>> GOOD AFTERNOON, EVERYONE.
WELCOME TO THE NEW YEAR. WE
WILL START OFF WITH A CPC CASE
AND THOSE INTERESTED IN
OBTAINING CME FOR TODAY'S TALK
THE CME CODE IS 57869 AND TEXT
THIS CODE TO HOPKINS NUMBER THAT
IS ON THE SLIDE TO RECEIVE
CREDIT FOR THIS LECTURE.
A COUPLE HOUSEKEEPING THINGS
BEFORE WE BEGIN, WE WOULD
APPRECIATE IT IF YOU COULD
PROVIDE US FEEDBACK FOR THIS
TALK AND ALL CLINICAL CENTER
GRAND ROUNDS TALKS THROUGH THE
LINK PROVIDED WHEN YOU SUBMIT
YOUR CME AND GET AN E-MAIL AND
IF YOU COMPLETE THAT, THAT WOULD
BE VERY MUCH APPRECIATED TO USE
THAT TO PREPARE FOR FUTURE GRAND
ROUNDS TOPICS AND WE WILL SAVE
THE QUESTIONS UNTIL THE END OF
THE TALK AND QUESTIONS FROM THE
LIVE AUDIENCE, WE WOULD
APPRECIATE IT IF YOU WOULD MOVE
TO THE AISLES AND USE
MICROPHONES TO AISLES AND THOSE
VIEWERS ONLINE A LIVE FEEDBACK
BUTTON ON THE PAGE TO USE THAT
AND SUBMIT QUESTIONS TO GET TO
THE END OF THEM AND END OF THE
TALK IF TIME PERMITS AND TODAY'S
SPEAKERS ARE GOING TO TALK ABOUT
THE GLOBAL MULTI-DISCIPLINARY
MANAGEMENT OR SEVERE
TUBERCULOSIS AND THANKS FOR
JOINING ME WITH [INDISCERNIBLE]
FELLOW AT CENTER FOR CANCER
RESEARCH AT SKI AND
[INDISCERNIBLE] A CHIEF OF THE
BODY IMAGING SECTION THERE AT
CLINICAL CENTER AND DR. SHAMIS
CAR ASSOCIATE RESEARCH PHYSICIAN
IN THORACICS BRANCH AND
[INDISCERNIBLE] AN ANO-TOMIC
PATHOLOGY RESIDENT IN LABORATORY
AT NCI AND LAST BUT NOT LEAST
KEVIN FEN ELLY WHO IS IN
CRITICAL CARE MEDICINE AND
PULMONARY BRANCH OF LBI.
WITH THAT I WILL HAND IT TO DR.
LORRAINE.
THANK YOU.
>> ALL RIGHT. WONDERFUL AND
THANKS FOR THAT INTRODUCTION.
I WILL BEGIN TALKING A LITTLE
ABOUT THE PATIENT PRESENTATION
AND CLINICAL COURSE AND NEITHER
I NOR PRESENTERS TODAY HAVE ANY
DISCLOSURES AND NOTABLY WE WILL
TALK ABOUT DUR ANNACE ALPHA AND
USE DURING THIS CASE AND ALSO
SHOWING PATIENT PHOTOGRAPHS THAT
PATIENT CONSENT HAS BEEN
OBTAINED AND THIS IS A 20 YEAR
OLD GENTLEMAN WHO PRESENTED
INITIALLY IN APRIL 2023 TO LOCAL
OUTPATIENT CLINIC IN GAMMIA AND
WITH ONE MONTH OF SYMPTOMS
INCLUDING FEVER AND PRODUCTIVE
COUGH AND NOTABLE FOR NIGHT
SWEATS AND WEIGHT LOSS AND
OTHERWISE HEALTHY AND NO KNOWN
PAST MEDICAL HISTORY OR NO PRIOR
TB AND HISTORY WAS NOTABLE FOR
HIM BEING A STUDENT LIVING AT
HOME WITH MOTHER AND SISTERS AND
HAVING NO KNOWN SICK CONTACTS OR
CONTACTS WITH TB AND INITIAL
WORKUP DEMONSTRATED A POSITIVE
SPUTIM AFB SMEAR AND MOLECULAR
ASSAY POSITIVE FOR TUBERCULOSIS
AND [INDISCERNIBLE] RESISTANCE
AND WAS HIV NEGATIVE HE WAS
STARTED ON THERAPY ON OUTPATIENT
BASIS AND PRESENTED AGAIN 1
MONTH LATER WITH ONGOING
SYMPTOMS FEVER AND WORSENING OF
SHORT BREATH AND AMBULATION AND
HAD IMPROVEMENT IN COUGH AND
SPEED OF PRODUCTION AND VITALS
WERE NOTABLE FOR TACKICARDIA
WITH HEART RATE IN 150S AND
DESATURATIONS TO LOWER 90S AND
UPPER 80S AND AT THIS POINT
ADMITTED TO MEDICAL RESEARCH
CENTER IN GAMMIA AND
DEMONSTRATING LARGE RIGHT SIDED
HYDROPNEUMOTHORAX AND
[INDISCERNIBLE] AND INFILL RATES
ON THE LEFT AND INSERTED AT THIS
TIME WITH MINIMAL IMPROVEMENT.
HE WAS ALSO STARTING ON
ANTI-BIOTICSES FOR POSSIBLE
SUPERIMPOSED COMMUNITY ACQUIRED
PNEUMONIA AND CHILD ON MULTIPLE
REGIMENTS SEEN ON SLIDE WITH
MINIMAL IMPROVEMENT AND ONGOING
FEVERS THRU ENTIRE HOSPITAL
COURSE AND REPEATED AND SHOWED
LARGE HYDROPNEUMOTHORAX AND THIS
POINT KERTING A TRAPPED LUNG
FROM [INDISCERNIBLE] 50ULA AND
GIVEN MINIMAL CLINIC IMPROVEMENT
THAT THIS PAKIENT HAD TEAM
DECIDED TO PLACE INTERNATIONAL
REFERRALS INCLUDING CT SURGERY
TEAM IN SENEGAL AND PULMONARY
TEAM IN UNITED KINGDOM AND BOTH
WHICH FELT THEY DIDN'T HAVE
ANYTHING FURTHER TO OFFER THE
PATIENT AND AT THIS POINT THEY
REACHED OUT TO NIH THROUGH MEANS
OF ANYAD AND NLBI AND FURTHER
DISCUSSIONS FELT WE HAD OPTIONS
FOR PATIENT AND ARC CREPTED AND
ULTIMATELY TRANSFERRED TO NIH IN
AUGUST OF 2023 AND TRANSFER WAS
UNCOMPLICATED WITH A TEST TUBE
IN PLACE AND INITIAL
PRESENTATION HERE AT NIH VITALS
WERE NOTABLE FOR TACKICARDIA AS
WELL AS NOTABLY HIS WEIGHT WAS
44 KILOS WITH BMI OF 14
CONSISTENT PRETTY SEVERE
MALNUTRITION AND PHYSICAL EXAM
NOTABLE FOR CABBING AXIA AND
SEVERE MOTOR SENSORY
NEUROPATHIES AND ADDITIONAL
WORKUP WAS DONE AND CRP WAS 66
AND BLOOD CULTURES AND IMAGING
WAS DONE AND NOTABLY HIS RIGHT
PLURA FLUID GREW A
[INDISCERNIBLE] STENOAND
PSEUDOMOWNIS CONSISTENT WITH
POLYMICROBIAL AND MPIEMA AND
REGIMENT AND NOTABLY AMBEAUTAL
AND [INDISCERNIBLE] WERE HELD
GIVEN NEUROPATHIES AND AMMI
CASEIN WERE ADDED TO REGIMENT.
