Department of Intensive Care, Faculty of Medicine, University of Thessaly, Larissa, Greece.
Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, Larissa, Greece.
Chest. 2022 Jul;162(1):e37-e41. doi: 10.1016/j.chest.2022.02.034.
A 50-year-old woman with a history of permanent atrial fibrillation (AF) treated with radiofrequency catheter ablation (RFCA) 6 months ago was admitted to the respiratory department of a tertiary hospital because of recurrent episodes of pleuritic chest pain in the preceding 5 months. The patient reported multiple visits to a regional hospital, where she was treated with broad-spectrum antibiotics after discovery of a left alveolar consolidation on chest radiograph (Fig 1), subsequently imaged with CT scan (Fig 2). On treatment failure and appearance of a left-sided pleural effusion during outpatient follow-up, the patient was re-admitted. Pleural fluid was obtained via thoracocentesis characterized by exudative features and lymphocytic predominance. Abdomen CT scan, with IV and per os contrast agent, was devoid of findings consistent with malignancy, and serum autoantibody levels were below positivity cut off values (antinuclear, cyclic citrullinated peptide antibody, rheumatoid factor, and anti-neutrophil cytoplasmic antibodies). The patient underwent flexible bronchoscopy without endobronchial pathology on visual inspection. Microbiologic studies and cytological examination of samples obtained by bronchial washing/aspiration yielded no clinically relevant information. Lung perfusion/ventilation scintigraphy was ordered to exclude chronic thromboembolic pulmonary hypertension; however, a deficit in vascularization for the left inferior lobe was found, prompting further investigation (Fig 3). Progression of left inferior lobe consolidation and the presence of a small pericardial effusion became evident on reimaging after a 2-month interval. The patient was empirically started on corticosteroids. After emergence of left hilar lymphadenopathy (< 1 cm), a PET-CT scan was performed. The left lower inferior lobe consolidation, whose metabolic activity pattern was consistent with that of inflammation (standardized uptake value equal to 4.4) (Fig 4), as well as the left sided-pleural effusion were markedly improved compared with previous imaging 20 days after corticosteroid initiation (Fig 2). On the grounds of recalcitrant pleuritic pain and pleural effusion recurrence during corticosteroid tapering, the patient was referred to the respiratory department of our university hospital to have her condition diagnosed.
一位 50 岁女性，有永久性心房颤动（AF）病史，6 个月前接受射频导管消融（RFCA）治疗，因前 5 个月反复出现胸痛，入住一家三级医院呼吸科。患者曾多次到一家地区医院就诊，胸部 X 线片发现左肺肺泡实变后，给予广谱抗生素治疗（图 1），随后行 CT 扫描（图 2）。在治疗失败和门诊随访时出现左侧胸腔积液后，患者再次入院。经胸腔穿刺获得的胸腔积液表现为渗出性特征和淋巴细胞优势。腹部 CT 扫描，静脉和口服造影剂，未发现与恶性肿瘤一致的发现，血清自身抗体水平低于阳性截断值（抗核抗体、环瓜氨酸肽抗体、类风湿因子和抗中性粒细胞胞质抗体）。患者行纤维支气管镜检查，但未见支气管内病理学改变。支气管冲洗/抽吸获得的样本的微生物学研究和细胞学检查未提供有临床意义的信息。为排除慢性血栓栓塞性肺动脉高压，进行了肺灌注/通气闪烁显像；然而，发现左下叶血管化不足，进一步进行了检查（图 3）。在间隔 2 个月的再次成像中，左下叶实变进展和小量心包积液的存在变得明显。患者开始经验性使用皮质类固醇。出现左侧肺门淋巴结肿大（<1cm）后，进行了 PET-CT 扫描。左下叶下叶实变，其代谢活性模式与炎症一致（标准化摄取值为 4.4）（图 4），以及左侧胸腔积液与皮质类固醇起始后 20 天的先前成像相比明显改善（图 2）。由于皮质类固醇减量期间顽固的胸痛和胸腔积液复发，患者被转诊到我们大学医院的呼吸科以明确诊断。
