Introduction: Hashimoto's thyroiditis is a common autoimmune thyroid disease; however, pulmonary involvement is a rare manifestation. Lymphocytic interstitial pneumonitis is commonly associated with autoimmune diseases, but its association with Hashimoto's thyroiditis remains poorly understood. Case: A 63-year-old male with prior diagnosis of Hashimoto's thyroiditis presented with recurrent massive pleural effusion and progressive dyspnea. He also experienced fatigue, cold intolerance, and constipation. Physical examination revealed facial puffiness, diffuse goiter, and dry skin. Thyroid function tests performed 6 months before admission confirmed overt hypothyroidism (thyroidstimulating hormone [TSH] 80.30 µIU/mL, free thyroxine 4 [FT4] 0.46 ng/dL). One month prior to admission, laboratory findings showed subclinical hypothyroidism (TSH 9.09 µIU/mL, FT4 1.42 ng/dL). Despite levothyroxine treatment TSH levels remained elevated at 21.8 µIU/mL during admission. Anti-thyroid peroxidase antibodies were positive (13.95 IU/mL). Repeated thoracentesis revealed exudative pleural effusion with lymphocytic predominance and no evidence of malignancy in cytological examination. Infectious etiologies and malignancy were ruled out. Thyroid ultrasonography demonstrated diffuse hypoechoic enlargement of the thyroid gland. Chest radiography showed massive unilateral pleural effusion, while thoracic computed tomography revealed ground-glass opacities with a reticulogranular pattern and interlobular septal thickening, accompanied by multiple thin-walled cysts, highly suggestive of lymphocytic interstitial pneumonitis. Thyroid immunohistochemical analysis was performed (CD 20, CD 3, CD 10, CD 138, Ki 67, BCL 2, BCL 6, Thyroglobulin, MUM 1, Cyclin D1), consistent with lymphocytic thyroiditis. Significant clinical and laboratory improvement was achieved after combined treatment with levothyroxine and corticosteroid. Conclusion This case underscores the importance of considering autoimmune-related lymphocytic interstitial pneumonitis in patients with Hashimoto's thyroiditis who present with unexplained recurrent pleural effusion after exclusion of more common etiologies, such as infection and malignancy. Early recognition may lead to favorable improvement.
Lung Diseases, Interstitial ; Pleural Effusion ; Thyroiditis

INTRODUCTION: Pleural infections are a significant cause of mortality. Intrapleural fibrinolytic therapy (IPFT) utilising alteplase and dornase is a treatment option for patients unsuitable for surgery. The optimal dose of alteplase is unknown, and factors affecting treatment success in an Asian population are unclear. We sought to determine the factors affecting treatment success in Tan Tock Seng Hospital, Singapore and evaluate the efficacy of lower doses of IPFT. METHOD: A retrospective analysis of patients with pleural infections treated with IPFT between July 2016 and November 2023 was performed. Treatment success was defined as survival without surgery at 3 months. Data, including patient demographics; comorbidities; RAPID (renal, age, purulence, infection source and dietary factor) scores; and radiological characteristics, were extracted from medical records and analysed. Linear mixed effects model and logistic regression were performed to determine factors affecting treatment success. RESULTS: A total of 131 cases were analysed. Of these, 51 (38.9%) reported positive pleural fluid culture, and the most common organism was Streptoccocus anginosus. Mean age was 65 years (standard deviation [SD] 15.5). Mean time from chest tube insertion to first dose of IPFT was 10.2 days (SD 11.5). Median starting dose of alteplase was 5 mg. Treatment success was reported in 112 cases (85.5%). There were no significant differences between the alteplase dose and radiological clearance. Patient age (odds ratio [OR] 0.94, confidence interval [CI] 0.89-0.98) and interval between chest tube insertion to first dose (OR 0.95, CI 0.91-0.99) were statistically significant variables for the treatment success. CONCLUSION Lower starting doses of alteplase remain effective in the treatment of pleural infection. Early IPFT may result in better outcomes.
Humans ; Tissue Plasminogen Activator/therapeutic use* ; Retrospective Studies ; Aged ; Fibrinolytic Agents/therapeutic use* ; Male ; Female ; Middle Aged ; Thrombolytic Therapy/methods* ; Treatment Outcome ; Singapore ; Pleural Effusion/drug therapy* ; Pleural Diseases/drug therapy* ; Cohort Studies ; Chest Tubes ; Deoxyribonuclease I ; Recombinant Proteins

