Kaposi Sarcoma With Bilateral Chylothorax Responsive to Octreotide

Humzah Iqbal, MD

Department of Internal Medicine, University of California San Francisco, Fresno, CA, USA

Abstract

Kaposi sarcoma (KS) is a soft tissue malignancy of the endothelial cells that can rarely invade the thoracic duct and cause bilateral chylothorax. Treatment for chylothorax includes drainage and dietary modification. However, octreotide has been reported to improve chylothorax in some pediatric and post-operative cases. We present a case in which a 9-day course of octreotide led to an improvement of non-traumatic malignant chylothorax.

Abbreviation list

• AIDS: acquired immunodeficiency syndrome
• CT: computed tomography
• HIV: human immunodeficiency virus
• KS: Kaposi sarcoma

Introduction

Kaposi sarcoma (KS) is a malignant, multifocal, highly vascularized tumor of the endothelial cells that most commonly affects the skin but may also include the lymph nodes, mucosa, and viscera (1). KS is commonly associated with human immunodeficiency virus (HIV) and can occur at any CD4 count (2). In very rare cases, Kaposi sarcoma can invade the thoracic duct and cause chylothorax (3). Chylothorax occurs when lymphatic fluid accumulates in the pleural cavity and is usually seen after damage to the thoracic duct following trauma or cardiothoracic surgery. It can also be caused by malignancy, however, bilateral chylothorax secondary to KS is rare. Treatment of chylothorax usually involves drainage of the effusion and initiation of a low-fat diet. Octreotide has been reported to improve traumatic chylothorax, but has only been reported in non-traumatic etiologies in a handful of cases (4). Here, we present a case of bilateral chylothorax associated with KS, which was successfully treated with octreotide.

Case Presentation 

A 40-year-old man with a previous diagnosis of acquired immunodeficiency syndrome (AIDS) and KS presented to the emergency department due to progressive tachypnea, dyspnea, bilateral lower extremity edema, and expansion of his KS lesions onto his legs and genital region. His vital signs were significant for a respiratory rate of 25 breaths per minute and pulse of 109 beats per minute. The patient denied recent infection, trauma, or procedures. Chest X-ray showed a large left pleural effusion with midline shift and a small right pleural effusion (Figure 1).

Figure 1. Upright chest X-ray demonstrating large left pleural effusion with midline shift and small right pleural effusion.

Computed tomography (CT) scan of the chest showed large bilateral pleural effusions with collapse of the right lower lobe and partial collapse of the upper lobes bilaterally (Figure 2).

Figure 2. Representative view from computed tomography (CT) scan (axial plane) in lung windows showing bilateral pleural effusions.

The patient developed hypoxemia and underwent thoracentesis with a total of 1.5 liters of pink, milky fluid removed (Figure 3).

Figure 3. Image of pleural fluid obtained from thoracentesis demonstrating pink, milky appearance.

Bilateral PleurX catheters (PleurX; Iskus Health; London, United Kingdom) were placed for persistent drainage. Fluid studies showed a triglyceride count of 147 mg/dL on the right side and 153 mg/dL on the left side. The patient continued to self-drain when symptomatic and drained about 600 mL of light-colored opaque fluid from each side daily. Serum albumin levels decreased to about 2.0 g/dL over the next week with concurrent development of diffuse pitting edema in all four extremities and abdomen. He was started on a high-protein, low-fat diet consuming up to 6-7 nutritional protein supplements per day with little to no improvement in his clinical state or serum protein levels. Given the patient’s poor response to treatment and persistence of his pleural effusions, a trial of octreotide was initiated. The patient was given octreotide 100 mg three times per day. About 3 days after initiating therapy, the patient refrained from draining his PleurX catheters for the first time and the frequency of draining decreased over the remainder of the week due to improvement in symptoms. The fluid was noted to be less opaque and clearer with each drainage. The patient’s tachypnea and oxygen saturation also showed improvement. After day 9 of octreotide, the treatment was discontinued and repeat pleural fluid studies showed a triglyceride count of 69 mg/dL on the right side and 89 mg/dL on the left side. With the resolution of his chylothorax and improvement in oxygenation status as well as his edema, the patient was discharged and will follow up with Oncology for continuation of his KS treatment.

Discussion

KS is known as an AIDS-defining illness that can invade a variety of tissues in the body leading to manifestations beyond the classic skin lesions. It can cause unusual neurologic, cardiac, orbital, laryngeal, endocrine, and gastrointestinal complications in rare cases (5). We present a case of bilateral chylothorax as another rare potential complication of KS. Other reported cases have presented similarly to our patient, such as a case presented by Pennington et al. (6) which also described dyspnea and hypoxemia with transient but significant improvements in ventilation with serial chest drainage as well as repeated reaccumulation of the chylothorax. In their case, however, the patient died as a result of his condition. Other cases of presumed KS-induced chylothorax have also resulted in marked nutritional deficiencies as seen in our patient (7).

