The corpus callosum is the largest white matter fiber bundle connecting the two cerebral hemispheres. In this work, we investigate the effect of callosal dysgenesis on functional magnetic resonance imaging (fMRI) restingstate networks and the functional connectome. Since alternate commissural routes between the cerebral hemispheres exist, we hypothesize that bilateral cortical networks can still be maintained in partial or even complete agenesis of the corpus callosum (AgCC). However, since these commissural routes are frequently indirect, requiring polysynaptic pathways, we hypothesize that quantitative measurements of interhemispheric functional connectivity in bilateral networks will be reduced in AgCC compared with matched controls, especially in the most highly interconnected cortical regions that are the hubs of the connectome. Seventeen resting-state networks were extracted from fMRI of 11 subjects with partial or complete AgCC and 11 matched controls. The results show that the qualitative organization of resting-state networks is very similar between controls and AgCC. However, interhemispheric functional connectivity of precuneus, posterior cingulate cortex, and insular-opercular regions was significantly reduced in AgCC. The preserved network organization was confirmed with a connectomic analysis of the resting-state fMRI data, showing five functional modules that are largely consistent across the control and AgCC groups. Hence, the reduction or even complete absence of callosal connectivity does not affect the qualitative organization of bilateral resting-state networks or the modular organization of the functional connectome, although quantitatively reduced functional connectivity can be demonstrated by measurements within bilateral cortical hubs, supporting the hypothesis that indirect polysynaptic pathways are utilized to preserve interhemispheric temporal synchrony.

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Indwelling pleural catheters (IPC) are increasingly used to relieve dyspnea in patients with malignant pleural effusions (MPE). Frequent drainage of IPCs often results in autopleurodesis. Autopleurodesis is defined as spontaneous cessation of pleural drainage and symptomatic relief of dyspnea without the use of a chemical agent. Our objective was to conduct a retrospective analysis to determine the rate and average time to autopleurodesis in patients who received IPC for MPE. METHODS: The study was designed as an observational retrospective analysis of patients who received placement of IPC by a single proceduralist at our institution from August 1st 2013 to December 31st 2018. Adults over the age of 18 with MPE or para-MPE with IPCs were included. Drainage of fluid was performed by individuals at home every other day. Primary endpoint was incidence of autopleurodesis, which was defined as drainage of less than or equal to 50cc of pleural fluid on three consecutive attempts with follow-up chest radiograph and/or lung ultrasound confirming lung re-expansion. RESULTS: Our study included 105 patients with 126 IPCs analyzed. Of those 69 cases (55%) did not have subsequent follow up, had expired, or enrolled in hospice. Autopleurodesis was achieved in 57 cases (45%). Complete response was achieved in 48 cases (38.1%) and partial response (7.1%). Median days to autopleurodesis was 44 d (95% CI 28-60 days). CONCLUSIONS: In this study we demonstrate that IPCs drained every other day leads to an acceptable rate of autoplerodesis. Thus, this approach may be a viable and effective treatment option for management of malignant pleural effusions. CLINICAL IMPLICATIONS: Drainage of IPC on every other day basis is effective for achieving palliation of symptoms and autopleurodesis. This may negate the need for use of sclerosing agents in the management of MPE.

INTRODUCTION: Coccidioidomycosis is an infection caused by the dimorphic environmental fungus Coccidioides immitis. Rapid progression of coccidioidoidal pneumonia is unusual in an immunocompetent host. We present the case of a 46-year-old agricultural worker who presented with fever, lymphadenopathy, and abnormal outpatient chest X-ray, who was found to have coccidioidomycosis which developed into a necrotizing pneumonia with Acinetobacter baumannii coinfection. CASE PRESENTATION: Patient is a 46-year-old male with previous cigarette smoking who presented after one week of left flank pain, fever, chills, drenching sweats, 10-pound weight loss in 1 month, and abnormal outpatient CXR. The patient was born in Mexico and had not returned for 15 years. He had occupational exposure to agricultural pesticides, as well as a remote history of incarceration and methamphetamine abuse. He was HIV-negative and was not on immunosuppressant drugs. He had no improvement in symptoms with outpatient amoxicillin-clavulanate and came to the emergency room. Admission CT chest showed mediastinal and left hilar lymphadenopathy and left lower lobe consolidation. He went for bronchoscopy with endobronchial ultrasound guided fine needle aspiration, transbronchial biopsies, and bronchoalveolar lavage. Respiratory cultures grew A. baumannii and the patient was started on meropenem. Station 7 lymph node FNA and LLL biopsy showed mild chronic inflammation and no malignancy. Patient had positive QuantiFERON-Gold with all AFB stains and cultures negative. He failed to improve after 5 days, and repeat CT chest showed rapidly evolving necrotizing features of the LLL consolidation. He went for thoracotomy with left lower lobectomy, left upper lobe wedge resection, and partial pericardial resection. Pleural biopsies and resected lung tissue grew C. immitis. Initial bronchoscopy BAL and station 7 lymph node FNA also later grew C. immitis. The patient was started on fluconazole and completed meropenem, with clinical improvement. Other cultures and fungal serologies were normal. He was eventually discharged home to complete a course of fluconazole, along with plans for later treatment of latent tuberculosis.

Invasive pulmonary aspergillosis (IPA) is a rapidly progressive and highly lethal disease classically affecting severely immunosuppressed individuals. We present an clinically challenging and unusual case of IPA in an immunocompetent patient previously treated for coccidioidomycosis. CASE PRESENTATION: A 79 year old male with history COPD and chronic coccidioidomycosis causing cavitary lung disease presented for follow up with complaints of 3 months of worsening dyspnea, cough, and occasional hemoptysis. He was treated for coccidioidomycosis 12 yrs prior with amphotericin B and again 2 years prior with voriconazole. Serial cocci titers had been stable. CT revealed a newly visualized left hilar heterogeneous density within previously visualized cavity measuring 3.8 x 2.7 cm, mediastinal lymphadenopathy, and diffuse tree-in-bud opacifications. Classic radiographic "air crescent sign" was suggestive of an aspergilloma. Serum 1,3 BD glucan was positive and fungal sputum cultures grew Aspergillus Fumigatus. Serum Aspergillus IgE was negative. In the setting of hemoptysis complicated by underlying COPD, the patient underwent quantitative V/Q study showing 7.3% of total lung perfusion and 8.6% ventilation on the left side. The estimated calculated postoperative FEV was 1.38L prior to surgery. Left sided thoracotomy with pneumonectomy and mediastinal lymph node dissection was performed. Surgical pathology confirmed invasion of lung tissue by Aspergillus fumigatus hyphae. The patient completed voriconazole with significant clinical improvement.