MULTIPLE TEAMS INVOLVED IN HIS
CARE INCLUDING ANYAD AND HIB
PULMONARY TEAM.
IT WAS DECIDED PATIENT NEEDED
FURTHER OPTIMIZATION PRIOR TO
PROCEEDING TO OR TO ENSURE BEST
OUTCOMES FOR PATIENT AND ABLE TO
REGAIN 6 KILOS AND WORK
DILIGENTLY WITH PCHLTD T AND OT
PRIOR TO PROCEEDING TO OR AND
ENDED UP UNDERGOING RIGHT
THOROUGH CLOTOMY AND RIGHT NUM
ONECTOMY AND FLAP CREATIONS IN
SEPTEMBER OF 2023 AND FURTHER
DETAILS OF THE SURGICAL
MANAGEMENT WILL BE DISCUSSED BY
DR. CAR IN A LITTLE MORE DEPTH
IN UPCOMING PORTION OF THIS
TALK.
HIS POST-OP ITERATIVE COURSE WAS
AS EXPECTED AND HE WAS TAKEN TO
THE ICU FOR RECOVERY AND
UNDERWENT MULTIPLE PLANNED RIGHT
VATS AND WASHOUTS DEMONSTRATING
NO SIGNS OF INFECTION IN THE
RIGHT CHEST AS WELL AS IN TACT
BRONXIAL STUMP AND DOWNGRADED TO
FLOOR POST-OP DAY 12 AND
CONTINUED TO DO WELL FOR QUITE
SOME TIME PREPARING FOR LOS OR
FLAP REVERSAL AND CHEST CLOSURE
AND WORKING WELL WITH NUTRITION
AND PT AND OT THAT IS UP UNTIL
END OF JANUARY OR EARLY FEBRUARY
WHEN HE DEVELOPED FEVERS AS WELL
AS A NEW LEUKOCYTOSIS AND RISING
CRP AS CAN BE SEEN ON RESPECTIVE
CURVES HERE AND WORKUP
DEMONSTRATED HE HAD A
PSEUDOMOWNUS INFECTION
COMPLICATED BY BIOFILM
PRODUCTION IN THAT RIGHT CHEST
THAT WAS RESISTENT TO OUR
TYPICAL ANTI-BIOTICSES SEEN BY
MULTIPLE SPIKES IN CRP AS WELL
AS WHITE COUNTS HERE ON THESE
CURVES.
WE ULTIMATELY ENDED UP EMPLOYING
A NOVEL INTRAPLURAL THERAPY
USING DORNASE WE WILL TALK ONCE
AGAIN IN GREATER DETAIL AND WE
ARE ABLE TO SUCCESSFULLY CLEAR
THIS INFECTION.
SO HERE IS HIS SUMMARY OF HIS
TREATMENT TIMELINE AND YOU CAN
SEE THAT IT IS QUITE PROLONGED
GIVEN COMPLEXITIES OF HIS CASE
AND ULTIMATELY WE WERE ABLE TO
CLEAR THAT INFECTION FROM HIS
RIGHT CHEST AND SUCCESSFULLY
CLOSE HIS CHEST WITH LOS OR FLAP
REVERSAL IN MAY FOLLOWED BY
SUCCESSFUL DISCHARGE.
PATIENT IS NOW THREE MONTHS OUT
AND CONTINUES TO DO QUITE WELL
AT CLINICAL FOLLOWUP.
NEXT, WE WILL DIVE INTO A FEW
MORE DIFFERENT ASPECTS OF THE
CASE STARTING WITH RADIOLOGY.
THAT WILL BE WITH DR. MELIARY.
>> THANK YOU DR. LORAINE.
THIS IS A PATIENT PRESENTATION
COMING TO NIH. YOU CAN SEE HERE
THERE IS A LARGE RIGHT
HYDROPNEUMOTHORAX AND MTS BASE
HERE PNEUMOTHORAX AND SMALL
MRURO FUSION AND PUT NORMAL
CHEST X-RAY ON RIGHT SIDE TO SEE
WHAT IS THE DIFFERENCE BETWEEN
THE TWO.
IN ADDITION TO FINDINGS OF RIGHT
HEMOTHORAX THERE IS OPACITIES ON
RIGHT SIDE THAT ENDED UP BEING
INFECTIOUS IN NATURE.
HERE IS THE INITIAL CT WE DID
FOR THE PATIENT. YOU CAN SEE
HERE HYDROPNEUMOTHORAX ON THE
RIGHT AND RIGHT LUNG IS
COMPLETELY OPACIFIED AND BARELY
ANY NORMAL LUNG CAN BE SEEN AND
ON THE LEFT SIDE, YOU CAN SEE
SEVERAL FULL SIDE OF
CONSOLIDATION OF THE MEAT
PORTION OF THE LEFT LUNG AND FOR
COMPARISON YOU CAN SEE A NORMAL
LUNG ON THE LEFT WITH NICELY
SHOWN VESSELS AND A BRONXIAL
TREE.
THIS PROFUSES IN A HOMOGENIS WAY
AND OPPOSED TO SCAN FROM OUR
PATIENT THAT THERE IS LOTS OF
ARCHITECTURAL DISTORTION AND
AREAS NOT PROFUSED BY CONTRAST
AND A LITTLE CONTRAST IN THE
SUPERIOR PORTION OF THE LEFT
LUNG.
SO, AGAIN, THIS PATIENT HAD A
PERSISTENT PNEUMOTHORAX ON RIGHT
SIDE AND ONE INTERESTING THING
FINDING THIS PATIENT WAS
BRONCHIAL MRURO 50ULA AND WE CAN
SEE HERE COMMUNICATION WITH
BRONCHIAL TREE AND PLURAL SPACE
CAUSING AIR INTO THE SPACE AND
PNEUMOTHORAX AND SEE AGAIN ON
THE LEFT SIDE THERE ARE AREAS OF
CONSOLIDATION AS WELL.