Treatment of chylothorax involves therapeutic thoracentesis, a low-fat diet that is high in medium-chain triglycerides which do not pass through the thoracic duct, and surgical correction or embolization of the defect (8). Though not a standard practice, the use of octreotide has been reported to improve chylothorax in some cases. The majority of these cases have been traumatic chylothorax following cardiothoracic surgery in adults or the pediatric population, or neonates with congenital chylothorax (8). There is a paucity of literature regarding octreotide in the management of malignant and other non-traumatic causes of chylothorax in the adult population. One case has been reported by Togashi et al. (9) which describes chylothorax secondary to idiopathic fibrosing mediastinitis that was treated successfully with octreotide. The exact mechanism is unknown, but as a somatostatin analogue, it may involve a decrease in splanchnic blood flow and subsequent reduction in lymphatic flow from the gastrointestinal system and through the thoracic duct (10-11). There is no standard protocol for the administration of octreotide, however, most studies report a 1-2 week course with recognizable improvements after 2-3 days of treatment, as seen in our patient (12).

Conclusion

Bilateral chylothorax is a rare manifestation of KS that can lead to respiratory failure, malnutrition, and death. We present a case of non-traumatic, malignant chylothorax that was treated successfully with octreotide, a somatostatin analogue. Further studies are necessary to elucidate the exact mechanism of its effect on chylothorax and to establish a standardized treatment protocol for the usage of octreotide in this condition. 

References

1. Cesarman E, Damania B, Krown SE, Martin J, Bower M, Whitby D. Kaposi sarcoma. Nat Rev Dis Primers. 2019 Jan 31;5(1):9. [CrossRef] [PubMed]
2. Crum-Cianflone NF, Hullsiek KH, Ganesan A, Weintrob A, Okulicz JF, Agan BK; Infectious Disease Clinical Research Program HIV Working Group. Is Kaposi's sarcoma occurring at higher CD4 cell counts over the course of the HIV epidemic? AIDS. 2010 Nov 27;24(18):2881-3. [CrossRef] [PubMed]
3. Cherian S, Umerah OM, Tufail M, Panchal RK. Chylothorax in a patient with HIV-related Kaposi's sarcoma. BMJ Case Rep. 2019 Jan 22;12(1):e227641. [CrossRef] [PubMed]
4. Ismail NA, Gordon J, Dunning J. The use of octreotide in the treatment of chylothorax following cardiothoracic surgery. Interact Cardiovasc Thorac Surg. 2015 Jun;20(6):848-54. [CrossRef] [PubMed]
5. Pantanowitz L, Dezube BJ. Kaposi sarcoma in unusual locations. BMC Cancer. 2008 Jul 7;8:190. [CrossRef] [PubMed]
6. Pennington DW, Warnock ML, Stulbarg MS. Chylothorax and respiratory failure in Kaposi's sarcoma. West J Med. 1990 Apr;152(4):421-2. [PubMed]
7. Judson MA, Postic B. Chylothorax in a patient with AIDS and Kaposi's sarcoma. South Med J. 1990 Mar;83(3):322-4. [CrossRef] [PubMed]
8. Schild HH, Strassburg CP, Welz A, Kalff J. Treatment options in patients with chylothorax. Dtsch Arztebl Int. 2013 Nov 29;110(48):819-26. doi: 10.3238/arztebl.2013.0819. [CrossRef] [PubMed]
9. Togashi Y, Kim YH, Miyahara R, et al. Octreotide, a somatostatin analogue, in the treatment of chylothorax associated with idiopathic fibrosing mediastinitis. Tohoku J Exp Med. 2010 Sep;222(1):51-3. [CrossRef] [PubMed]
10. Katz MD, Erstad BL. Octreotide, a new somatostatin analogue. Clin Pharm. 1989 Apr;8(4):255-73. [PubMed]
11. Rosti L, De Battisti F, Butera G, et al. Octreotide in the management of postoperative chylothorax. Pediatr Cardiol. 2005 Jul-Aug;26(4):440-3. [CrossRef] [PubMed]
12. Kalomenidis I. Octreotide and chylothorax. Curr Opin Pulm Med. 2006 Jul;12(4):264-7. [CrossRef] [PubMed]

Cite as: Iqbal H. Kaposi Sarcoma With Bilateral Chylothorax Responsive to Octreotide. Southwest J Pulm Crit Care Sleep. 2022;25(5):69-72. doi: https://doi.org/10.13175/swjpccs048-22 PDF

September 2020 Pulmonary Case of the Month: An Apeeling Example

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 67-year-old woman who developed a chronic nonproductive cough beginning in October 2019. After 4 weeks, she consulted her primary care physician.

PMH, SH, and FH

• She had a history of several prior pneumonias, including respiratory syncytial virus in 2018
• Irritable bowel syndrome
• Hypertension
• Prior smoker: 28 pack years, none since 1999
• FH negative

Physical Examination

Her physical examination is recorded as unremarkable other than decreased nasal flow.

