Public Release: 

CHEST Annual Meeting 2015 Case Reports

Poppers, a bear, lung injury from a blank cartridge pistol shot, and buttock augmentation gone wrong

American College of Chest Physicians

MONTRÉAL (October 19, 2015)- The CHEST Annual Meeting 2015 at the Palais des congrès de Montréal begins this week, and clinicians and researchers from around the globe will present unique case studies on pulmonary, critical care and sleep medicine topics.

The jungle juice blues
Monday, October 26, 3:15 PM, 512dh Convention Center

Physicians from New York University Langone Medical Center will present two rare cases of methemoglobinemia after ingestion of "Jungle Juice," a recreational drug that surfaced in the 1960s. The drug is often referred to as a "popper" and contains acetone and isobutyl nitrate. A husband and wife, both emergency room physicians, presented with toxic ingestion of the drug. The 39-year-old husband called EMS after his wife, age 33, developed vomiting and diarrhea, followed by a witnessed seizure. Upon arrival to the hospital, the patients manifested severe cyanosis and were hypotensive and hypoxemic despite high flow oxygen.

Methemoglobinemia is a condition in which oxidation of ferrous iron creates an altered state of hemoglobin that is unable to adequately unload oxygen, resulting in tissue hypoxia. The patients received IV methylene blue and hydration, and all symptoms resolved within 6 hours of presentation.

The Kardashian effect?
Tuesday, October 27, 1:30 PM, Exhibit Hall, Student/Resident Case Reports

A team from John H. Stroger Jr. Hospital in Chicago will present a case report outlining a rare but serious complication of gluteal augmentation. A 29-year-old woman presented with worsening dyspnea, chest pain and dry cough for 5 days. She denied smoking, illicit drug use, recent travel, or sick contacts. Patient appeared acutely ill and dyspneic but able to speak in complete sentences. Scattered crackles were revealed in all lung zones, and lab results were significant for a white blood cell count of 12,000/cu mm. Chest x-ray showed extensive air space opacities. The patient later revealed that she had received 1,000 mL of silicone into both buttocks 1 day prior to onset of symptoms. A CT scan revealed peripherally located airspace and interstitial opacities in both the lungs with no pulmonary embolism. Patient continued to deteriorate and was transferred to ICU care, started on a regimen of methylprednisolone via IV daily and placed on noninvasive ventilation. After 3 days of steroids, the patient's symptoms improved significantly, and she was discharged home on supplemental oxygen and a tapering dose of prednisone.

Silicone emboli to the lungs can rarely induce an acute pneumonitis syndrome. Pulmonary silicone embolus could occur in a number of ways, including inadvertent direct injection into a blood vessel or high-pressure administration of large volumes of silicone. Treatment is mainly supportive, and early use of corticosteroids may prevent development of severe ARDS. The diagnosis can frequently be missed with a wide differential diagnosis by radiology combined with incomplete patient history.

A rare cause of pleural effusion
Tuesday, October 27, 1:30 PM, Exhibit Hall, Student/Resident Case Report Posters

A team from Jersey City Medical Center will present a case report of a rare cause of pleural effusion. A 44-year-old woman presents to the ED with left side chest pain with worsening shortness of breath for 3 weeks without cough, sputum production, fever or chills. She underwent bilateral mastectomy and breast augmentation surgery with silicone implants 6 weeks ago. Examination was consistent with left side pleural effusion with normal exam of other systems. She was treated with empiric antibiotics.

The concern for foreign body reaction to implants, or ruptured or infected implants, was raised with subsequent involvement of a breast surgeon. In exploratory surgery, significant inflammation and mild fluid collection was noted without any rupture. Patient's symptoms significantly improved after the explanation. Cytologic examination of pleural fluid revealed mesothelial cells, macrophages, and lymphocytes, with no malignant cells.