INTERESTINGLY, ON THE SOFT
TISSUE IMAGES, YOU CAN SEE THERE
ARE MULTIPLE AREAS OF
HYPODENSITY IN THE RIGHT LUNG
THAT ARE MOST LIKELY ABSCESSES.
THE RIGHT LUNG IS COMPLETELY
OPACIFIED.
INTERESTINGLY, ON THE RIGHT, YOU
CAN SEE THE PLURA IS THICKENED
AND PLURA SHOULD BE BARELY
PERCREPTABLE IN A NORMAL PATIENT
OR NORMAL SITUATION AND YOU CAN
SEE HERE THAT IT IS THICKENED
HERE.
YOU HAVE PLURA A FUSION AND
PLURA THICKENING IS INDICATIVE
AND EXECUTIVE NATURE OF PLURA
FUNCTIONING AND NEUROPLASM AND
HERE IS ONE MONTH AFTER. YOU
CAN SEE THAT THE PATIENT
UNDERWENT RIGHT PNEUMONEKT MY
WITH PACKING MATERIAL IN THE
RIGHT HEMITHORAX HERE AND
PERSISTENT CONSOLIDATIONS IN THE
LEFT LUNG AGAIN.
TWO MONTHS AFTER, YOU CAN SEE
THAT THE PACKING MATERIAL IS
REMOVED AND THERE IS A DIRECT
COMMUNICATION BETWEEN RIGHT
HEMOTHORAX AND RIGHT PLURAL
SPACE AND OUTSIDE AND OPEN
THOROUGH COTOMY THAT IS DONE AND
SEE HERE CONSOLIDATIONS ON THE
LEFT ARE GETTING BETTER AND 5
MONTHS LATER IS BEND IN
PATIENT'S TRAJECTORY.
YOU CAN SEE THERE IS A CAVITY
FORMATION IN THE LEFT LUNG WITH
THICK WALL AND SMALL
PNEUMOTHORAX. IF YOU CAN SEE IT
HERE.
THAT ENDED UP BEING PSEUDOMONA
AND DR. FEN ELE WILL ELABORATE
ON THIS FURTHER AND IN ADDITION
ON THE RIGHT SIDE PLURA IS
GETTING VERY THICK, WHICH I
THINK IS A BIOFILM THAT DR. KARL
WILL DISCUSS MORE.
SO THIS IS FIVE MONTHS AFTER THE
IMAGE ON THE LEFT.
YOU CAN SEE THAT THE CAVITY IS
ALMOST GONE WITH SOME AREAS OF
CALCFICTION THAT ARE LIKELY
DISTROUGH FIBBING IN NATURE AND
RIGHT LUNG IS FILLED WITH FLUID
DENSITY MATERIAL AND AGAIN DR.
CAR WILL ELABORATE FURTHER ON
THIS IN HIS TALK AND THIS IS
MOST RECENT SCAN WE HAVE FROM
THE PATIENT.
YOU CAN SEE THAT THE
CONSOLIDATIONS ARE MUCH BETTER
AND THERE IS SOME VOLUME ON THE
RIGHT THAT PLURA CAVITY IS
FILLED IN WITH FLUID.
HERE, WE PUT THESE IMAGES HERE
FOR YOU TO SEE THAT THE CLOSURE
OF OPEN THROKOTOMY AND
APPRECIATE VOLUME LOSS ON THE
RIGHT AND CONSOLIDATIONS THAT
ARE ALMOST GONE IN THE LEFT
LUNG.
WITH THAT, I WILL HAND IT OVER
TO DR. CARR, WHO WILL DISCUSS
THE SURGICAL COURSE OF THIS
PATIENT.
>> THANK YOU VERY MUCH. WE WILL
PICK UP AND KIND OF GO BACK A
LITTLE BIT IN TIME AND KIND OF
TALK A LITTLE BIT ABOUT THE
SURGICAL ISSUES THAT WE HAD TO
CON TEMPLATE WHEN WE WERE
GETTING READY TO MANAGE THIS
PATIENT.
THESE PATIENTS, LOTS OF THEM
WITH CHRONIC DISEASE HAVE
INCREDIBLY POOR NUTRITION AS
DEMONSTRATED BY OUR PATIENT THAT
IS WEIGHING 42 TO 44 KILOS JUST
FOR KIND OF -- HE STANDS ABOUT
177 CENTIMETERS AND 5 FOOT 9 AND
WEIGHING BARELY 90 POUNDS AND WE
HAVE TO WORRY ABOUT ACTIVE
INFECTION AND POOR NUTRITION CAN
LEAD TO POOR WOUND HEALING AND
ACTIVE INFECTION LEADS TO THINGS
FALLING APART ON US AND
OPERATING PATIENTS OPTIMIZE
NUTRITION AND ENSURE THAT THEY
DON'T HAVE ACTIVE INFECTION
ONGOING AND ADDITIONALLY WE WILL
OPERATE ON PATIENTS AND IN CHEST
SURGERY WE OPERATE ON -- IF
OPERATING ON THE RIGHT LUNG WE
ACTUALLY COLLAPSE THE RIGHT LUNG
AND DON'T VENT LATE IT AND YOU
ARE ONLY VENTILATING ONE SIDE
AND HAVE TO BE ABLE TO SURVIVE
AN OPERATION WHILE ONLY USING
ONE OF YOUR TWO LUNGS AND WANT
TO MAKE SURE THAT LUNG IS ABLE
TO SUPPORT THE PATIENT.
WE FINALLY PUT THIS ALL TOGETHER
WITH AN OVERALL FUNCTION IN
STATUS AND FRAILTY AND TRY TO
DECIDE IS THIS PERSON GOING TO
REALLY DO WELL?
IN OUR CASE WE HAVE A VERY -- 20
YEAR MALE THAT IS OTHERWISE
HEALTHY BEFORE COMING DOWN WITH
THIS OPPOSED TO SOMEONE YOU CAN
IMAGINE THAT IS INCREDIBLY FRAIL
THAT IS MUCH OLDER AND HAD SOME
ISSUES.
NEXT PART THAT WE HAVE TO WORRY
ABOUT WHEN CONSIDERING SURGERY
IS WHAT ARE OTHER INDICATIONS
AND THERE ARE CLINICAL SIGNS
THAT CAN FORCE OUR HAND AND WE
LOOK AT THEM IN THREE
CATEGORIES, EMERGENT, URGIENT
AND NONURGENT.
EMERGENT ARE PATIENTS WITH
MASSIVE HOM OPT SIS COUGHING UP
KIDNEY BASE IN 24 HOURS AND LUNG
HEMORRHAGE HEMORRHAGING ON
[INDISCERNIBLE] AND NOT
CONNECTED TO AIRWAYS BUT YOU SEE
PROCESS GETTING WORSE. URGENT
IRREVERSIBLE PROGRESSION DESPITE
APPROPRIATE THERAPIES OR
RECURRENT SUBHOM OPT SIS AND
PATIENT HAD NONE OF THESE
[INDISCERNIBLE] PATIENTS WITH
BRONXAL PLURA 50ULA THAT PATIENT
HAD ANDFISTULA THAT
PATIENT HAD AND.