Which of the following is/are common cause(s) of a chronic cough? (Click on the correct answer to be directed to the second of seven pages)

1. Cough-variant asthma
2. Gastroesophageal reflux disease
3. Upper airway cough syndrome (UACS) secondary to rhinosinus diseases
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2020 pulmonary case of the month: an apeeling example. Southwest J Pulm Crit Care. 2020;21(3):56-63. doi: https://doi.org/10.13175/swjpcc048-20 PDF

Infected Chylothorax: A Case Report and Review

Louis Eubank¹, Luke Gabe¹, Monica Kraft¹, and Dean Billheimer²

¹Departments of Medicine and Biostatistics, College of Medicine

²Department of Biostatistics, College of Public Health

University of Arizona Health Sciences Center

Tucson, AZ USA

Abstract

Infected chylothorax is a rare complication of a rare pathology with limited literature entirely consisting of case reports, meeting abstracts, and letters to the editor. The case of a 56-year-old male with a spontaneous infected chylothorax successfully treated and discharged to home without any residual effects is described. A systematic review of the literature revealed 11 prior cases of infected chylothoraces. Their etiologies (when known), initial pleural fluid values, and treatment are described. These cases show that while infected chylothorax has a varied presentation and affects a broad range of patients, conservative management including antibiotics, pleural fluid drainage, and symptomatic relief is a safe and appropriate starting point.

Introduction

Chylothorax, a pleural effusion caused by chyle accumulation from obstruction or disruption of the thoracic duct (please see SWJPCC’s Image of the week: chylothorax for an image of non-infected chyle fluid), is a rare condition that may arise from a diversity of etiologies broadly categorized as traumatic or non-traumatic/spontaneous (1). Traumatic causes commonly include iatrogenic injury and chest trauma, although insults as minor as sneezing, light exercise and emesis have been reported (1-3). Non-traumatic chylothorax has been linked to several immunologic and infectious etiologies (1). Regardless of the underlying mechanism, chyle has classically been considered inherently bacteriostatic (1). We present a case of spontaneous infected chylothorax and the first review of infected chylothoraces reported in the literature.

Case Report

A 56-year-old man with alcoholic cirrhosis and remote right-sided hepatic hydrothorax presented to the emergency department complaining of shortness of breath. Patient reported slowly worsening dyspnea over the last six weeks without any other symptoms that had acutely worsened on morning of presentation

Initial vital signs were temperature 38.0°C, heart rate 115, blood pressure 81/60mmHg, and respiratory rate 30 breaths/min on 4L O₂ by nasal cannula; labs significant for white blood cell count of 3100/mm³ and lactate 5.0 mmol/L (normal <2.0 mmol/L).  Physical exam demonstrated a fatigued patient with accessory muscle use on inspiration and absent breath sounds at the left lung base. Computed tomography (CT) study of the chest showed a large free-flowing left-sided pleural effusion (Figure 1A&B) as well as subacute rib fractures (Image 1C).

Figure 1. Thoracic CT on the day of presentation. Panel A: Axial view showing pleural effusion. Panel B: Sagittal view showing pleural effusion. Panel C: Coronal view showing rib fractures (white arrows).

Chart review demonstrated an emergency department visit five months previously for a fall with acute left-sided rib fractures and minimal left-sided pleural effusion.

Thoracentesis removed two liters free-flowing, brown, milky, purulent fluid; analysis significant for 58,880 total nucleated cells (32,800 RBCs), 94% neutrophils, glucose <5, LDH 573 IU/dL (serum 193 IU/dL), triglycerides 191 mg/dL, albumin 1.8 g/dL (serum albumin 2.6 g/dL, laboratory lower limit of normal 3.4 g/dL).

The patient remained hypotensive despite fluid boluses, tachypneic with increasing oxygen requirements, and a repeat lactate was 6.4 mmol/L. Norepinephrine and broad-spectrum antibiotics were started and patient was admitted to the intensive care unit.

Pleural fluid and blood cultures grew Escherichia coli resistant to fluoroquinolones. Chest x-ray showed persistent pleural effusion; a chest tube was placed which drained an additional 1.6 L over the following 24 hrs. The patient subsequently improved: serum lactate normalized within 24 hours, vasopressors were weaned within 36 hours, and supplemental oxygen was discontinued within 72 hours.

Chest tube output decreased to less than 200 ml/day within 48 hours of placement; however, repeat thoracic CT demonstrated a persistent multi-loculated left pleural effusion. Surgical evacuation and pleurodesis were considered given the lack of literature regarding intrapleural lytic therapy in infected chylothorax (a single case report described use of streptokinase in a persistent non-infected chylothorax, 1).  However, the patient’s operative risk was considered prohibitively high. He was managed conservatively with a fat-free diet to reduce chyle leak.

Eleven days after initial presentation fluid studies were significant for triglyceride 45mg/dL with negative cultures. Given that a pleural fluid triglyceride level <50mg/dL yields a less than 5% likelihood of being chylous and the clinical stability of the patient, the chylothorax was felt to be resolved (1). The patient was discharged to home twelve days after initial presentation.

The etiology of patient’s infected chylothorax was never fully elucidated. The most likely explanation is the trauma causing rib fractures also caused a traumatic chylothorax that later became infected. The thoracic duct lies alongside the vertebrae until it drains into the left brachiocephalic vein (Figure 2).

Figure 2. Thoracic duct anatomy (black arrows).

A blow to the posterior left thorax sufficient to fracture multiple ribs is more than sufficient to damage the nearby thoracic duct (1-4).  Arguing against this is most patients with large traumatic chylothoraces present within 10 days of injury (1,2).

