Poncet Disease: A Case-based Review of an Uncommon Extrapulmonary Manifestation of Tuberculosis Background: Tuberculosis (TB), an ancient infectious disease caused by the bacteria Mycobacterium tuberculosis, still remains a leading cause of morbidity and mortality in our modern world, causing ∼1.3 million deaths worldwide in 2017 alone. Because it disproportionately impacts the developing world, the unique manifestations of TB may be less encountered and therefore less known to many physicians in developed countries. Case: A 63-year-old woman, with a past medical history of ulcerative colitis, who was on tumor necrosis factor-α inhibitor therapy, presented with fevers, lymphadenopathy, erythema nodosum, and diffuse joint pains. The differential diagnosis included sarcoidosis manifesting as Lofgren syndrome and TB. A tissue biopsy of her right supraclavicular lymph node confirmed the diagnosis of tuberculous lymphadenitis, reactivated in the setting of her adalimumab therapy. Given the patient’s arthritic symptoms, we were also suspicious for Poncet disease (PD), a lesser-known entity defined by reactive arthritis in the setting of TB. Discussion: This case of an immunocompromised woman with fevers, lymphadenopathy, polyarthritis, and erythema nodosum demonstrates a unique presentation of TB. PD is defined as reactive arthritis due to infection with TB elsewhere in the body. Although PD was first described in 1897, it stills remains a disputed and lesser-known entity. This case highlights the importance of recognizing this unique manifestation of TB to prevent misdiagnosis and delay. It also demonstrates the diagnostic challenge in distinguishing the overlapping features of sarcoidosis manifesting as Lofgren syndrome and PD.

The Safety and Efficacy of General Anesthesia Bronchoscopy in Patients With Metastatic Brain Lesions Background: Lung cancer is the leading cause of cancer-related death in the United States and has a high propensity to metastasize to the brain. According to multiple studies, primary lung malignancy is the leading cause of brain metastasis. In many cases, patients with suspected lung cancer will present with brain metastasis and require bronchoscopy for diagnostic and therapeutic purposes, specifically, endobronchial ultrasound transbronchial needle aspiration, which can both diagnose and stage lung cancer. There is a concern that general anesthesia and bronchoscopic procedures can increase intracranial pressures and lead to neurological complications. Methods: We conducted a retrospective study evaluating the safety of performing bronchoscopy under general anesthesia in patients with known space-occupying brain lesions at Keck Hospital of the University of Southern California between 2015 and 2018. Results: Overall, 10% of patients who underwent bronchoscopy had brain lesions at the time of the procedure, similar to previous studies, which showed rates of 10% to 20%. Overall complication rate with general anesthesia and bronchoscopy was 21% in our patients with brain lesions; however, only 3.5% of patients experienced serious adverse events, including respiratory failure or neurological deterioration requiring intensive care unit admission and intervention. There was no difference in complications among those with brain metastasis and those without who underwent bronchoscopy. Conclusion: These results confirm that the rate of serious complications in patients with space-occupying brain lesions who undergo bronchoscopy with general anesthesia is similar to that in patients without brain lesions, indicating that bronchoscopy can be performed safely in this patient population.

Diffuse Alveolar Hemorrhage in the Setting of an Acute Exacerbation of Chronic Hypersensitivity Pneumonitis Due to Drug Rash With Eosinophilia and Systemic Symptoms: A Case Report Drug rash with eosinophilia and systemic symptoms (DRESS) is a well-recognized phenomenon that is considered to be a hyperinflammatory reaction in response to the administration of a drug. It is typical to have systemic signs of inflammation, and the most commonly reported pulmonary manifestations include pneumonitis, interstitial lung disease, and acute respiratory distress syndrome. Here, we present a 62-year-old woman with a history of chronic hypersensitivity pneumonitis who presented in respiratory distress with a new progressive rash. Bronchoscopy demonstrated diffuse alveolar hemorrhage (DAH), and a clinical diagnosis of DRESS was made. The patient was diagnosed with respiratory failure from DAH in the setting of acute exacerbation of chronic hypersensitivity pneumonitis and DRESS. We review the available literature on the pathophysiology, diagnosis, and clinical presentation of DRESS and DAH. To our knowledge, there is no reported case associating DRESS with DAH.