>> REMINDER WE WER TALK BEING HE
MENTIONED ABOUT SOFT TISSUE
AREAS RIGHT IN HERE AND WANT TO
DRAW ATTENTION TO THAT. WE
DIDN'T FULLY PICK UP WHAT THAT
WAS UNTIL WE GOT INTO THE
OPERATING ROOM AND THAT IS
SOMETHING THAT ACTUALLY BECOMES
KIND OF IMPORTANT DOWN THE ROAD,
WHICH LIKELY WOULD HAVE GIVEN US
MAYBE BETTER RECOGNIZE MIGHT
HAVE GIVEN US OR BEEN ABLE TO
TALK TO THE PAISHIENT MORE ABOUT
THE LIKELIHOOD OF HIM NEEDING A
NUM ONECTOMY AND OUR PLAN FOR
SURGERY WAS EVENTUALLY TO GET
HIM NUTRITIONALLY OPTIMIZED AND
TRY TO SAVE THIS RIGHT LUNG.
SO WE TOOK A MULTI-DISCIPLINARY
APPROACH AND NUTRITION AND
PHYSICAL AND OCCUPATIONAL
THERAPY AND RESPIRATORY THERAPY
INFECTIOUS DISEASE PULMONARY AND
NEUROLOGY AND LIST GOES ON AND
ON AND WORK TO GET PATIENTS
PROTEIN LEVELS UP AND WEIGHT UP
AND OPTIMIZE FROM ANTI-BOTIC
REJIM TO MAKE SURE DIDN'T HAVE
ACTIVE FUNCTION ONGOING AND
PHYSICAL THERAPY RESPIRATORY
THERAPY AND OCCUPATIONAL THERAPY
TO GET PATIENT UP AND WALKING
AND MOVING AND WHEN HE ARRIVED
TO SEE US HE HAD NOT BEEN OUT OF
A HOSPITAL BED IN FOUR MONTHS
WHILE BEING IN THE GAMMIA.
WE HAD A LONG WAY TO GO.
SO AFTER APPROXIMATELY A MONTH
IN THE HOSPITAL, WE TOOK HIM TO
THE OPERATING ROOM.
ON YOUR LEFT IS THE BEGINNING OF
THE CASE AND THE BEFORE. BEFORE
WE STARTED TO REALLY GET
INVOLVED THAT IS OPENING LOOK
INSIDE OF THE CHEST. YOU CAN
SEE HERE THROUGH THE RETRACTOR
THAT YOU CAN SEE THE LUNG HERE
THAT IS THICK AND HEAVY AND LOTS
OF WHITE SPLOTCHES AND DOTS ALL
OVER THAT ARE ACTUALLY
GRANULOMAS AND AFTER PICTURE IS
AFTER WE DID DECOURTICATION AND
TRYING TO PEEL VISCERAL PLURA
OFF THE LUNG AND CHEST AS
PARIETAL MRUR YA LINE INSIDE OF
THE CHEST AND VISCERAL PLURA
LINING THE LUNG AND PEEL IT OFF
AND GET THE LUNG TO REEXPAND
THAT WAS OUR HOPE AND
UNFORTUNATELY WE FOUND AN
INCREDIBLY DENSE AND
CONSOLIDATED LUNG DAMAGED WITH
SIGNIFICANT AMOUNT OF GRANULOMAS
YOU CAN SEE DEPENDING HOW LIGHTS
ARE AND PROBABLY BETTER ONLINE
AND WE WERE UNFORTUNATELY ABLE
TO GET THE LUNG TO EXPAND AND
THIS PICTURE ON THE AFTER SIDE,
YOU ARE RIGHT.
IT IS WITH THE PATIENT ON TWO
LUNG VENTILATION THAT IS STILL
NOT FILLING THIS SPACE AND SEE
THERE CONTINUES TO BE CAVITY
THAT LUNG IS NOT EXPANDING INTO
AND LEAVE A CHEST LIKE THAT YOU
WILL GET COMPLICATIONS AND END
OF THORACIC SURGICAL PROCEDURE
LEAVING LUNG BEHIND YOU HAVE
PLURAL PLURAL APPLICATION SO
LUNG MUST TOUCH THE CHEST WALL.
WE WERE UNABLE TO DO THAT AND
NEEDED TO PERFORM A NUM ONECTOMY
AND ARE INTEROPERATIVE PICTURES
THAT WE WILL REVIEW THE
PATHOLOGY SHORTLY AND THIS IS
THE RIGHT MIDDLE LOBE HERE ON
YOUR LEFT. YOU CAN SEE
GRANULOMAS THROUGHOUT THE LUNG
AND THIS PICTURE HERE IS ENTIRE
RIGHT LUNG THAT YOU CAN SEE IS
INCREDIBLY DENSE AND FIBROUS AND
NOT COMPRESSING AND IS A BIG
SOLID MASS.
SO WHAT DO WE DO? RIGHT NUM
ONECTOMY AND DID A ROTATIONAL
PERICARDIAL PATCH TO PATCH THE
BRONCHIAL STUMPS HIGH RATE
FALLING APART AND MORE COMMON ON
RIGHT THAN LEFT SIDE OF
BRONCHIAL STUMP FALLING APART
AND IDEA VASCULARIZED HEALTHY
TISSUE ON BRONCHIAL STUMP TO
PROTECT IT TO HAVE THAT DREADED
COMPUTATION AND THIS SPACE IS
INFECTED WITH ENHIGHEMIA AND
CLOSED UP WOULDN'T HAVE GOTTEN
ALL BACTERIA OUT AND ALLOWING
FLUID TO EGRESS OUT OF THE CHEST
THAT WE WILL TALK ABOUT IN A
SECOND AND GIVE US A CHANCE TO
LET US HEAL AND TALKED ABOUT WHY
WE DID THIS SENSE OF LUNG
DESTRUCTION IN [INDISCERNIBLE]
WHAT IS LOSER FLAP THIS IS
INVENTED BY LEO LOSER THORACIC
SURGEON AT STANFORD IMMIGRATED
UP FROM MEXICO AND 1936
DESCRIBED A WIN DOUGH INTO THE
CHEST FOR USE AND TREATMENT OF
PATIENTS WITH TUBERCULOSIS AND
EMPIEMYEMA.
THIS IS THE PATIENT WITH LOSER
FLAP CREATED ALLOWING WINDOW
INTO THE CHEST TO EASILY DO
DRESSING CHANGES AT BEDSIDE.
YOU MAY HAVE HEARD OF A CLAGET
WIN DOUGH SIMILAR BUT DIFFERENT.