Another explanation is the patient developed bacterial empyema secondary to hepatic hydrothorax (ascites that has passed through diaphragm from the peritoneal cavity) followed by non-traumatic chylothorax. These empyemas can demonstrate an indolent course and Escherichia coli is one of the most common causative pathogens isolated (1). Arguing against this is the patient’s previous hepatic hydrothorax was right-sided.

Finally, the chylothorax may have arisen from one of the many known causative medical pathologies (2). Chylous ascites secondary to cirrhosis that migrates into the pleural space via diaphragmatic leaks defects is a known phenomenon, albeit extremely rare (2).

In follow-up two months after discharge the patient had total resolution of respiratory symptoms and no recurrence of the effusion.

Systematic Review

Methods

A MEDLINE search (PubMed) from January 1975 to January 2018 and a Google Scholar search (all years) was conducted to identify eligible studies using the following terms: “Infected Chylothorax” (all fields) OR “Infection AND Chylothorax” (all fields) OR “Chylothorax AND Empyema” (all fields) OR “Chylous Empyema” (all fields). The inclusion criteria for studies were patients with infected non-traumatic chylothorax. A triglyceride level > 110 mg/dL or the presence of chylomicrons in pleural fluid was used to confirm the diagnosis of chylothorax; pleural fluid culture speciation was used to confirm the infection. The exclusion criteria were a lack of laboratory data and duplicate data. Two reviewers (LE, LG) independently reviewed the titles, abstracts, and, when necessary, the full text regarding the inclusion/exclusion criteria. Data extraction was performed independently by two reviewers (LE, LG) using data extraction forms defined beforehand. Discrepancies were resolved by consensus discussion with a third reviewer (MK).

Results

Eight case reports, two published abstracts, and one letter to the editor met the inclusion criteria; all eleven were included in the analysis (Figure 3, 13-23). 

Figure 3. Flow diagram of the literature review.

The general characteristics, demographics, and etiology of infected chylothorax are summarized in Table 1, the initial pleural fluid values are reported in Table 2.

Table 1. Population data.

Table 2. Initial pleural fluid values.

There were 11 patients total: six males and five females; age range 5 days-78 years, mean age 40.5 years (standard deviation 28.5 years). One patient was pharmacologically immunosuppressed while others had chronic diseases known to reduce immune system function including diabetes, excessive alcohol intake, and obesity (24-26). Four (36%) were iatrogenic. Three patients (27%) were infected with Streptococcus viridans and five (45%) were infected with Streptococcus genus. In those with available data, three of ten patients (30%) required intravenous vasopressors. No patients required ventilator management for their chylothorax (two patients were already intubated, one for acute respiratory distress syndrome, the other for unstable hemodynamics secondary to large subarachnoid hemorrhage). Two patients (18%) were managed surgically – one was specifically noted to have failed conservative management (17). Of the known outcomes, eight of nine (89%) survived to discharge and all eight remained asymptomatic at follow-up. The mean follow-up duration was 13.3 months (range 6-24 months).

Discussion

Given the paucity of published experience regarding infected chylothoraces, we believe a descriptive summary is warranted. First, there is a large variation in patient characteristics, including age range, immune competence, comorbid medical conditions, and infectious organism (eight different bacterial species and one parasite).

Second, many of the reviewed cases had a more benign presentation than might be anticipated in the context of a large, infected intrathoracic fluid collection.  Seven of the patients (73%) were hemodynamically stable on presentation and the majority of these patients had very mild chief complaints.

Third, the available data suggest a surprisingly good prognosis considering a previously estimated morality of 10-25% in non-infected chylothoraces, depending on etiology (27). The one patient who did not survive to discharge died due to brain herniation. Those with documented outpatient follow-up were asymptomatic up to 16 months post-discharge. 

Fourth, conservative management was frequently efficacious. Eight patients (73%) were medically managed without complication and did not require extensive antibiotic duration, intrapleural lytic therapy, or surgical intervention. The decision to pursue surgical intervention is not well defined given the very limited number of cases requiring surgical management. A brief discussion of non-infected chylothoraces and their management is therefore warranted.

Non-infected chylothorax is universally described as a rare event, although its exact incidence has not been described. Chylous ascites, which sometimes shares pathogenesis with chylothorax and is one of the causes of spontaneous chylothorax, has an occurrence of one in 20,000 hospital admissions (12). Trauma accounts for approximately 50% of chylothoraces, with esophagectomy being the most common iatrogenic cause (28). Thirty percent are due to malignancy; lymphoma accounts for 70-75% of malignant cases (11). While there are no consensus guidelines on how to treat chylothoraces, many authors agree that first line treatment is conservative management with thoracentesis or chest tube drainage, fat free or medium chain triglyceride diet, and consideration of somatostatin or octreotide (1,5,11,27-29). Although somatostatin or octreotide are used at many institutions, data regarding indications & efficacy of these medications are limited and/or inconsistent – some institutions use these medications at the beginning of treatment, others only if/when initial management has failed (5,27).

