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We present a case of eosinophilic pneumonia due to ceftaroline used for the treatment of methicillin-resistant Staphylococcus aureus bacteremia associated with a postoperative spinal infection. Our patient developed shortness of breath and hypoxemia on the fifth week of ceftaroline therapy. Chest imaging disclosed diffuse bilateral infiltrates. Laboratory abnormalities included peripheral eosinophilia and eosinophilic predominant bronchoalveolar lavage fluid. The combination of ceftaroline discontinuation plus initiation of steroid treatment resulted in complete resolution of signs, symptoms, and radiologic abnormalities. We speculate about possible mechanisms underlying this adverse event and diagnostic criteria for drug-induced eosinophilic pneumonia.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and positron emission tomography (PET)-computed tomography (CT) are valuable tools for lung cancer staging. Data from tertiary referral centers suggest that these modalities are superior to mediastinoscopy in mediastinal staging.To validate EBUS-TBNA for lung cancer staging in a community center with operators with various levels of experience.At an 800-bed community hospital, we reviewed all cases where EBUS-TBNA and PET-CT were performed for mediastinal staging by one of seven private practice pulmonologists. Cases were reviewed with lymph node dissection by mediastinoscopy after negative EBUS-TBNA.Of the 333 cases that were reviewed, 44 underwent mediastinoscopy after negative EBUS-TBNA. Four patients were positive for malignancy at stations 4R and 7 lymph nodes. In none of these cases did EBUS-TBNA reveal lymphoid tissue confirming the sample location. PET-CT showed mediastinal lymph nodes with increased avidity in two of the false-negative cases. EBUS-TBNA plus PET-CT had a sensitivity, specificity, and negative predictive value of 98.86, 100, and 94.87%, respectively, compared with mediastinoscopy for detecting metastasis.EBUS-TBNA is accurate in detecting mediastinal metastasis of lung cancer in the community setting. PET-CT without uptake in lymph nodes reduces the likelihood of malignancy but cannot rule out mediastinal involvement.

Women with pulmonary lymphangioleiomyomatosis (LAM) who present with a sentinel spontaneous pneumothorax (SPTX) will experience an average of 2.5 additional pneumothoraces. The diagnosis of LAM is typically delayed until after the second pneumothorax.We hypothesized that targeted screening of an LAM-enriched population of nonsmoking women between the ages of 25 and 54 years, who present with a sentinel pneumothorax indicated by high-resolution computed tomography (HRCT), will facilitate early identification, definitive therapy, and improved quality of life for patients with LAM.We constructed a Markov state-transition model to assess the cost-effectiveness of screening. Rates of SPTX and prevalence of LAM in populations stratified by age, sex, and smoking status were derived from the literature. Costs of testing and treatment were extracted from 2007 Medicare data. We compared a strategy based on HRCT screening followed by pleurodesis for patients with LAM, versus no HRCT screening.The prevalence of LAM in nonsmoking women, between the ages of 25 and 54 years, with SPTX is estimated at 5% on the basis of the available literature. In our base case analysis, screening for LAM by HRCT is the most cost-effective strategy, with a marginal cost-effectiveness ratio of $32,980 per quality-adjusted life-year gained. Sensitivity analysis showed that HRCT screening remains cost-effective for groups in which the prevalence of LAM in the population subset screened is greater than 2.5%.Screening for LAM by HRCT in nonsmoking women age 25-54 that present with SPTX is cost-effective. Physicians are advised to screen for LAM by HRCT in this population.

Introduction The clinical and epidemiological significance of community-acquired pneumonia (CAP) with a chest radiograph demonstrating no parenchymal infiltrate has not been studied. We determined the percentage of patients with a clinical diagnosis of CAP who did not have radiographic opacifications and compared this group with patients with CAP and radiographic infiltrates. Methods Patients admitted with a diagnosis of CAP were identified. Clinical history, physical examination, laboratory studies, and microbiological cultures were reviewed in a random sample of 105 patients. Admission and subsequent chest radiographs were interpreted without knowledge of the clinical data. Results Twenty-one percent (22/105) of patients with a clinical diagnosis of CAP had negative chest radiographs at presentation. Demographic, clinical, and laboratory data were the same in both groups. Fifty-five percent of patients with initially negative chest radiographs who had follow-up studies developed an infiltrate within 48 hours. Conclusions In patients admitted with a clinical diagnosis of CAP, the initial chest radiograph lacks sensitivity and may not demonstrate parenchymal opacifications in 21% of patients. Moreover, greater than half of patients admitted with a negative chest radiograph will develop radiographic infiltrates within 48 hours. Further studies are needed to develop evidence-based criteria for the diagnosis of CAP.

Summary Background Lymphangioleiomyomatosis (LAM) is a rare, progressive and frequently lethal cystic lung disease that almost exclusively affects women and has no proven therapies. An improved understanding of the pathogenesis has identified promising molecular targets for clinical trials. Although barriers, modifiers, and benefits for clinical trial participation in common diseases such as cancer have been studied, we are unaware of such evaluations concerning rare diseases. Methods We performed a survey of a population-based registry of 780 LAM subjects in North America to identify predictors of trial participation. Logistic regression analysis evaluated the association of demographic and clinical features with trial participation. Results 41 of 263 (16%) LAM patient respondents in North America had participated in a clinical trial. Age, disease duration, lack of any college education, use of oxygen therapy, and presentation without chest pain were associated with trial participation in unadjusted analyses. Multivariate analyses indicate that patient age was the strongest independent predictor for trial participation (OR=2.07, p =0.004 per decade greater of patient age). Common reasons reported against trial participation included not meeting enrollment criteria (44%), drug toxicity (25%), and stable disease (20%). The most frequent reason reported for trial participation was to help future patients (85%). Conclusions Study entry criteria, drug toxicity, and stability of disease are barriers to trial enrollment among subjects with LAM. Older LAM patients and those with more advanced disease are more likely to have participated in clinical trials. Altruism is commonly a motivating factor.