Invisible bullets?
Tuesday, October 27, 1:30 PM, Exhibit Hall, Convention Center, Global Case Reports

Researchers from Konya Education and Research Hospital in Turkey will present a case report of penetrating lung injury caused by a close-range blank cartridge pistol shot. A 17-year-old male was brought to the ED with chest injury by a gunshot from a blank cartridge. A single entrance wound in the chest with no exit wound was observed. CT scans revealed left hemopneumothorax, lacerations, and contusion of the left lung. The patient underwent left thoracotomy, along with wedge resection of lingular segment of upper lobe. He was discharged after 9 days without any complaints.

Originally, blank cartridges were designed and produced for military training. Today, they are used for funeral honors, starter pistols for races, historical reenactments, theater, and special effects in movies. These blank cartridges are mostly unregulated and popular among criminals due to low price and easy accessibility. The cartridges do not contain a bullet but can be powerful enough to penetrate soft tissue and even bones at close range. They can, and have, led to severe and fatal injuries without modification.

Breast implants, laughter and cystic fibrosis
Tuesday, October 27, 1:30 PM, Exhibit Hall, Student/Resident Case Report Posters

A team from the University of Kansas School of Medicine in Kansas City, Kansas, will present a case of a 36-year-old woman with cystic fibrosis who presented with a partial small bowel obstruction. Prior surgeries included a right upper lobe lobectomy 8 months prior, and bilateral breast augmentation without complications 13 years ago. The small bowel obstruction resolved with medical management. On the day of planned discharge, the patient had an episode of coughing while laughing, and noticed her right breast implant had disappeared. This had happened intermittently in the past but had always returned to the proper position with a Valsalva maneuver. Thoracic CT scan revealed migration of the entire right breast implant into the right chest cavity with a small right pleural effusion concerning for implant leak. During surgical exploration, the implant was found to be intact in the right pleural space. A 5 x 3 cm defect was noted in the thoracic wall where the implant migrated. The defect was closed, and the patient was advised to have no further breast augmentation.

Migration of breast implants into the thoracic cavity is an extremely rare complication, but clinicians should recognize and educate patients about this risk. Studies also show body image disorders are more common in cystic fibrosis patients, which can predispose patients to undergo cosmetic procedures more frequently than the general population. Patients with cystic fibrosis are also more likely to undergo thoracic surgeries for pneumothorax, chronic infection, hemoptysis, or lung transplantation.

Some days you're the hunter; some days you're the bear
Wednesday, October 28, 11:00 AM, 513ef, Convention Center

Researchers from UC Davis Medical Center in Sacramento will present a case of trichinellosis, a rare parasitic infection. A 47-year-old man presented with 1 week of worsening fevers, edema, and myalgia. He progressed to hypercapnic respiratory failure necessitating a transfer to the ICU and noninvasive ventilation. He was found to have decreasing lung volumes and decreased bilateral excursion. Further history revealed that he was a hunter, and 3 weeks prior caught and ate a wild bear. His blood count revealed profound leukocytosis, and a parasitic evaluation revealed Trichinella antibodies; he was initiated on albendazole and prednisone. Samples of the bear meat were later confirmed by microscopy and PCR as T spiralis.

Trichinella infection is associated with reductions in diaphragmatic function related to number of larvae, duration of infection, and inflammatory response to the infection. Recovery of muscular function can take months to years. Evolutionarily, Trichinella's preferences for striated muscle may be beneficial in weakening the host to promote capture and subsequent parasitic transmission.

###

CHEST 2015 is the 81st annual meeting of the American College of Chest Physicians, held October 24-28, 2015, in Montréal, Canada. The American College of Chest Physicians, publisher of the journal CHEST, is the global leader in advancing best patient outcomes through innovative chest medicine education, clinical research, and team-based care. Its mission is to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research. It serves as an essential connection to clinical knowledge and resources for its 18,700 members from around the world who provide patient care in pulmonary, critical care, and sleep medicine. For more information about CHEST 2015, visit http://chestmeeting.chestnet.org, or follow the CHEST meeting hashtag, #CHEST2015, on social media.

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.