Additional treatments may depend on the etiology of the chylothorax: it is suggested that earlier surgical intervention in iatrogenic traumatic chylothoraces, especially post-esophagectomy, may be beneficial (30). Conservative management is likely to fail and surgical intervention is recommended in the following situations: 1) daily drainage greater than 1000 mL chyle (adults) or greater than 100mL chyle/kg body weight (children); 2) chyle leak that persists for more than 14 days; 3) unchanged chest tube output for 7-14 days; 4) clinical deterioration (27,28).

Conservative management for infected chylothoraces appears efficacious in our small sample size with the obvious modification of treating the infection. Most antibiotics adequately penetrate the pleural space, although aminoglycosides should be avoided as they appear to be inactivated by the low pH and relative anaerobic conditions (31).

Limitations

The limitation of this systematic review was the inclusion of only case reports, abstracts, and letters to the editor and the small sample size. Unfortunately, given the rarity of infected chylothoraces, studies with sufficient sample size are unlikely to be available.

Conclusion

Infected chylothorax is a rare complication of an already rare pathology. Our case report and literature review show that it can affect any age group, can be caused by several different organisms, and has a variable presentation. Our data suggests that an initial conservative management strategy in infected chylothoraces can be a safe and effective option.

References

1. McGrath E, Blades Z, Anderson P. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010;104:1-8. [CrossRef] [PubMed]
2. García-Tirado J, Landa-Oviedo HS, Suazo-Guevara I. Spontaneous bilateral chylothorax caused by a sneeze: an unusual entitiy with good prognosis. Arch Bronconeumol. 2017 Jan;53(1):32-3. [CrossRef]
3. Torrejais JC, Rau CB, de Barros JA, Torrejais MM. Spontaneous chylothorax associated with light physical activity. J Bras Pneumol. 2006 Nov-Dec;32(6):599-602. [CrossRef] [PubMed]
4. Rodrigues AL, Romaneli MT, Ramos CD, Fraga AM, Pereira RM, Appenzeller S, Marini R, Tresoldi AT. Bilateral spontaneous chylothorax after severe vomiting in children. Rev Paul Pediatr. 2016 Dec;34(4):518-521. [PubMed]
5. Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg. 2016 Jan;49(1):18-24. [CrossRef] [PubMed]
6. Verma SK, Karmakar S. Hodgkin's lymphoma presenting as chylothorax. Lung India. 2014 Apr-Jun; 31(2):184-6. [CrossRef] [PubMed]
7. Kuan YC, How SH, Ng TH, Abdul Rani MF. Intrapleural streptokinase for the treatment of chylothorax. Respir Care. 2011 Dec;56(12):1953-5. [CrossRef] [PubMed]
8. Nair SK, Petko M, Hayward M. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg. 2007 Aug;32(2):362-9. [CrossRef] [PubMed]
9. Pillay TG, Singh B. A review of traumatic chylothorax. Injury. 2016 Mar;47(3):545-50. [CrossRef] [PubMed]
10. Tu CY, Chen CH. Spontaneous bacterial empyema. Curr Opin Pulm Med. 2012 Jul;18(4):355-8. [CrossRef] [PubMed]
11. Skouras V, Kalomenidis I. Chylothorax: diagnostic approach. Curr Opin Pulm Med. 2010 Jul;16(4):387-93. [CrossRef] [PubMed]
12. Tsauo J, Shin JH, Han K, Yoon HK, Ko GY, Ko HK, Gwon DI.Transjugular intrahepatic portosystemic shunt for the treatment of chylothorax and chylous ascites in cirrhosis: a case report and systemic review of the literature. J Vasc Interv Radiol. 2016 Jan;27(1):112-6. [CrossRef] [PubMed]
13. Bensoussan AL, Braun P, Guttman FM. Bilateral spontaneous chylothorax of the newborn. Arch Surg. 1975 Oct;110(10):1243-5. [CrossRef] [PubMed]
14. Asnis DS, Saltzman HP, Iakovou C, Byrns DJ. Anaerobic empyema and chylothorax. Inf Dis Clin Pract. 1994;3(5):368-70. [CrossRef]
15. Natrajan S, Hadeli O, Quan SF. Infected spontaneous chylothorax. Diagn Microbiol Infect Dis. 1998 Jan;30(1):31-2. [CrossRef] [PubMed]
16. Guarracino JF, Murruni A; Basílico H, Villasboas RM, Halabe K, Barroso S, Demirdjian G. Chylothorax: Unusual complication presented in a burned child with an inflation injury under the effects of mechanical ventilation (Originial title Quilotórax: Complicación pocofrecuente en un ni-o quemado en asistencia respiratoria mecánica por síndrome inhalatorio). Revista Argentina de Burns 2000:15 (1). Available at: http://www.medbc.com/meditline/review/raq/vol_15/num_1/text/vol15n1p30.htm  (accessed 8/24/18).
17. Wang JT, Hsueh PR, Sheng WH, Chang SC, Luh KT. Infected chylothorax caused by Streptococcus agalactiae: a case report. J Formos Med Assoc. 2000 Oct;99(10):783-4. [PubMed]
18. Biswas A, Ghosh JK, Chatterjee A, Basu K, Chatterjee S. Infected chylothorax caused by escherichia coli in a non-immunocompromised child. Indian J Pediatr. 2008 Feb;75(2):192-3. [CrossRef] [PubMed]
19. Alkassis SH, Bou Khalil BK. Infected chylothorax [abstract]. Presented at American Thoracic Society international meeting 2010 https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2010.181.1_MeetingAbstracts.A4591 (accessed 8/24/18).
20. Epelbaum O, Kazianis J. Chylous empyema or empyematous chylothorax? [Abstract] Presented at American Thoracic Society international meeting 2011. https://www.atsjournals.org/doi/pdf/10.1164/ajrccm-conference.2011.183.1_MeetingAbstracts.A6460 (accessed 8/24/18)
21. Wright RS, Jean M, Rochelle K, Fisk D. Chylothorax caused by paragonimus westermani in a native Californian. Chest. 2011 Oct;140(4):1064-6. [CrossRef] [PubMed]
22. Bakar B, Pampal K, Tekkok IH. Infected bilateral chylothorax in a problematic case. Curr Surg. 2012 April;2(2):62-5. [CrossRef]
23. Di Marco Berardino A, Inchingolo R, Smargiassi A, Re A, Torelli R, Fiori B, d'Inzeo T, Corbo GM, Valente S, Sanguinetti M, Spanu T. Empyema cause by prevotella bivia complicating an unusual case of spontaneous chylothorax. J Clin Microbiol. 2014 Apr;52(4):1284-6. [CrossRef] [PubMed]
24. Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus. FEMS Immunol Med Microbiol. 1999 Dec;26(3-4):259-65. [CrossRef] [PubMed]
25. Boule LA, Ju C, Agudelo M, et al. Summary of the 2016 Alcohol and Immunology Research Interest Group (AIRIG) meeting. Alcohol. 2018 Feb;66:35-43. [CrossRef] [PubMed]
26. Milner JJ, Beck MA. The impact of obesity on the immune response to infection. Proc Nutr Soc. 2012 May;71(2):298-306. [CrossRef] [PubMed]
27. Schild HH, Strassburg CP, Welz A, Kalff J. Treatment options in patients with chylothorax. Dtsch Arztebl Int. 2013 Nov 29;110(48):819-26. [CrossRef]
28. Rudrappa M, Paul M. Chylothorax. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan. [PubMed]
29. Nadolski G. Nontraumatic Chylothorax: diagnostic algorithm and treatment options. Tech Vasc Interv Radiol. 2016 Dec;19(4):286-90. [CrossRef] [PubMed]
30. Misthos P, Kanakis MA, Lioulias AG. Chylothorax complicating thoracic surgery: conservative or early surgical management? Updates Surg. 2012 Mar;64(1):5-11. [CrossRef] [PubMed]
31. Sahn SA. Diagnosis and management of parapneumonic effusions and empyema. Clin Infect Dis. 2007 Dec 1;45(11):1480-6. [CrossRef] [PubMed]