Medical Malpractice and Bronchoscopy: Why Do Physicians Face Litigation? Despite bronchoscopy’s minimally invasive approach, it is not without errors and complications. When such errors do occur, patients may seek legal redress. The aim of the study was to describe the setting, contributing characteristics, and outcomes of litigation targeting bronchoscopic procedures. Westlaw (Thompson Reuters), an online legal research data set, was queried for all medical malpractice cases reported in the United States from 1983 to 2018 wherein bronchoscopy was performed. A total of 87 cases were included. Pulmonology was the most common specialty named in the cases (n=42, 48%). The most common alleged reason for litigation was procedural complication (n=25, 29%), followed by failure to diagnose (n=24, 28%) and failure to treat (n=16, 18%). A total of 49 cases (56%) were decided in favor of the defendant physician, and a settlement was reached before the trial verdict in 20 cases (23%). A verdict delivered in favor of the plaintiff occurred in 18 cases (21%). The median (interquartile range) plaintiff award and settlement payouts were $1,729,560 ($497,088 to $3,895,337) and $648,000 ($184,961 to $2,874,875), respectively. Failure to obtain complete informed consent was the only case characteristic that was significantly associated with an increased risk of payout (odds ratio: 6.67, 95% confidence interval: 1.1-84, P=0.04). Despite bronchoscopy’s utility in identifying numerous pulmonary pathologies, bronchoscopy-related complications were found to be the leading cause of litigation. Identifying and addressing errors with care and proper consent may reduce the number of malpractice claims related to bronchoscopy. Level of Evidence: Level III.

When the Lesion Should Be There, But Isn’t … Diagnostic imaging plays a prominent role in the evaluation of numerous medical conditions, ranging from suspected infections to assessment of the acutely injured patient to staging malignancies and numerous other conditions, both common and rare. Imaging can be a very powerful tool in the diagnosis of medical disorders and plays a major role in the assessment of therapeutic response as well. It is common in practice for imaging studies to provide findings that may corroborate the clinical or laboratory impression of a disorder, allowing a presumptive diagnosis and institution of therapy, often circumventing the morbidity and even mortality that could be associated with an invasive tissue confirmation of a suspected diagnosis. Furthermore, imaging may occasionally detect entirely unsuspected disorders in minimally symptomatic, or even entirely asymptomatic, patients, the latter typically in the context of screening for malignancies. However, on occasion, imaging may fail to disclose a condition that “should be there” on the basis of findings at clinical and/or laboratory examination; this situation is particularly true when imaging fails to reveal abnormalities in the context of a suspected paraneoplastic syndrome. In this circumstance, there may be few, if any, alternatives to approach diagnosing such patients, and the appropriate treatment of these patients becomes exceedingly difficult. Such a situation can even lead to unnecessary, perhaps even inappropriate, interventions. In this circumstance, careful reconsideration of the imaging findings is paramount for correct patient management.

Corticosteroids in Community-acquired Pneumonia: To Give or Not To Give? Synopsis: Several randomized controlled trials (RCTs) and meta-analyses have shown improved outcomes when using corticosteroids in community-acquired pneumonia (CAP), including shorter length of stay, reduced treatment failure, and even lower mortality rates in severe disease. In this reviewed study, a bundled intervention including corticosteroids did not improve outcomes and suggested that corticosteroids may even cause harm. Source: Lloyd M, Karahalios A, Janus E, et al. Effectiveness of a bundled intervention including corticosteroids on outcomes of hospitalized patients with community-acquired pneumonia. JAMA Intern Med. 2019;179:1052–1060.

Can C-reactive Protein Testing Help Guide Antibiotic Therapy for Outpatients With COPD Exacerbations? Synopsis: C-reactive protein may be a useful point-of-care tool to assist in antibiotic guidance in outpatients with an acute COPD exacerbation. This multicenter, randomized controlled trial demonstrated that CRP guided prescribing results in lower antibiotic use with no effect on quality of life. Source: Butler CC, Gillespie D, White P, et al. C-reactive protein testing to guide antibiotic prescribing for COPD exacerbations. N Engl J Med. 2019;381:111–120.

Biomarkers in Pulmonary Infections: Erratum No abstract available