A previously healthy patient was seen in the Emergency Department for evaluation of a one-month history of cough and one-day history of hemoptysis. A computed tomography scan of the thorax found a mass on the right lower pulmonary lobe and a mass on the left upper lobe. A biopsy specimen of the right lobe lung mass, obtained during bronchoscopy, demonstrated papilloma. This case report, from a pulmonologist's perspective, includes a comprehensive review of the patient's clinical presentation and outcome, as well as a discussion of recurrent respiratory papillomatosis.

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Introduction: There is limited data suggesting that recovery from severe pulmonary infection with Coccidioides may be hastened by the addition of systemic corticosteroids. Methods/Results: We report two patients with persistent and progressive coccidioidomycosis who demonstrated a dramatic response to adjunctive corticosteroid therapy. Both patients had Coccidioides immiitis cultured from respiratory samples. One was a 69 year old man who had been treated with combination fluconazole and liposomal amphotericin for over six weeks, with persistent fever and pneumonia. The other was a 61 year old man treated with fluconazole and then amphotericin for three weeks, with progression to acute respiratory distress syndrome (ARDS) and shock. Both received short courses of intravenous methylprednisolone and recovered to be discharged home. Conclusion: As opposed to associated hypersensitivity, corticosteroid treatment in these cases was directed at modulating the ongoing destructive effects of unchecked inflammation. Rapid improvement was noted in both cases and raises the possibility that the addition of systemic corticosteroids may hasten recovery in patients with severe coccidioidomycosis.

Abnormalities of the upper airway anatomy are an underrecognized cause of obstructive sleep apnea. We present a unique case of a 51-year-old man with episodic sleep-maintenance insomnia and oromandibular dystonia requiring botulinum toxin injections of the temporalis and masseter muscles. He underwent multiple sleep studies and was found to have obstructive sleep apnea temporally associated with the severity of dystonia symptoms and dosing of botulinum toxin.