Cite as: Eubank L, Gabe L, Kraft M, Billheimer D. Infected chylothorax: a case report and review. Southwest J Pulm Crit Care. 2018;17(2):76-84. doi: https://doi.org/10.13175/swjpcc097-18 PDF

July 2018 Pulmonary Case of the Month

Anjuli M. Brighton, MB, BCh, BAO

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Completion of an evaluation form is required to receive credit and a link is provided on the last page of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Anjuli M. Brighton, MB. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives: As a result of completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2017-December 31, 2018

Financial Support Received: None

History of Present Illness

An 81-year-old gentleman was admitted for syncope. He had felt unwell for one month. His recent illness started with the “flu”. He had lingering productive cough, low volume hemoptysis and felt very fatigued. After a coughing episode he apparently lost consciousness and was taken to the emergency department.

Past Medical History, Social History and Family History

He has a past medical history of hypertension, glaucoma, diverticulosis and COPD. He was taking only antihypertensives including a diuretic. He has a 30 pack-year history of smoking but quit 10 years ago.

Physical Examination

• Normotensive
• Tachypneic
• SpO2 96% on 2L NC
• Afebrile
• Diffuse wheezing, diminished at L base
• Irregularly irregular heart rate

Which of the following are indicated at this time? (Click on the correct answer to be directed to the second of six pages)

1. Chest x-ray
2. Complete blood count (CBC)
3. Electrocardiogram (EKG)
4. 1 and 3
5. All of the above

Cite as: Brighton AM. July 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;17(1):1-6. doi: https://doi.org/10.13175/swjpcc073-18 PDF 

May 2018 Pulmonary Case of the Month

Kenneth K. Sakata, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 70-year-old man was referred because of new anemia and a heme-positive stool. Esophagogastroduodenoscopy (EGD) was performed which revealed gastritis. Ascites developed and a chest x-ray noted a left pleural effusion. He was managed with weekly high-volume thoracentesis and paracentesis. He was referred to pulmonary medicine.

Past Medical History, Social History and Family History

He has a history of coronary artery disease having undergone coronary bypass grafting in 2016. He also has type 2 diabetes mellitus managed by diet and recently diagnosed orthostasis. He smokes about ½ pack of cigarettes per day but does not drink alcohol. He denies any inhalational exposures. He is Native American and works as a judge. There is no family history of any similar disorders.

Physical Examination

• No acute distress
• Slight bruise to left eye
• No lymphadenopathy
• Decreased breath sounds on left
• Protuberant distended abdomen
• Significant left leg edema
• Discoloration of a few nails

A point of contact ultrasound is performed (Figure 1).