Objective: To analyze the radiological characteristics of chest high-resolution computed tomography (HRCT) of patients with asbestosis, and to investigate the signs of predicting the disease progression of asbestosis. Methods: A prospective method was used to enroll 68 patients with asbestosis who were regularly followed up from 2013 to 2016. The radiological characteristics of patients with asbestosis were described by the International Classification of HRCT for Occupational and Environmental Respiratory Diseases (ICOERD) , and the differences between patients with and without progression were compared during the observation period. The Cox proportional hazards regression model was used to analyze the chest HRCT radiological signs predicting the progression of asbestosis. Results: The study included 68 patients with asbestosis aged (65.5±7.8) years old, of which 64.7% (44/68) were female, 29.4% (20/68) had a history of smoking. There was no significant difference in age, sex, smoking and asbestos exposure between patients with progressive asbestosis (20.6%, 14/68) and patients without progressive asbestosis (79.4%, 54/68) (P>0.05) . Chest HRCT of patients with asbestosis showed irregular and/or linear opacities, of which 5.9% (4/68) were accompanied by honeycombing. Irregular and/or linear opacities were mainly lower lung preponderant, often accompanied with ground glass opacity and mosaic perfusion. 98.5% (67/68) had pleural abnormalities, of which 39.7% (27/68) had diffuse pleural thickening with parenchymal bands and/or rounded atelectasis. The analysis of multivariable Cox proportional hazard regression showed that the risk of the progression of asbestosis was increased with higher irregular and/or linears opacities cores (HR=1.184, 95%CI: 1.012-1.384, P=0.034) and the appearance of honeycombing (HR=6.488, 95%CI: 1.447-29.097, P=0.015) . Conclusion: The irregular and/or linear opacities scores and honeycombing on chest HRCT are independent influencing factors for predicting the disease progression of asbestosis.
Aged ; Asbestos/adverse effects* ; Asbestosis/diagnostic imaging* ; Female ; Humans ; Lung ; Middle Aged ; Pleural Diseases/chemically induced* ; Tomography, X-Ray Computed/methods*

Objective: To investigate the clinical characteristics and diagnosis and treatment strategies of patients with severe traumatic aortic injury (TAI). Methods: A total of 25 patients with TAI, who hospitalized in our hospital between August 2005 to March 2021 and underwent thoracic aortic endovascular repair (TEVAR), were included in this retrospective study. According to the time from admission to TEVAR, the patients were divided into emergency TEVAR group (14 cases, TEVAR within 24 h of admission) and elective TEVAR group (11 cases, patients underwent surgery or fracture reduction and fixation first for serious injuries and then underwent TEVAR more than 24 h after admission). The general clinical data of patients, injury severity score (ISS), time from admission to intervention, total hospital stay, the proportion of closed chest drainage and the proportion of abdominal organ repair were obtained and compared. Clinical follow-up and 1-year postoperative aortic computed tomography angiography (CTA) were performed on the patients. Death, the occurrence of aortic adverse events and injury recovery were followed up and recorded. Results: The mean age of these 25 TAI patients was (41.4±14.4) years, 20 patients were males (80.0%). 21 patients (84.0%) had persistent chest and back pain, 17 (68.0%) had pleural effusion and 5 (20.0%) had mediastinal hematoma. The injury severity score (ISS) was significantly higher in the elective TEVAR group than in the emergency TEVAR group (24.9±14.4 vs. 35.5±9.3, P=0.044). The time from admission to intervention ((1.0±0.0) d vs. (3.4±0.9) d, P<0.001], the time from admission to TEVAR ((1.0±0.0) d vs. (11.5±13.8) d, P=0.030) and total hospital stay ((6.1±2.3) d vs. (26.8±7.7) d, P<0.001) were significantly longer in elective TEVAR group than in emergency TEVAR group. The proportion of thoracic closed drainage was significantly lower in the elective TEVAR group than in the emergency TEVAR group (9 (64.3%) vs. 2 (18.2%), P=0.042). The proportion of abdominal organ repair was significantly higher than in the emergency TEVAR group (0 vs. 4 (36.4%), P=0.026). All of 25 patients were discharged alive and followed up for (84.0±30.5) months. All patients survived and completed 1-year postoperation CTA. There were no aortic adverse events occurred, and no complications after surgery, and the fractures and organ injuries healed well. Conclusions: The clinical characteristics of severe TAI are acute multi-injuries combined with persistent chest and/or back pain, pleural effusion, and mediastinal hematoma. Timely diagnosis and treatment are important factors for the outcome. The treatment strategy for multi-injuries should give priority to dealing with life-threatening injuries. TEVAR is the primary treatment strategy for severe TAI and is related to satisfactory outcomes.
Adult ; Aorta, Thoracic/surgery* ; Aortic Diseases ; Blood Vessel Prosthesis Implantation/adverse effects* ; Endovascular Procedures/methods* ; Female ; Hematoma/surgery* ; Humans ; Male ; Middle Aged ; Pleural Effusion/surgery* ; Retrospective Studies ; Risk Factors ; Treatment Outcome

