Case Reports in Pulmonology

Legionella bozemanii pneumonia is a rare form of Legionnaires’ disease caused by the bacterium Legionella bozemanii. It is well known to cause pneumonia in immunocompromised patients and has rarely been reported in immunocompetent hosts. We describe a case of a 59-year-old immunocompetent female presented with pneumonia, acute respiratory failure, acute respiratory distress, and septic shock, who was treated with azithromycin, goal-directed resuscitation, and extracorporeal membrane oxygenation (ECMO) but did not survive. Clinicians should have high suspicion of rare legionella pathogens as causative agents for pneumonia.

A 60-year-old man treated with valproic acid (VPA) for epilepsy developed atelectasis and respiratory failure after an accidentally aspirated VPA tablet-induced mucus hypersecretion. Following bronchoscopic removal of the aspirated tablet, his respiratory status improved and massive sputum production did not recur. We hypothesized that the aspirated VPA tablet increased the expression of mucin-related genes, thereby increasing mucus production. Our in vitro experiments using a human respiratory epithelial cell line revealed that VPA directly upregulates the airway mucin-related genes. We believe that this is the first case report of aspirated VPA-induced severe atelectasis and respiratory failure, which were successfully treated with the bronchoscopic removal of the VPA tablet.

Background. Pulmonary Langerhans cell histiocytosis (LCH) commonly presents as bilateral reticulonodular and cystic lung changes on chest imaging. Isolated lung nodule presentation is rare. Case Presentation. Our patient was an elderly male and an active smoker, who was referred to the pulmonology clinic for an incidental 19 mm lung nodule seen on a chest CT scan. A CT-guided transthoracic needle biopsy was performed to rule out malignancy. The biopsy sample showed marked inflammatory infiltrate with abundant eosinophils and epithelioid histiocyte-like cells suggestive of Langerhans cell histiocytosis. Antibodies against CD1a and Langerhans were positive which confirmed the diagnosis. During follow-ups, the patient had reduced smoking, and the lung nodule had decreased in size to 14 mm. Conclusion. An isolated lung nodule in a patient with a smoking history always warrants a malignancy workup. Characteristic pathological findings with immunostaining are necessary to differentiate pulmonary LCH in these cases. Failure to perform immunostaining in such cases may lead to missing this vital diagnosis.

Acute mitral regurgitation typically presents with dyspnea, chest pain, and hemodynamic instability. It is an uncommon cause of hemoptysis. We present a case of a patient presenting with dyspnea and hemoptysis without hemodynamic instability along with right-sided infiltrate on chest radiography a few days after an acute inferolateral STEMI who was found to have posterior papillary muscle rupture resulting in acute mitral regurgitation. Our case illustrates that the aforementioned symptoms and signs should raise concern for acute mitral regurgitation and prompt cardiac evaluation in the appropriate clinical setting as they may mimic acute pulmonary processes and delay critical diagnosis and treatment.

We report a singular case of renal embolism in a hitherto healthy 46-year-old female. The patient initially presented with symptoms of exertional distress and chest discomfort. Following an extensive diagnostic workup, she was subsequently diagnosed with acute pulmonary embolism. On the day succeeding her admission, the patient manifested sustained abdominal discomfort. Abdominal computed tomography angiography (CTA) subsequently revealed the presence of renal artery embolisms and infarctions. Concurrently, an echocardiographic evaluation disclosed a patent foramen ovale (PFO) and pulmonary hypertension. In this specific case, we hypothesize that the embolic event traversed through the PFO, ultimately localizing in the renal artery and culminating in renal embolism.

Background. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first introduced in China in 2019, and it has rapidly spread all around the world. Cryptococcus neoformans is the leading cause of fungal meningitis in human immunodeficiency virus- (HIV-) infected patients. A variety of laboratory tests have been introduced for rapid diagnosis of meningitis. Methods. Here, we report a case of coinfection with COVID-19 and cryptococcal meningitis in a HIV-positive patient with abnormal laboratory findings. In this case, COVID-19 was positive by polymerase chain reaction (PCR) and computerized tomography (CT) scan diagnosis. Cryptococcal antigen testing of CSF was negative, whereas India ink staining and cerebrospinal fluid (CSF) culture confirmed the presence of C. neoformans. Results. Although the patient was in a critical stage of illness, serum and CSF levels of procalcitonin were abnormally low, within normal limits. On the other hand, although initial lumbar puncture had showed elevated protein level, the repeat CSFs presented remarkably reduced protein levels. Our findings indicate that despite COVID-19 infection, procalcitonin level may remain normal in HIV-associated cryptococcal meningitis, and findings of an apparently normal procalcitonin level should not exclude the possibility of infection. Also, antigen testing may present false-negative result, and it should not be the sole laboratory method for diagnosis of infectious meningitis. Consequently, CSF culture and staining is recommended, even when antigen testing of organism is negative and CSF profile is unremarkable. Conclusion. Laboratory information should be combined with a good understanding of clinical manifestations of patient to determine if meningitis is present and confirmed COVID-19 should not ignore possibility of other infections for consideration.