SESSION TITLE: Bronchology/Interventional Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Endobronchial valves (EBV) were marketed for use in severe emphysematous COPD. However, they have demonstrated efficacy in managing persistent Bronchopleural Fistulas (Pneumothoraces). In 2008, the FDA approved the use of the IBV Valve System via the Humanitarian Device Exemption Program. There is still limited literature detailing the use of these valves in treating persistent air leaks, few involving thoracic infections, and none involving fungal infections. This case demonstrates treatment of a persistent pneumothroax secondary to Histoplasmosis in an immunosuppressed patient.
CASE PRESENTATION: A 60 year old Caucasian female presented to an OSH for acute diverticulitis immunosuppressed with prednisone. PMHx was significant for rheumatoid arthritis. Social history was significant for a move to a new house by a draining swamp resulting in fine airborne particulate matter. Extensive upper lobe cavitary disease and right sided pneumothorax were incidentally found. She was diagnosed with histoplasmosis via endobronchial washing and urine histoplasma antigen. A chest tube was placed requiring continuous wall suction. The patient was transferred for evaluation for EBV placement after surgical evaluation. She underwent flexibile bronchoscopy with balloon occlusion and 2 EBV valves were placed in the RB2 and RB3 (absent RB1) of the Right upper lobe with significant improvement of the leak (measured in the ventilator) making the patient tolerate water seal with some leak and eventually removal of the chest tube.
DISCUSSION: Histoplasma infection limited the intervention options available for treatment of a persistent pneumothorax. Although not demonstrated in fungal infections, EBVs have been shown to be curative in bacterial thoracic infections. A review of the current literature revealed no other cases involving the use of EBVs to treat fungal disease. One of the complexities of fungal infection is the duration of treatment. Histoplasma treatment can be anywhere from 6-52 weeks in length. This is significantly longer than most bacterial infections, ~1-6 weeks. Additionally, EBV placement did not completely seal the air leak, where other reports document a complete seal; however, this partial resolution was sufficient to allow for an improved outcome.
CONCLUSIONS: EBVs offers a previously unavailable treatment for infection induced persistent pneumothoraces, even when incompletely sealed. This is especially true when the antimicrobial duration of treatment and tissue viability limit surgical intervention.
Reference #1: Schweigert M, Kraus D, Ficker JH, Stein HJ. Closure of persisting air leaks in patients with severe pleural empyema--use of endoscopic one-way endobronchial valve. Eur J Cardiothorac Surg. 2011;39(3):401-3.
Reference #2: Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis. 2007;45(7):807-25.
DISCLOSURE: The following authors have nothing to disclose: Niral Patel, Andrew Worden, Rajul Patel, Javier Diaz-Mendoza, Lisa Stagner
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