Figure 1. Image from the point of contact ultrasound.

What should be done next? (Click on the correct answer to proceed to the second of seven pages)

1. Needle biopsy of pleural mass
2. Thoracentesis
3. Thoracic surgery consultation for video-assisted thorascopic surgery (VATS)
4. 1 and 3
5. All of the above

Cite as: Sakata KK. May 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(5):237-44. doi: https://doi.org/10.13175/swjpcc059-18 PDF 

December 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 29-year-old man who presented to the emergency room with right-sided pleuritic chest pain, fever, cough, and progressive dyspnea over 2 weeks.

Past Medical History, Social History and Family History

He had no prior significant medical issues and had been well until 2 weeks ago. A native of India, he has been in the US for about 5 months and works at American Express. He is a nonsmoker. Family history is noncontributory.

Physical Examination

• Vitals signs: Temperature 38.0^◦ C, Blood Pressure 155/85 mm Hg, Heart Rate 140 beats/min, Respirations 24 breaths/min
• General: Appears to be in moderate pain and respiratory distress
• Lungs: Decreased breath sounds on the right
• Heart: regular rhythm with a tachycardia
• Abdomen: unremarkable
• Extremities: unremarkable
• Neurologic: unremarkable

Radiography

His initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest radiograph.

Which of the following best describes the chest x-ray? (Click on the correct answer to proceed to the second of seven pages)

1. Elevated right hemidiaphragm
2. Large right pleural effusion
3. Right lower lobe and middle lobe consolidation
4. Right lung atelectasis
5. None of the above

Cite as: Wesselius LJ. December 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(6):268-75. doi: https://doi.org/10.13175/swjpcc122-16 PDF

October 2016 Pulmonary Case of the Month

Coya T Lindberg, BS¹

Ryan R Nahapetian, MD²

F Zahra Aly, MD, PhD, FRCPath³

¹University of Arizona College of Medicine Tucson, Tucson, AZ

²Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona, Tucson, AZ

³Brody School of Medicine at East Carolina University, NC

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Coya Lindberg, BS.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

A 49-year-old man presented with chest discomfort to an outside medical facility in Arizona. He was previously healthy and had no chronic medical diseases. Physical examination was unremarkable and he was afebrile. A chest X-ray was performed (Figure  1).

Figure 1. Initial chest x-ray

Which of the following is most likely? (Click on the correct answer to proceed to the second of five panels)

1. There is a large right chest mass
2. There is a loculated pleural effusion in the minor fissure
3. There is a right ventricular aneurysm
4. There is right lower lobe consolidation
5. There is right middle lobe consolidation

Cite as: Lindberg CT, Nahapetian RR, Aly FZ. October 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(4):152-8. doi: http://dx.doi.org/10.13175/swjpcc096-16 PDF

September 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Lewis J. Wesselius, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

The patient is a 52 year-old woman with prior renal transplant in 1998 due to complications of pre-eclampsia. She had a recent decline in renal function leading to re-transplant on June 23 of this year. She was admitted to the hospital on July 8th with ventricular tachycardia. Treatment with amiodarone was begun with no further ventriuclar tachycardia. She is also taking usual anti-rejection medications.

Past Medical History, Social History and Family History

Other than the renal transplantation she has no other significant past medical history and has never smoked. Family history is noncontributory.

Physical Examination

Physical examination was unremarkable other than the surgical wounds associated with her renal transplants.

Radiography

Her chest x-ray is shown in Figure 1.

Figure 1. Admission chest radiograph.

What should be done at this time? (Click on the correct answer to proceed to the second of four panels)

1. Discontinue the amiodarone
2. Empiric antibiotics
3. Plasma brain naturetic peptide (BNP)
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(3):101-7. doi: http://dx.doi.org/10.13175/swjpcc086-16 PDF

July 2016 Pulmonary Case of the Month

Kashif Yaqub, MD

Robert Viggiano, MD

Imran S. Malik, MD

Zayn A. Mian

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Kashif Yaqub, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 53 year-old woman presented to the emergency department with dyspnea over 3 weeks. There was no cough, wheezing or other complaints.

Past Medical History, Social History and Family History

She has no significant past medical history. She was a nonsmoker. Family history was unremarkable.

Physical Examination

Decreased breath sounds over the left lower chest but otherwise unremarkable.

Laboratory Evaluation

• Elevated white blood cell count with a left shift
• Na+ 130 mEq/L
• 10-20 RBCs on urinalysis

Radiographic Evaluation

A CT angiogram of the chest was performed for possible pulmonary embolus (Figure 1).

Figure 1. Representative images from the thoracic CT in lung windows (A) and soft tissue windows (B).

Which of the following is appropriate at this time? (Click on the correct answer to proceed to the second of six panels)

1. Biopsy of left pleural mass
2. Bone marrow aspiration
3. Diuretics for congestive heart failure
4. Empiric antibiotics for empyema
5. Thoracentesis

Cite as: Yaqub K, Viggiano R, Malik IS, Mian AZ. July 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(1):1-8. doi: http://dx.doi.org/10.13175/swjpcc051-16 PDF

March 2016 Pulmonary Case of the Month

Ramachandra R. Sista, MD

Maxwell L. Smith, MD

 Lewis J. Wesselius, MD

Departments of Pulmonary Medicine and Pathology

Mayo Clinic Arizona

Scottsdale, AZ

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Ramachandra R. Sista, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 74-year-old man was referred for a recently identified right pleural effusion and dyspnea on exertion.  