TWO PICTURES HERE CLAGET WINDOW
CUT OUT SKIN AND CHEST WALL IN
ONE SHOT AND TAKE IT STRAIGHT
DOWN AND WORKS SIMILAR TO LOSER
FLWE WANTED TO ENSURE WE HAD
SOMETHING THAT WAS EASY AND
SIMPLE AND STRAIGHTFORD WE COULD
CLOSE AND DR. LO ESKER HIELOE
AT.
WE DIVIDE INTO EARLY AND LATE
STAGES EARLY AND LATE
COMPLICATIONS ARE SIMILAR IN
LOTS OF WAYS.
BIG PICTURE HERE IS THAT ABOUT
40% OF THE TIME THEY HAVE SOME
COMPLICATION PATIENT DID
REQUIRED REINTUBATION AND COUPLE
COMPLICATIONS IN ICU AND NOT
EXPECTED BUT HE DID QUITE WELL.
WE TALKED ABOUT WE DID PLANNED
VATS WASHOUTS AND DID THIS TO
GET THE TISSUE TO HEAL AND GET
ANY BIT OF BACTERIA WE COULD OUT
OF THE SYSTEM POST-OP ITERATIVE
DAY 4 TOOK PERSON TO THE FIRST
AND LOOKING UP DIAPHRAGM TOWARDS
APEX OF THE CHEST AND THIS IS
TOP OF THE CHEST THAT IS RIGHT
UP HERE.
ARROW HERE IS POINTING AT
PERICARDIAL PATCH THAT IS
SITTING ON TOP OF THE BRONCHIAL
STUMP.
AFTER CLEANING IT OUT AND
WASHING IT OUT AND REPACKING IT,
WE TOOK PATIENT BACK TO THE
OPERATING ROOM TWO DAYS LATER.
YOU SEE MARKED IMPROVEMENT IN
PARIETAL PLURA THAT BECOMES
HEALTHY AND GRANULATES AND
LIKELIHOOD OF INFECTION BEGINS
TO GO DOWN AND CONTINUE THIS
PROCESS MULTIPLE TIMES.
AGAIN, ONCE WE KNEW THAT THE
PATIENT WAS BETTER WE HOPE TO
CLOSE THE CHEST.
THIS WAS DESCRIBED WELL BY GROUP
AT MAYO CLINIC IN NUMBER OF
PATIENTS YOU CAN'T CLOSE OPEN
THORIA COTOMY BUT WE CAN TRY.
IDEA IS ONCE EVERYTHING IS
CLEANED UP CULTURE IS NEGATIVE
TAKE PERSON TO OPERATING ROOM
AND FILL CHEST WITH SALINE OF
ANTIBIOTIC THAT IS AGAINST
BACTERIA GROWING AND CLOSE CHEST
IN A WATER TIGHT MANNER.
DR. LORRAINE HAS SHOWN PICTURES
HERE AND FIRST TIME PATIENTS CRP
AND WHITE COUNT SPIKED WE
NOTICED THIS PROBLEM PATIENT
DIAGNOSED WITH PSEUDOMOWNIS AND
HAVE ANTI-BIOTICSES AND THINGS
ARE BETTER AND WE WILL GO AND NO
RISING COUNT OF COP AGAIN AND AT
THIS POINT TOOK PATIENT TO OR
AND RE-EVALUATED RIGHT CHEST TO
SEE IF THERE IS ANYTHING GOING
ON.
THIS IS WHAT WE FOUND.
THINK ABOUT THE PRIOR PICTURE
WITH PLURA THAT IS HEALTHY AND
PINK AND RED.
YOU WANT TO SEE A LIME GREEN
COLORED BIOFILM COVERING THE
CHEST AND PICTURES ARE TAKEN
FROM SAME ANGLE BY DIAPHRAGM
LOOKING AT APEX OF THE CHEST YOU
SEE HERE AND HERE THIS IS
ANTERIOR ON THIS SIDE AND ON
THIS SIDE AND THIS IS DIAPHRAGM
KIND OF BULGING RIGHT THERE AND
BIOFILM WAS EASY WE WIPED IT OWE
OF PIECE OF CAKE AND TRIED
ANTI-BIOTICSES THIS WILL BE FINE
AND UNFORTUNATELY WE HAD ANOTHER
SPIKE OF WHITE COUNT IN CRP
DESPITE BEST THERAPIES THAT ARE
INSTILLED IN ANTI-BIOTICSES AND
WE MADE A DECISION TO ADD DNA
DOR NEIGHS ALPHA AND PULL MA
SDIEM THAT IS COMMONLY USED IN
THORACIC SURGERY TO BREAK UP
LOCKULATIONS IN CHEST TO EASILY
DRAIN OUT THROUGH A CHEST TUBE
AND IDEA HERE THAT DR. FENNELLY
WILL SPEAK ABOUT IN MORE DETAIL
IS USED TO HELL DOR NEIGHS ALPHA
TO BREAK UP FILM TO GET AT IT
AND BACTERIA NO PLACES TO HIDE
AND CONTINUE INSTALLATION WITH
ANTI-BIOTICSESNASE ALPHA TO
BREAK UP FILM TO GET AT IT AND
BACTERIA NO PLACES TO HIDE AND
CONTINUE INSTALLATION WITH
ANTI-BIOTICSES.
THIS IS A VIDEO LOOKING IN
TOWARDS APEX OF THE CHEST YOU
CAN SEE IT UP HERE.
THINK ABOUT THE LAST FILM WHERE
YOU HAD GREEN BIOFILM COVERING
EVERYTHING AND BIOFILM HAD BEEN
RESOLVED AND WE TAKE THIS AND
HAVE ARTICLE CURRENTLY WE WORKED
ON WITH OTHER MEMBERS OF THE
TEAM THAT IS CURRENTLY IN PRESS.
SO POST UPDATE 226, THINGS ARE
GOING WELL AND THIS IS WHAT
ELOESSOR FLAP SHOULD LOOK LIKE
226 DAYS LATER AND TOOK PATIENT
TO OPERATING ROOM FOR CLOSURE.
THIS IS CLOSURE OF ELOESSOR FLAP
AND SEE YOU TAKE DOWN SKIN FLAP
HERE AND RUN STITCHES BETWEEN
CHEST WALL AND DIAPHRAGM THAT IS
THIS MUSCLE HERE AND PULL UP AND
PARACHUTE IT TOGETHER TO
ABLITERRATE AND PULL DIAPHRAGM
UP TO CHEST WALL AND OBLITERATE
THAT OPENING AND TIE IT OFF AND
BEFORE CLOSING YOU FILL UP CHEST
WITH FLUID.
