No abstract

Interstitial lung diseases (ILDs), also called diffuse parenchymal lung diseases, represent a variety of disorders that affect the lung parenchyma and cause various respiratory symptoms. They are classified as either idiopathic or secondary to other known causes. Correct diagnosis is crucial to decide specific treatments, avoid exposure to ineffective or harmful therapies, and inform the patient about the prognosis of the disease. I present a case of Hodgkin's Lymphoma presenting initially as ILD.CASE PRESENTATION: A 33-years-old male with a past medical history of poorly controlled diabetes type 1 and chronic kidney disease was admitted for shortness of breath and fatigue starting a few weeks before admission and progressively worsening. Vital signs were significant for tachypnea with RR of 30/min. His oxygen saturation was 66% on room air requiring 60 Ls of oxygen with FIO2 of 60%. He was afebrile. Examination revealed moderate respiratory distress, mild intercostal retractions, and bilateral lung rhonchi. Also, he had mobile and non-tender right posterior cervical lymphadenopathy. CT scans showed extensive bilateral ground-glass interstitial opacities, bilateral pleural effusions, and right cervical lymphadenopathy. Labs showed WBCs of 25.5 K/uL with absolute eosinophils of 1500/uL, CRP 11.3 mg/L, procalcitonin 0.15 ng/mL, and IgE 2785 UI/ml. He was started on IV antibiotics and antifungals without significant improvement. Thorough infectious, cardiac, and hypersensitivity workups were all negative. A bronchoscopy with bronchoalveolar lavage (BAL) was also performed and the differential cell profile was normal. Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) was performed from multiple lymph node stations. Histopathology did not show identified lymphoid components and was declared non-diagnostic. An excisional biopsy of the right cervical lymph node was performed with the histopathology results later confirming nodular sclerosing Hodgkin's Lymphoma (NSHL). The patient was started on Brentuximab plus AVD chemotherapy per oncology recommendations. Further tests and imaging for staging were done as well. His oxygen requirements improved significantly, and he was discharged on 2L of O2 on exertion via nasal cannula.DISCUSSION: Lymphomas can involve the lungs either as primary if there is no nodal or extrapulmonary involvement or secondary. They can present radiologically as solitary masses, multiple nodules, or in a diffuse pattern mimicking ILD. Although lymphoma presenting with lung involvement is not unusual, the uniqueness of this case lies in the radiologic presentation.CONCLUSIONS: Excisional biopsies are typically used to diagnose lymphoma, but EBUS-TBNA is a minimally invasive diagnostic procedure, that was found in multiple studies to be a valuable tool even with "negative" results.

Objectives: Multiple studies have reported the safety of same day discharge (SDD) post-electrophysiology (EP) procedures, while patient satisfaction associated with this approach has not been well- studied. We sought to evaluate whether SDD would be associated with a comparable patient satisfaction rate compared with next day discharge (NDD) in various EP procedures. Furthermore, we aimed to assess patient preferences regarding discharge timing. Methods: A cohort of patients was identified using our institutional record of all outpatient EP lab procedures from August 2013 to November 2014. From this list, 6 groups were created based on discharge timing “SDD/NDD” and procedure “Ablation (A)/Pacemaker (P)/ICD (I)”. All operators offered SDD and were included. We excluded generator change and lead extraction procedures. Patients who stayed more than one night were also excluded. Post-discharge phone surveys were conducted starting from the most recent procedure until the target number was reached. The research team gathering surveys was blind to patient characteristics. The survey was composed of 24 questions, 10 of which were for Post-Discharge Coping Difficulty Scale (PDCDS). Results: We surveyed 132 patients, 53F/79M, 66 SDD/66 NDD with mean age (SD) of 63 (15). We had 29 patients in each A group, 17 in each I group, and 20 in each P group. Patients’ rating of overall satisfaction and readiness for discharge, as well as, calculated PDCDS outcomes were not significantly different in SDD vs. NDD for all procedures, I+A only, and A only ( p >.05). Patient characteristics and procedural complications between groups did not differ significantly, though different operators did differ in numbers of SDD or NDD procedures. No significant interactions were found between various covariates and study outcomes including age, gender, BMI, number of home medications, operator, and type of procedure. Approximately1/3 of patients (43/132) were given the choice of the two discharge strategies by the operator. The majority of them (93%; 40/43) opted for SDD and rated “the opportunity for this choice” with a mean of 9.1 (1-10 scale, 10 excellent) in comparison to a mean of 6.7 for those who were not given the choice ( p <. 0001). Only 12% (8/66) of SDD patients wished they had the alternative discharge strategy (P < .0001), in comparison to 38% of NDD patients (25/66) ( p <. 07). Overall, 51% (67/132) of all patients preferred SDD if they were to undergo similar procedure in the future. Conclusions: SDD strategy resulted in similar patient satisfaction to NDD strategy across different EP procedures and operators. Patients significantly appreciated the choice of SDD. The SDD group was more willing to repeat their discharge experience. This further supports following SDD strategy, whenever possible, to improve quality of care; in addition to the cost savings and increased efficiency associated with this approach.

Incomplete lung fissures on quantitative CT analysis seem to be a key image phenotype associated with substantial improvements in VA during transpleural ventilation via spiracles in severe emphysema.