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Abstract: Fine crackles are frequently heard in patients with interstitial lung diseases (ILDs) and are known as the sensitive indicator for ILDs, although the objective method for analyzing respiratory sounds including fine crackles is not clinically available. We have previously developed a machine-learning-based algorithm which can promptly analyze and quantify the respiratory sounds including fine crackles. In the present proof-of-concept study, we assessed the usefulness of fine crackles quantified by this algorithm in the diagnosis of ILDs.We evaluated the fine crackles quantitative values (FCQVs) in 60 participants who underwent high-resolution computed tomography (HRCT) and chest X-ray in our hospital. Right and left lung fields were evaluated separately.In sixty-seven lung fields with ILDs in HRCT, the mean FCQVs (0.121 ± 0.090) were significantly higher than those in the lung fields without ILDs (0.032 ± 0.023, P < .001). Among those with ILDs in HRCT, the mean FCQVs were significantly higher in those with idiopathic pulmonary fibrosis than in those with other types of ILDs (P = .002). In addition, the increased mean FCQV was associated with the presence of traction bronchiectasis (P = .003) and honeycombing (P = .004) in HRCT. Furthermore, in discriminating ILDs in HRCT, an FCQV-based determination of the presence or absence of fine crackles indicated a higher sensitivity compared to a chest X-ray-based determination of the presence or absence of ILDs.We herein report that the machine-learning-based quantification of fine crackles can predict the HRCT findings of lung fibrosis and can support the prompt and sensitive diagnosis of ILDs., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Cisplatin is one of the key drugs that is frequently used for treating various types of malignancies. Although renal and digestive toxicities are well-known cisplatin-related toxicities, attention should also be paid to acute aortic thrombosis, a relatively rare but potentially fatal disorder caused by cisplatin. Additionally, D-dimer is mainly measured to detect venous thromboembolism or disseminated intravascular coagulation, whereas its usefulness for detecting aortic thrombosis remains unclear. Here, we report a case of squamous cell lung cancer treated with cisplatin-based chemotherapy, wherein acute aortic thrombosis was diagnosed based on elevated D-dimer levels., Patient Concerns: A 65-year-old man with stage IV squamous cell lung cancer presented with elevated D-dimer levels during treatment with second-line chemotherapy with cisplatin and S-1. Contrast-enhanced computed tomography (CT) revealed an intramural thrombus, which had not been previously identified, extending from the abdominal aorta to the common iliac artery., Diagnoses: We diagnosed the patient as having acute aortic thrombosis caused by cisplatin., Interventions: The patient received intravenous administration of unfractionated heparin for 9 days followed by oral warfarin., Outcomes: One month after initiating treatment, the patient's D-dimer levels decreased to the normal range, and contrast-enhanced CT revealed that the thrombi had nearly completely disappeared without any sequelae or organ damage., Lessons: Our findings revealed that cisplatin can cause acute aortic thrombosis and that regular measurements of D-dimer levels before and during chemotherapy may contribute to the early detection of acute aortic thrombosis., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Some patients with pulmonary arteriovenous malformation (PAVM) present with hypoxemia and life-threatening complications, including stroke and cerebral abscess. Catheter embolization is currently the preferred treatment for PAVM. However, previous studies have revealed that the incidence of PAVM recanalization is approximately 10% 5 to 7 years after embolization. In contrast, there are no studies where recanalization has occurred over 10 years after embolization., Patient Concerns: Herein, we report 2 cases diagnosed with cerebral embolism due to PAVM recanalization 13 years and 30 years after catheter treatment, in case I and II, respectively., Diagnoses: Both cases were diagnosed with PAVM recanalization on chest computed tomography (CT) examination performed after cerebral embolism development. Furthermore, pulmonary artery angiography revealed blood flow from the pulmonary artery to the vein in the PAVM, confirming PAVM recanalization., Interventions: Coil re-embolization was performed for the all recanalized PAVM., Outcomes: All the target lesions were successfully re-embolized in both cases. However, in case I, the second recanalization of embolized PAVM was confirmed 1 year after coil re-embolization. Consequently, the third embolization was performed in case I. In contrast to case I, the patient in case II was followed up without recanalization for 2 years after embolization., Lessons: We described the first 2 cases diagnosed with PAVM recanalization >10 years after the first catheter embolization. These cases suggest that patients with PAVMs should undergo life-long follow-up after catheter embolization.