THIS IS WHAT IT LOOKS LIKE WHEN
IT IS ALL SAID AND DONE AND HAVE
NICE ELLIPSOID PARABOLIC
INCISION RIGHT THERE AND CHEST
FILLED WITH THOUSANDS OF CCS
WITH SALINE WITH 5 HUNDRED MG OF
AMMA CASEIN AND PSEUDOMOWNIS WE
HAD BEFORE WAS SENSITIVE TO IT
AND CLOSURE HAD TO BE
HYDROSTATIC AND FINAL CHEST
RADIO GRAPH SHOWING WHAT DR.
MALIARI HAS ALREADY TALKED TO US
ABOUT AND YOU CAN SEE HERE THAT
CRP IS NORMAL AT FOLLOW UP A FEW
WEEKS AGO AND BRIEF REVIEW OF
SURGICAL COURSE AND AT THIS
POINT I WOULD LIKE TO INVITE DR.
AKABILAD TO THE PODIUM TO HELP
DISCUSS THE PATHOLOGY.
>> THANK YOU. WHAT WE RECEIVED
IN THE LAB FROM THIS PATIENT IS
RIGHT NUM OWNECTOMY SPECIMEN
PARTS AND THIS SECTION BELONGS
TO RIGHT, MIDDLE AND
[INDISCERNIBLE] MONTH AND THIS
IS PLURAL SURFACE AND TISSUE
THAT COVERS SURFACE OF THE LUNG
AND LOW MAGNIFICATION, WE CAN
SEE THAT WHOLE LUNG TISSUE IS
INVOLVED WITH INFLAMMATORY AND
DISTRACTIVE PROCESS AND DIVER
SIFTIC LESIONS IN CHIMA AND
ASSOCIATED HEMORRHAGE.
ON RIGHT IS EXAMPLE OF HEALTHY
LUNG TISSUE AND HOW IT SHOULD
LOOK UNDER THE MICROSCOPE AND
ALVEOLI ARE NICELY OPENED AND
YOU SEE STRIKING DIFFERENCE IN
PATIENT'S LUNG THERE IS NO OPEN
AIRWAY SPACE LEFT.
WHEN WE LOOK AT CLOSER, WHOLE
LUNG PERICHIMA WAS INVOLVED WITH
ILL-DEFINED GRANULOMAS AND ONE
IS CIRCLED HERE AND COMPOSED OF
[INDISCERNIBLE] AND MULTINUCLEIC
GIANT SELLS AND NECK
RECEIPTIZING AREAS WITHIN
GRANUL
GRANULOMAS, INFLAMMATION AND
FIBROSIS PROCESS WAS INVOLVING
THE LUNG ALL THE WAY TO THE
PLURA.
THE CYSTIC AREAS WERE ALSO
SURROUNDED WITH THESE GIANT
MULTINUCLEIC CELLS AND IN
BACKGROUND CHRONIC INFLAMMATION
IS GOING ON TOO AND RIGHT UPPER
LOBE SIMILAR FINDINGS THAT YOU
SEE LUNG TISSUE IS DESTROYED
WITH THIS PROCESS AND WE HAD
LARGE NECK RECEIPTIZING AREAS IN
THE LOBE TOO AND PERFORMED AFB
STAIN ON MULTIPLE SECTIONS AND
SCATTERED STRUCTURES THAT ARE
HIGHLIGHTED WITH ARROWS HERE.
ONLY A FEW OF THEM.
WE ALSO RECEIVED VISCERAL PLURAL
FRAGMENTS THAT WAS THICKENED
MEASURING 2.5 MILLIMETERS HERE
AND NORMAL AND HEALTHY PLURA
SHOULD ONLY MEASURE .2
MILLIMETERS AND WHEN LOOKING AT
IT CLOSER PLURA IS INVOLVED WITH
CHRONIC INFLAMMATORY PROCESS
WITH THIS REACTIVE VASCULAR
PROLIFERATIONS.
PLURA ALSO HAD NECK RECEIPTIZING
GRANOMAS.
HERE, THE ARROW POINTS TO
NECROSIS THAT IS SURROUNDED WITH
MULTINUCLEIC GIANT CELLS AND
RECEIVED A COUPLE LYMPH NODES
THAT WERE INVOLVED WITH
GRANULOMAS ARROW POINTING HERE
AND NECK RECEIPTIZING GRANULOMA
IN THE LYMPH NODE AND OVERALL
PATH OL OJIC FINDINGS
INFLAMMATION AND FIBROSIS AND
HEMORRHAGE EXTENSIVELY MOVING
LOBES OF THE RIGHT LUNG AND
VISCERAL PLURA AND NO RESIDUAL
LEFT AND REGIONAL LYMPH NODES
WERE INVOLVED BY INFLAMMATION
AND SPECIAL STAINS IS CONSISTENT
WITH [INDISCERNIBLE]
TUBERCULOSIS IS IDENTIFIED AND
HISTMORPHOLOGIC FINDINGS ARE
SUPPORTIVE OF TB AND ASSOCIATED
SEVERE LUNG DAMAGE AND THANK
YOU. I WILL HAND IT OVER TO DR.
FENNELLY.
>> THANK YOU. THE FINAL
CLINICAL DIAGNOSIS HERE IS TB
DESTROYED LUNG. AS DR. JUST
SHOWED YOU, THERE WERE NO
ALVEOLI PRESENT. THE ENTIRE
LUNG WAS ESSENTIALLY JUST SIMPLY
DESTROYED.
JUST A FEW COMMENTS ABOUT TB IN
GENERAL, THE TRAGEDY IS THAT TB
IS PREVENTABLE AND CURABLE.
UNFORTUNATELY IT IS THE NO. 1
KILLER AMONG ALL INFECTIOUS
DISEASES.
WE HAD A SHORT PERIOD THERE
WHERE THE PANDEMIC TOOK OVER.
IT IS ODD NOW TO HEAR TB
COLLEAGUES SAYING, HEY, WE ARE
NO. 1 AGAIN.
IT HAS BEEN THAT WAY FOR MANY
YEARS BEFORE THE PANDEMIC AND
OVER 10 MILLION PEOPLE ARE ILL
EACH YEAR AND OFTEN HOSPITALIZED
WITH OCTAVE TB.
ABOUT 25% OF THE WORLD'S
POPULATION IS THOUGHT TO BE
INFECTED AND IS TO HAVE LATENT
TB MEANING WE INHALED IT AND THE
BODY HAS CONTROLLED IT AND ARE
AT RISK FOR REACTIVATING TB AT
SOME TIME IN THE FUTURE.
THIS CURVE HERE, IT IS JUST A
DEMONSTRATION OF WHAT HAPPENED
WITH THE PANDEMIC.
NOT THAT TB WENT AWAY BUT ALL
PUBLIC HEALTH PEOPLE SUCK
CRUMBED TO TAKING CARE OF COVID
CASES NO TB NOTIFICATIONS TO WHO
AND ARE IN A REBOUND CATCHING UP
ALL CASES NOW BEING IDENTIFIED.
SO IN GAMBIA THOSE THAT DON'T
KNOW IT IS A VERY SMALL COUNTRY
IN WESTERN AFRICA.
