No abstract

Sarcoidosis is a granulomatous inflammatory disease of unknown etiology. Sarcoid like granuloma may develop concurrently or following cancer. Detection of granuloma in mediastinal lymph nodes biopsy in patient with pulmonary nodules may be a concern for undiagnosed lung cancer. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic modality of choice for the lung lesions. We discussed A 71-year-old man with history of chronic obstructive lung disease (COPD), who presented with a lung nodule and mediastinal lymphadenopathies. The nodule was 9.9 mm when detected and his endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) of lymph nodes in station 7 & 4R showed normal lymph node structure. Two years later, his surveillance chest CT scan indicated an increase in the size of the nodule to 15 mm, and PET/CT showed Fluorodeoxyglucose (FDG) avid nodule & mediastinal Lymph nodes. He complained of Shortness of breath after 2–3 climbs of stairs, without any history of cough or fever. He quit cigarette smoking recently and smoked 50 pack years before. He underwent another set of EBUS and was referred for sarcoidosis treatment due to finding non-necrotizing granuloma in 4L and 11L lymph nodes. The patient also underwent another biopsy of the nodule concerning the possibility of cancer sarcoid syndrome. A poorly differentiated lung adenocarcinoma positive for GATA3, positive for P63 and CK7, TTF-1 was reported. Concurrent lung cancer and granulomatous reaction in mediastinal lymph nodes are being reported more often. Recent studies have shown a better survival of patients with diagnosis of cancer and granulomatous findings of sarcoidosis. Performing lung biopsy from any nodular lesion in a patient with sarcoidosis is essential for the differential diagnosis and early therapeutic measures.

Denosumab is a fully human antibody to receptor activator of nuclear factor kappa-B ligand (RANKL), and it is administered every 6 months in women with postmenopausal osteoporosis (PMO) at high risk for fracture. Adverse effects of denosumab include musculoskeletal pain, hypercholesterolaemia, symptomatic hypocalcaemia, osteonecrosis of the jaw and cutaneous events such as angioedema, cellulitis and pustular dermatitis. While the possibility of vasculitis was mentioned in the product Monograph as well as in the WHO Newsletter, this is the first case, to our knowledge, of cytoplasmic-ANCA (c-ANCA) associated vasculitis officially published in the literature. 1 2 The pathogenic mechanisms behind drug-induced vasculitis remain to be defined and appear to be multifactorial. Once suspicion for drug-induced vasculitis arises, the offending agent should be discontinued and immunosuppressive therapy should be initiated according to the severity of organ involvement to inhibit progression to severe, irreversible disease. As new medications continue to be developed, the number of agents causing drug-induced vasculitis is expected to increase.

The surge in critically ill patients requiring mechanical ventilation fueled by the COVID-19 pandemic has strained healthcare systems globally. With the increasing need for critical care resources, tracheostomy can facilitate weaning from mechanical ventilation and potentially increase availability of critical care resources. In this case series of three patients, we describe our technique for performing bedside percutaneous tracheostomy on patients with persistently positive SARS-CoV-2 real time polymerase chain reaction (RT-PCR). We hope to provide proceduralists with a specific method for percutaneous tracheostomies that is both safe for the patient and provider.