Pancreaticopleural fistula (PPF) is a rare complication in patients with pancreatitis. Its symptoms are similar to those of empyema or pleural effusion; therefore, it is important to consider PPF in the differential diagnosis. Herein, we describe the diagnosis and treatment of PPF in a patient presenting with unusual empyema and delayed hemoptysis.
Diagnosis ; Diagnosis, Differential ; Empyema ; Fistula ; Hemoptysis ; Humans ; Magnetic Resonance Imaging ; Pancreatitis ; Pleural Diseases ; Pleural Effusion ; Thoracic Surgery, Video-Assisted ; Thoracoscopy

Patients undergoing thoracic surgery show various lesions such as chronic obstructive lung diseases, pleural adhesion, pneumonia, acute respiratory distress syndrome, atelectasis, pleural effusion, pulmonary edema, and pneumothorax throughout preoperative, operative, and recovery periods. Therefore, lung ultrasonography has potential for perioperative use in thoracic surgery. Benefits of lung ultrasonography over conventional chest X-ray are convincing. First, ultrasonography has higher sensitivity than X-ray in various lesions. Second, it can be performed at bed side to obtain diagnosis immediately. Third, it does not expose patients to radiologic hazard. If anesthesiologists can obtain necessary skills and perform lung ultrasonography as a routine evaluation process for patients, territory of anesthesia would become broader and patients would obtain more benefit.
Anesthesia ; Diagnosis ; Humans ; Lung Diseases, Obstructive ; Lung* ; Pleural Effusion ; Pneumonia ; Pneumothorax ; Pulmonary Atelectasis ; Pulmonary Edema ; Respiratory Distress Syndrome, Adult ; Thoracic Surgery* ; Thorax ; Ultrasonography*