IT HAS A VERY HIGH RATE OF TB,
ABOUT 150 PER 100,000 CASES AND
FRAME OF REFERENCE WERE UNDER 5
PER HUNDRED THOUSAND NOW IN
GENERAL IN THE US.
FORTUNATELY THERE IS NOT MUCH
MULTIDRUG RESISTENT TB AND
TRAGEDY IS CASE FATALITY RATIO
IS 23% AND MEANING ABOUT A
QUARTER OF PEOPLE WHO DEVELOPED
TB IN GAMBIA DIE FROM THE
DISEASE AND HAVE NO DOMESTIC
FUNDING AND 100% OF CARE IS FROM
INTERNATIONAL FUNDING AND
MEDICAL RESEARCH CENTER THAT YOU
HEARD ABOUT IS FROM THE UK, THE
MEDICAL RESEARCH COUNCIL THAT
PROVIDES CARE THERE AND THERE
ARE NO PULMONOLOGISTS OR
THORACIC SURGEONS IN THE WHOLE
COUNTRY AND THESE POOR GENERAL
DOCTORS WERE TRYING TO TAKE CARE
OF THIS VERY COMPLICATED CASE
PUTTING IN CHEST TUBES TO BE
CONGRATULATED FOR WHAT THEY
COULD DO.
ONE THING THAT IS UNUSUAL ABOUT
THE GAMBIA TO REST OF SUBIS A
HAIRANT AFRICA IS HIV IS NOT
MAIN UNDERLYING CAUSE BUT IT IS
REALLY MALNUTRITION THAT OUR
PATIENT DEMONSTRATED.
SO, TB DESTROYED LUNG IS FAIRLY
UNUSUAL AND CAN BE SEEN IN
PEDIATRIC CASES.
MOSTLY IN ADULTS AND AS IN OUR
CASE, ONE LOBE IS -- ONE LUNG IS
DESTROYED AND CONTRALATERAL
UPPER LOBE IS EFFECTED AS DR.
MALIARY DEMONSTRATED AND SOME OF
THE BEST RECENT DATA COMES FROM
BEIJING AND CHINA AND 1% OF TB
PATIENTS WILL DEVELOP THIS AND
FORTUNATELY THEY HAVE FAIRLY
GOOD SURVIVAL IN THE FIRST FEW
YEARS THAT YOU CAN SEE OUT TO
FIVE OR SO YEARS, THEY CAN BE I
HAD A POINTER HERE WE GO. 90%
STILL ALIVE AFTER FIVE YEARS AND
IT DROPS OFF AND THEY
DEMONSTRATED THAT SURGICAL
TREATMENT DEFINITELY IMPROVES
SURVIVAL AND OLDER DATA FROM
NIGERIA LOOKED AT 20
NUMONECTOMIES AND LUNGS REMOVED
BECAUSE OF TB AND ALL TREATED
FOR OVER THREE YEARS AT THAT
TIME AND HAD NEGATIVE CULTURES
WHEN THEY WENT TO SURGERY.
SOME WERE REFERRED BECAUSE OF
MASSIVE HEEM OPTMOPTYSIS.
UNFORTUNATELY AT THAT TIME IN
NIGERIA, 18% OF CASES OF
PULMONARY TB CARRIED TOTAL
DESTROYED LUNG AND AT THAT TIME
NO DIRECTLY OBSERVED THERAPY AND
THINGS IMPROVED FAIRLY
DRAMATICALLY THIS IS A TABLE OF
THE KNOWN CASES WE HAVE OF
POST-OP ITERATIVE BRONXAL PLURAL
FISTULA AND REFERRING TO THIS
THIS IS NOT BRONCHIAL FISTULA
YOUNG MAN PRESENTED WITH BUT
AFTER A SURGEON REMOVES WHOLE
LUNG AND RISK IS IF AREA IS
INFECTED IN OTHER WORDS IF DR.
CARR GOES IN AND STAPLES ACROSS
A SEGMENT AND IF AIRWAYS ARE
INFECTED WITH TB AND THEY BREAK
DOWN PATIENT DEVELOPS TB
EMPYEMA.
IT IS FATAL AND I HAVE SEEN
CASES FROM NONTUBERCULOSIS
MICROBACTERIAL DISEASE AND THIS
FROM 1978 FROM HANKINS WAS FROM
UNIVERSITY OF MARYLAND IN
BALTIMORE AND THEY FOUND IF
THERE WAS A POSITIVE CULTURE
THAT 42% DEVELOPED A BPF.
OBVIOUSLY, THAT WAS NOT A GOOD
FINDING AND SUBSEQUENTLY WORK
LARGELY AT NATIONAL JEWISH --
YOU KNOW, MY SENIOR COLLEAGUE
AND MENTOR MIKE EISMAN PUBLISHED
THIS PAPER ON TOP OF TB COULDN'T
GET CULTURE NEGATIVE IF SMEAR
NEGATIVE AND LOW AMOUNT PATIENTS
DID MUCH BETTER.
WHAT IS THE PERFECT TIMING?
WE DON'T REALLY KNOW. AS DR.
HANKINS POINTED OUT WAY BACK IN
THE 70S, AVOIDANCE OF RESECTION
WHEN PATIENTS ARE STILL CULTURE
POSITIVE AS PREFERRED AND JUST
BECAUSE OF HIGH RISK OF THAT
TISSUE BREAKING DOWN.
EARLY INTERVENTION SEEMS TO HAVE
ADVANTAGE OF REDUCING RISK OF TB
PROGRESSION REQUIRING DRUG
RESISTANCE AND IF YOU CAN WAIT
YOU CAN PRETREAT WITH EFFECTIVE
DRUGS WE DID IN THIS CASE AND
ARE AGGRESSIVELY TREATING THIS
YOUNG MAN SO HE WOULDN'T HAVE A
BPF DUE TO TISSUE BREAKDOWN AND
WERE ABLE TO GET NUTRITION UP AS
DR. CA ARE, R MENTIONED AND
APPEARS SOMETIME AROUND 2 TO 4
MONTHS IS PROBABLY OPTIMAL AND
WHAT WE ARE -- AROUND FIVE
MONTHS OR SO AND KEY THING TO
HAVE PATIENT BE SMEAR NEGATIVE
AND CULTURE NEGATIVE.
SO THIS WAS A POINT I GOT
ANXIOUS AS DR. MALIARI
DEMONSTRATED IN JANUARY THAT WE
SAW THIS LARGE NODULE HERE
CAVITIATE AND ONE THING I WAS
CONCERNED ABOUT IS HOW DO YOU
DEVELOP DRUG RESISTENT TB AND
WERE WE IN FOR TROUBLE AFTER
THAT AND PULMONARY FELLOW WITH
ME THOUGHT I WAS CRAZY. OH,
YEAH IT IS PSEUDOMOWNIS WE CAN
TREAT IT AND IT WAS NOT DRUG
RESISTENT.
