insertion. Subsequently a computerised tomography scan was performed which suggested primary lung malignancy and CT guided biopsy was arranged. Pathological analysis revealed actinomycosis infection. We discuss the clinical, radiological and pathological findings in actinomycosis and how it can often be mistaken for lung cancer. This may put patients at risk of unnecessary morbidity or even unwarranted surgery and therefore clinicians should have a high clinical suspicion of thoracic actinomycosis, especially if a patient has underlying risk factors, such as aspiration.An incidental finding of a lung lesion in a patient with systemic sclerosisAhsan R. Akram, John H. Reid, William Wallace, Simon W. Watkin, Jacqueline F. Faccenda10.1016/j.rmedc.2011.03.006Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports178180http://www.resmedcme.com/article/PIIS1755001711000297/abstract?rss=yesAbstract: Spontaneous pneumomediastinum is defined as free air within the mediastinum, not associated with trauma. Causes include exercise, drugs, asthma, vomiting, difficult labour and Valsalva maneuvers. It’s a rare, usually benign and self-limited condition, more prevalent in young males. The triad of thoracic pain, dyspnoea and subcutaneous emphysema is typical.We report a case of a 23 year old man presenting to the emergency room complaining of odynophagia, thoracic pain and neck swelling. He had fever and productive purulent cough in the previous week. He had no abnormal findings but subcutaneous emphysema. We found a pneumomediastinum without pneumothorax, treated conservatively with complete resolution.Although frightening, this condition usually has good prognosis without specific treatment, other than avoidance of the cause.Spontaneous pneumomediastinum revisitedJosé Meireles, Sara Neves, Alexandra Castro, Margarida França10.1016/j.rmedc.2011.03.005Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports181183http://www.resmedcme.com/article/PIIS1755001711000285/abstract?rss=yesAbstract: This report describes a 40-year old man with a history of acquired immunodeficiency syndrome (AIDS) diagnosed with Pneumocystis jiroveci pneumonia (PJP) twice prior to this admission, who presented with 3 days of fever, non-productive cough and shortness of breath. The patient was treated empirically for PJP, but his condition deteriorated rapidly and he expired despite resuscitative efforts. The bronchoalveolar lavage (BAL) and blood cultures grew Cryptococcus neoformans. Very few cases of disseminated cryptococcosis presenting as acute respiratory failure have been reported. Cryptococcosis is a common opportunistic infection that should be considered in patients with AIDS presenting with bilateral pulmonary infiltrates and fever.A forty-year old man with advanced acquired immune deficiency syndrome and bilateral pulmonary infiltratesIkjot Kaur, Agustina Saenz, Harish Iyer, Glenn Eiger, Robert Fischer, Vladimir Zagrebelsky10.1016/j.rmedc.2011.03.004Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports184186http://www.resmedcme.com/article/PIIS1755001711000169/abstract?rss=yesAbstract: The rheumatoid arthritis (RA) is can affect multiple organs and tissues including the lung. Several pleuropulmonary manifestations are associated with rheumatoid arthritis involving the lung parenchyma, pleura, airways, and vasculature. The various pulmonary radiological findings have been defined in patients with RA.In this study, we aimed to retrospectively evaluate of the pulmonary radiologic findings in the five patients with RA.In the present study, pleural effusion, hydropneumothorax, chylothorax, pulmonary micronodular, macronodular and necrobiotic nodular lesions, pleural plagues, ground glass opacity and interstitial lung diseases were defined according to chest radiographs and computed tomography. The most common pulmonary radiologic findings were pulmonary nodules in three of patients, necrobiotic nodule in two of patients, pleural plague in two of patients and pleural effusion in two patients. The one of them had hydropneumothorax. Interstitial lung diseases were defined in two of patients.In conclusion, the pulmonary changes may be accompanied as a systemic component of the RA. If these changes are well recognized, they can help in the diagnosis of the RA.The pulmonary radiologic findings of rheumatoid arthritisSevket Ozkaya, Salih Bilgin, Semra Hamsici, Serhat Findik10.1016/j.rmedc.2011.03.003Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports187192http://www.resmedcme.com/article/PIIS1755001711000157/abstract?rss=yesAbstract: A 16 years old female with history of cerebral palsy, juvenile rheumatoid arthritis and severe scoliosis presents for recurrent pneumonia. Multiple prior plain films demonstrate progressive increased consolidation confined to the left lower lobe. Subsequently, a CT of the chest was preformed which showed a plastic gastrostomy (MIC-Key tube) bumper in the proximal esophagus causing severe tracheal narrowing. The patient underwent endoscopic removal of the gastrostomy bumper without incident.Recurrent pneumonia due to esophageal migration of the gastrostomy MIC-Key tube remnant causing proximal esophageal obstructionQureshi Zeeshan, Ramadass Satya, Radhika J. Satya, Jacob P. Pickering, Nabeel Qureshi10.1016/j.rmedc.2011.03.002Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports193195http://www.resmedcme.com/article/PIIS1755001711000145/abstract?rss=yesAbstract: We present a case of apparent convincing bilateral hilar lymphadenopathy on a chest radiograph, which on further investigation was found to be allergic bronchopulmonary aspergillosis with symmetrical bilateral apical lower lobe infiltrates. This case demonstrates the role of three-dimensional imaging for disorders of the hila and mediastinum, which are poorly delineated on plain radiography.Misleading chest radiograph in a case of allergic bronchopulmonary aspergillosisAhmed M.A. Adlan, Simon E. Brill, Harman T. Saman, David J. Evans10.1016/j.rmedc.2011.03.001Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports196197http://www.resmedcme.com/article/PIIS1755001711000133/abstract?rss=yesAbstract: Esophageal diverticula are usually asymptomatic and clinically insignificant. We report a case of a hemothorax resulting from perforation of an esophageal diverticulum. A 45-year-old man complained of severe back pain. Computed tomography of the chest showed a mediastinal mass. On the next day, a left pleural effusion was revealed, which was a hemothorax. Gastrointestinal fiberscopy suggested perforation of the esophagus; an esophagectomy was performed, and the patient was diagnosed with a pathologic perforation of the esophageal diverticulum. This is the only report of a hemothorax resulting from perforation of an esophageal diverticulum in the English literature to date.A case of hemothorax resulting from perforation of an esophageal diverticulumEtsuko Watanabe, Yoshiro Mochiduki, Yasuharu Nakahara, Tetsuji Kawamura, Shin Sasaki10.1016/j.rmedc.2010.12.006Respiratory Medicine CME 4, 4 (2011)Respiratory Medicine CME44S1755-0017(11)X0005-2Case Reports198200