Connective tissue diseases (CTDs) can affect all compartments of the lungs, including airways, alveoli, interstitium, vessels, and pleura. CTD-associated lung diseases (CTD-LDs) may present as diffuse lung disease or as focal lesions, and there is significant heterogeneity between the individual CTDs in their clinical and pathological manifestations. CTD-LDs may presage the clinical diagnosis a primary CTD, or it may develop in the context of an established CTD diagnosis. CTD-LDs reveal acute, chronic or mixed pattern of lung and pleural manifestations. Histopathological findings of diverse morphological changes can be present in CTD-LDs airway lesions (chronic bronchitis/bronchiolitis, follicular bronchiolitis, etc.), interstitial lung diseases (nonspecific interstitial pneumonia/fibrosis, usual interstitial pneumonia, lymphocytic interstitial pneumonia, diffuse alveolar damage, and organizing pneumonia), pleural changes (acute fibrinous or chronic fibrous pleuritis), and vascular changes (vasculitis, capillaritis, pulmonary hemorrhage, etc.). CTD patients can be exposed to various infectious diseases when taking immunosuppressive drugs. Histopathological patterns of CTD-LDs are generally nonspecific, and other diseases that can cause similar lesions in the lungs must be considered before the diagnosis of CTD-LDs. A multidisciplinary team involving pathologists, clinicians, and radiologists can adequately make a proper diagnosis of CTD-LDs.
Bronchiolitis ; Communicable Diseases ; Connective Tissue Diseases ; Connective Tissue ; Diagnosis ; Fibrin ; Hemorrhage ; Humans ; Idiopathic Pulmonary Fibrosis ; Lung Diseases ; Lung Diseases, Interstitial ; Lung ; Pleura ; Pleural Diseases ; Population Characteristics

Introduction: Dermatomyositis is an autoimmune inflammatory process typically presenting with symmetric proximal muscle weakness preceded by skin lesions. We report a case of dermatomyositis initially presenting with pleural effusion before developing rashes and proximal muscle weakness. Case presentation: A 46-year-old female with no known comorbidities presented with four weeks of anorexia. On work-up, she was found to have bilateral pleural effusion. Diagnostic and therapeutic thoracentesis done draining one liter. Pleural fluid analysis showed exudative character with no presence of bacteria or malignant cells. Intravenous piperacillin-tazobactam 4.5g every eight hours was given for one week but effusion persisted. After 10 days of intravenous antibiotic, antibiotic was shifted to oral cefixime 400mg tab once daily and levofloxacin 500mg tab once daily. However patient developed maculopapular rashes over the face, neck and arms two days after starting the oral antibiotics. The antibiotics were withheld and antihistamine was given for possible drug reaction. No improvement thus oral prednisone 20mg/day for six days was given. After 14 days of oral prednisone, rashes persisted, now with proximal muscle weakness in all extremities associated with the ‘V-sign’ and ‘shawl sign’. The patient was readmitted and work-up showed resolution of pleural effusion. ANA was positive and CKMM level was markedly high. Other rheumatologic tests were unremarkable. Patient was started on Intravenous hydrocortisone 200mg/day and methotrexate 7.5mg/ day once a week. Nine days after initiating intravenous glucocorticoid and methotrexate, patient’s symptoms resolved. Patient was advised for malignancy work-up on follow-up but was lost to follow-up. Discussion: Dermatomyositis initially presents with rashes (100%) and proximal myopathy (95.2%). Interstitial lung disease (ILD) may occur (28.6%), but pleural involvement is rare with only three reported cases and all were associated with ILD. There are no reports of pleural effusion as the initial manifestation. Dermatomyositis is confirmed using the Bohan and Peter Criteria and our patient fulfilled a definitive diagnosis. Glucocorticoids and immunosuppressive drugs are mainstay treatment. Pleural effusion involvement was observed to have good response to treatment, in contrast to ILD which was associated with higher mortality thus should be ruled out in patients with pleural effusion. Conclusion Autoimmune diseases are known for classic manifestations, but may rarely mimic common clinical manifestations thus high index of suspicion is warranted to provide prompt management.
Dermatomyositis ; Pleural Effusion ; Autoimmune Diseases