Past Medical History, Family History and Social History

He has a history of anemia, hypertension, and prostate cancer with a prostatectomy in 2015. He is a life-long nonsmoker and has no occupational exposures. Family history is noncontributory.

Physical Examination

He had diminished breath sounds at the right lung base and a palpable spleen. Otherwise the physical examination was unremarkable.

Laboratory

CBC: hemoglobin  8.5 g/dL, white blood count  7.7 X 109 cells/L,  platelets 357 X 109 cells/L.

Radiography

A chest X-ray showed a right pleural effusion. Representative images from the CT scan are shown in Figure 1.

Figure 1. Representative images from the CT scan.

Which of the following is the most likely diagnosis? (Click on the correct answer to proceed to the second of five panels)

1. Empyema
2. Lung cancer
3. Tuberculosis
4. Usual interstitial pneumonia
5. Valley fever (coccidioidomycosis)

Cite as: Sista RR, Smith ML, Wesselius LJ. March 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;12(3):74-80. doi: http://dx.doi.org/10.13175/swjpcc020-16 PDF

March 2013 Pulmonary Case of the Month: Don’t Rein Me In

Robert W. Viggiano, MD

Michael B. Gotway, MD

Departments of Pulmonary Medicine and Radiology

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 70 year old man was referred for a pleural effusion. The patient had pitting edema of the lower extremities noted in March, 2013. At that time a myocardial perfusion study and an echocardiogram were interpreted as being normal with an ejection fraction of 55%. His primary care physician stopped the amlodipine he was taking for hypertension and his edema resolved. However, the amlodipine was restarted a few weeks later for blood pressure control.

PMH, SH, FH

He has a past medical history of hypertension and asthma. He was diagnosed with prostrate cancer in mid 2012. At that time a CT scan of his abdomen/pelvis and a MRI of his pelvis were negative for metastatic disease. He underwent robot assisted radical prostatectomy and bilateral pelvic lymph node dissection in August 2012. His final diagnosis was Gleason 4+5 disease present throughout the prostate with focal extraprostatic extension and lymphovascular and perineural invasion and invasion of right seminal vesicle. He was staged T 3B.

Present medications

• Amlodipine 5 mg at bedtime
• Omelsartan (Benicar®) 40 mg/day
• Salmeterol/fluticasone (Advair®) 100/50 1 puff twice a day
• Clonazepam 0.5 mg twice a day
• Lycopene 10 mg daily

He has a 10 year smoking history but no alcohol or drug use.

Family history is unremarkable.

Physical Examination

Vital signs: Normal

Lungs: Decreased breath sounds in both lung bases

Heart: Elevated JVP; Normal S1 and S2

Abdomen: Negative

Extremities: 2-3+ pitting edema

Laboratory

• CBC: normal
• Electrolytes: normal
• Serum creatinine: 1.0 mg/dL
• Total protein: 6.8 g/dL
• Albumin: 4.3 g/dL
• NT-pro brain naturetic peptide (BNP): 255 pg/ml

Radiography

Chest x-ray is shown in figure 1.

Figure 1. PA (panel A) and lateral (panel B) chest radiography.

Which of the following is false?

1. The patient’s chest x-ray shows bilateral pleural effusions right larger than left
2. A NT-pro BNP 255 pg/ml makes heart failure an unlikely diagnosis
3. His pleural effusion is most likely due to metastatic prostate cancer
4. A normal heart size on chest x-ray excludes heart failure
5. A normal echocardiogram excludes heart failure

Reference as: Viggiano RW, Gotway MB. March 2013 pulmonary case of the month: don't rein me in. Soutwest J Pulm Crit Care. 2013;6(3):93-102. PDF

December 2012 Pulmonary Case of the Month: Applying Genetics

Lewis J. Wesselius, MD¹

Thomas D. Kummet, MD²

¹Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

²Olympic Medical Cancer Center

Sequim, WA

History of Present Illness

A 65 year old woman presented to her physician in with upper abdominal pain in August, 2007.  A CT scan of the abdomen demonstrated no abnormalities in her abdomen, but a 3.7 x 2.4 cm mass in the left lower lobe was noted.

PMH, FH and SH

She has no significant prior medical history. She is a life-long nonsmoker. There is no significant family history

Physical Examination

Her physical examination is unremarkable.

Which of the following is true?

1. Lung cancer does not occur in nonsmokers
2. The lesion is likely a rounded pneumonia based on its size
3. A family history of lung cancer is not associated with an increase in lung cancer
4. Calcification of the mass usually indicates lung cancer
5. Adenocarcinoma is the most common lung cancer seen in nonsmokers

Reference as: Wesselius LJ, Kummet TD. December 2012 pulmonary case of the month: applying genetics. Southwest J Pulm Crit Care 2012;5:272-8. PDF