Rationale: The efficacy of direct oral anticoagulants (DOACs) in the treatment and prophylaxis of cancer-related venous thromboembolism (VTE) is reportedly similar to that of heparin. However, the effect of DOACs on the prophylaxis of cancer-related arterial thromboembolism (ATE) remains unclear. To our knowledge, we present the 1st case where cerebral ATE was encountered during edoxaban administration for VTE in a patient with lung adenocarcinoma., Patient Concerns: In March 2017, a 63-year-old female was diagnosed with lung adenocarcinoma (cT2aN3M1b stage IVa) along with having asymptomatic VTE; thus, 60 mg/day edoxaban administration was initiated. In addition, 1st-line chemotherapy generated a partial antitumoral response. However, owing to lung cancer progression, a secondary treatment with pembrolizumab administration was initiated. The patient suddenly experienced aphasia 11 days after pembrolizumab administration., Diagnosis: The patient was diagnosed as multiple cerebral ATE using brain magnetic resonance imaging. However, VTE recurrence was not observed. Based on the findings of lung cancer progression and increased coagulation, cerebral ATE was diagnosed as Trousseau syndrome., Interventions: DOAC administration was switched to heparin administration., Outcomes: Coagulation profile normalized and aphasia improved without any further disease symptoms., Lessons: We considered that DOACs are effective for the treatment and prophylaxis of VTE but may be insufficient for ATE prevention. Therefore, DOACs should be replaced with heparin to prevent ATE when cancer and coagulation become uncontrollable with DOAC.

Several studies have investigated the incidence of and risk factors for acute exacerbation (AE) in patients with interstitial lung disease (ILD) after lung resection surgery. However, the incidence and risk factors for AE-ILD after non-pulmonary surgery are not known. The aim of this study was to investigate the incidence of and risk factors for AE-ILD after non-pulmonary surgery.Eighty patients who were diagnosed with ILD on preoperative chest computed tomography (CT) imaging and underwent non-pulmonary surgery under general anesthesia at Hiroshima University Hospital between September 2011 and September 2017 were enrolled. We retrospectively compared the preoperative patient characteristics, laboratory findings, and factors associated with anesthetic management between the patients who developed AE-ILD and those who did not.The incidence of AE-ILD after non-pulmonary surgery was 6.3% and the mortality rate was 80%. Univariate logistic analysis showed that a usual interstitial pneumonia pattern on computed tomography, a high C-reactive protein (CRP) level, a long operating time, high blood loss, and blood transfusion during surgery were significant risk factors for AE-ILD. In multivariate analysis, only a high CRP level (odds ratio 2.556, 95% confidence interval 1.110-5.889, P = .028) was identified as an independent risk factor for AE-ILD after non-pulmonary surgery.The risk of AE-ILD should be kept in mind in patients with ILD and a high CRP level before non-pulmonary surgery. These patients should also be monitored carefully for development of AE-ILD after surgery.

The aim of this study was to evaluate whether serial measurements of serum Krebs von den Lungen-6 (KL-6) could be used to monitor disease activity and to detect recurrence in patients with interstitial pneumonia (IP) with anti-aminoacyl-tRNA synthetase antibodies (ARS-IP).This retrospective cohort study included 44 patients with ARS-IP. Thirty-six patients had serial data of blood tests and pulmonary function tests. Baseline and longitudinal analyses were performed to investigate whether lung function parameters were associated with serum biomarkers (KL-6, lactate dehydrogenase [LDH], and C-reactive protein [CRP]) using Pearson correlation coefficient. Additionally, the diagnostic accuracy of changes in these biomarkers for detecting ARS-IP recurrence was analyzed by receiver operating characteristic curve analysis.Baseline levels of serum KL-6 were significantly associated with vital capacity (VC) and diffusion capacity for carbon monoxide (DLco) (r = -0.40, P = .015, and r = -0.44, P = .010, respectively). Longitudinal changes in KL-6 were inversely correlated with changes in VC and DLco (r = -0.57, P <.001 and r = -0.42, P <.001, respectively), whereas those in LDH and CRP were not. Moreover, longitudinal changes in serum KL-6 were significantly associated with recurrence of ARS-IP and could be used to detect ARS-IP recurrence; the area under the curve was 0.79 (P = .002).The present study demonstrated that serial measurement of KL-6 is useful for monitoring disease activity and detecting recurrence of ARS-IP.