PURPOSE: Refractory Mycoplasma pneumonia (RMP) has been increasing not only in Korea but worldwide. We investigated the incidence of M. pneumonia resistant to macrolides and risk factors for RMP. METHODS: From October 2015 to May 2016, 62 pediatric patients who were admitted due to pneumonia diagnosed on the basis of chest x-ray with respiratory symptoms and positive for M. pneumoniae in polymerase chain reaction with no evidence of other bacterial or viral infections were included. Sequence analysis of the 23S rRNA gene in M. pneumoniae was performed to identify macrolide resistance. Patients with congenital anomalies, history of pulmonary disease, and unclear information on antibiotic use were excluded. RESULTS: Mutations in the 23S rRNA gene were detected in 50 of 62 patients (80.6%). Risk factors were analyzed in only 45 patients. The RMP group consisted of 26 patients (57.8%) who had fever lasting more than 5 days and deteriorating chest x-ray findings. The lactate dehydrogenase (LDH) and C-reactive protein (CRP) levels were significantly higher in the RMP group than in the non-RMP group (LDH: 300±79 U/L vs. 469±206 U/L, CRP: 4.9±4.3 mg/dL vs. 2.5±1.7 mg/dL; P = 0.04 vs. P = 0.026). In univariate analysis, the RMP group was significantly associated with 23S rRNA gene mutation, lobar pneumonia, and pleural effusion (odds ration [OR]: 10.8, 4.1, 5.3; P = 0.004, P = 0.036, P = 0.046). The presence of macrolide resistance was found to be only a significant risk factor in logistic regression (OR; 8.827; 95% confidence interval, 1.376–56.622; P = 0.022). CONCLUSION: Macrolide resistance was a significant risk factor in patients with RMP and identification of macrolide resistance might be helpful in predicting RMP and establishing target therapy for RMP.
C-Reactive Protein ; Child ; Fever ; Genes, rRNA ; Humans ; Incidence ; Korea ; L-Lactate Dehydrogenase ; Logistic Models ; Lung Diseases ; Macrolides ; Mycoplasma ; Pleural Effusion ; Pneumonia ; Pneumonia, Mycoplasma ; Polymerase Chain Reaction ; Risk Factors ; Sequence Analysis ; Thorax

BACKGROUND: Bronchial pleural fistula (BPF) is a common complication after thoracic surgery for lung resection. Clinical treatment is complex and the effect is poor. The treatment of BPF after lung resection has plagued thoracic surgeons. We reviewed retrospectively the clinical and follow-up data of 6 patients in our hospital who underwent the omentum transplantation in thorax to cover bronchial stump as treatment of BPF after pulmonary resection to analyze why BPF occurs and describe this treatment method. We intend to discuss and evaluate the feasibility, safety and small sample success rate ofthis treatment method. METHODS: During August 2016 to February 2018, six patients in our hospital underwent remedial open thoracotomy and omentum transplantation in pleura space to cover bronchial stump as treatment of bronchopleural fistula after pulmonary resection. Four patients had undergone a prior pneumonectomy and two patients had undergone a prior lobectomy (the residual lungs were resected with the main bronchus cut by endoscopic stapler during the reoperation). The bronchial stumps were sutured by 4-0 string with needle and covered by omentums, which were transplanted in pleura space from the cardiophrenic angle. Postoperatively, the pleura space was irrigated and drained. Summarize the clinical effect and technique learning points. RESULTS: The patients were all males, aged 61 to 73 years (median age: 66). BPF occurred from postoperative day 10 to 45 (median postoperative day 25). The reoperation was finished in 80 mins-150 mins (median 110 mins). Total blood loss was 200 mL-1,000 mL (median 450 mL). These patients were discharged on postoperative day 12-17 (median 14 days), and there was no more complications associated with bronchopleural fistula. All six patients' bronchial stumps were well closed (100%) and have recovered well during the follow-up period, which lasted 1 month-18 months. CONCLUSIONS Remedial operation should be performed as soon as possible when BPF after pulmonary resection diagnosed. Excellent prognoses can be achieved by omentum which is easy to get transplanted in thorax to cover bronchial stump as treatment in patients with BPF after pulmonary resection those who can tolerate reoperation.
Aged ; Bronchi ; surgery ; Bronchial Fistula ; etiology ; surgery ; Female ; Humans ; Lung ; surgery ; Lung Neoplasms ; complications ; surgery ; Male ; Middle Aged ; Omentum ; transplantation ; Pleura ; surgery ; Pleural Diseases ; etiology ; surgery ; Pneumonectomy ; adverse effects ; Postoperative Complications ; etiology ; surgery ; Retrospective Studies ; Thoracotomy