SO, DR. CARR MENTIONED BIOFILM.
I WANTED TO JUST REVIEW A FEW
CONCEPTS.
ONE IS THAT THERE IS NO
CONCENSUS AGREEMENT WHAT BIOFILM
IS AND SIMPLE DEFINITION LOOKING
AT IT GROSSLY AS WE DID IN THE
CHEST OF THE YOUNG MAN IS IT
LOOKS LIKE SLIME THAT WAS JUST
THIS GREEN, SMOOTH MATERIAL
COVERING UP THE PLURAL SURFACE.
LOOKING AT IT MICROSCOPICALLY,
OLD THOUGHT WAS IT WAS JUST A
BUNCH OF THE SAME BACTERIA THAT
IS IMBEDDED IN THIS MATRIX.
THERE WAS A BARRIER TO
PENETRATION AND WE KNOW NOW IT
IS NOT QUITE SO SIMPLE AND THERE
IS TO AND FRO ACTIVITY WITH
ORGANISMS GOING INTO THE MATRIX
AND IS USUALLY NOT JUST ONE
ORGANISM AND PUBLISHED A PAPER
SEVERAL YEARS AGO AND I WAS
SURPRISED TO LEARN THERE WAS
FUNGI AND BACTERIA AND THINGS
INSIDE OF THE BIOFILM.
SO, THE KEY THING WE WANTED TO
DO IS, YOU KNOW, SCRAPING OFF
BIOFILM WASN'T WORKING.
WHAT WE WANTED TO DO WAS GET
BUGS IN THE GANGS INSIDE OF THE
BIOFILM. WE WANTED TO GET THE
BIOFILM BROKEN UP SO THE
PLANKTONIC BACTERIA OUT HERE AND
SINGLE BACTERIA AND BACHELORS
ONCE SEPARATED ARE MORE
SUSCEPTIBLE TO ANTI-BIOTICSES
SHOWN IN PEDIATRICS FOR MIDDLE
EAR INFUSIONS AND OTHER TYPES OF
BIOFILM INFECTIONS.
SO THIS IS A NICE PAPER THAT
REVIEWED HOW DO WE GET RID OF
THIS SLIME? THIS EXTRA CELLULAR
POLYMERIC SUBSTANCE AND NUMBER
OF METHODS PROPOSED AND ONLY
PRACTICAL THING WE HAVE
AVAILABLE IS DORI NEIGHS ALPHA
OR DNASE DR. CA ARE, R MENTIONS
AND WE USE IN CYSTIC FIBROSIS
PATIENTS THAT INHALE IT AND
BREAK UP PSEUDOMOWNUS BIOFILM
AND BE [INDISCERNIBLE] AND BREAK
UP VERY THICK SECRETIONS CF
PATIENTS HAD AND DR. CARR
MENTIONED IT IS USED ROUTINELY
NOW OFTEN ALONG WITH FIBRO
ANALYTICS IN COMPLICATED
INFUSIONS WHERE THERE IS
INFECTION IN PLURA SPACE AND
ALLOW THEM TO DRAIN OUT OF A
CHEST TUBE.
WHERE WERE WE AT END OF THE
YOUNG MAN'S COURSE? LOOKING AT
PULMONARY FUNCTION THINKING DID
WE DO HIM ANY FAVORS? LUNG
FUNCTION IS 25% OF NORMAL.
YOU HAVE TO REMEMBER HE IS
MISSING A WHOLE LUNG NOT 50%
PREDICTED BUT DISEASE IN
CONTRALATERAL LUNG AND DOING
QUITE WELL IN 6-MINUTE WALK THAT
IS ACTUALLY A VERY NICE AND
SIMPLE TEST OF PHYSICAL
FUNCTIONING IS A DECENT DISTANCE
THAT HE DOESN'T DESATURATE AND
GOOD OXYGEN SATURATION AND
DOESN'T NEED TO STAY ON OXYGEN
AND DOESN'T HAVE RISK FOR
DEVELOPING PULMONARY
HYPERTENSION.
SO WE ARE NOW LEFT WITH POST TB
LUNG DISEASE THAT IS ACTUALLY A
FAIRLY NEW CONCEPT.
NIAD JUST RELEASED FUNDING FOR
THIS WITHIN THE LAST TWO YEARS.
FOR MOST OF MY CAREER, WE SAID
OH, GOSH WE ARE GREAT DOCTORS
AND CURED TB AND PEOPLE ARE LEFT
WITH DEBILITATING RESPIRATORY
IMPAIRMENTS. GLOBALLY IS
ESTIMATED ABOUT 155 MILLION TB
SURVIVORS AND ABOUT HALF OF THEM
HAVE POST TB LUNG DISEASE AND
CLEARLY OUR YOUNG MAN CLEARLY
HAS BRONXY ECT CIS AND WE ARE
NOT SEEING LUNG FIBROSIS AND
LONGSTANDING PATIENTS DEVELOP
AND HAD MINOR CAVITATION THAT
CLEARED UP AND MICEO TOMORROWAS
REFERS TO MOLD GETTING INTO
CAVITIES CAUSING PROBLEMS AND
DOESN'T APPEAR TO HAVE PULMONARY
HYPERTENSION THAT IS HIGH BLOOD
PRESSURE INSIDE OF THE LUNGS AND
CHRONIC PULMONARY CHRONIC
DISEASE AND ALL IN ALL, HE SEEMS
TO BE DOING QUITE WELL AND WHAT
CAN BE DONE?
A LOT OF OUR LUNG DISEASE
PATIENTS DO WELL TO GET THEM TO
PULMONARY REHABILITATION AND
GRATIFYING THING IN MY CAREER
HAS BEEN TO SEE SOME OF OUR
FORMER COLLEAGUES IN UGANDA WHO
HAVE TAKEN ON FIELDS LIKE THIS.
BRUCE WHO WAS INVOLVED IN A
PAPER WITH AFANIA AND NIDI AND I
WAS IN A STUDY THAT WAS 20 YEARS
AGO AND WAS A FASCINATING PIECE
OF WORK. BRUCE WAS GREAT TO
WORK WITH.
HE AND COLLEAGUES DID THIS VERY
SMALL PILOT STUDY AND ENDED UP
HAVING 29 PATIENTS THAT
COMPLETED PROGRAM AT MAIN MILL
AGROHOSPITAL IN UGANDA AND
DEMONSTRATED WITH TWICE A WEEK
PROGRAM THERE ARE SYMPTOMS AND
THEIR WALK DISTANCE IMPROVED AND
THEY HAVE ADDITIONAL FUNDING AND
ARE DOING PULMONARY REHAB FOR
THIS.
A WHILE BACK, THE ATS, AMERICAN
THORACIC SOCIETY RELEASED
GUIDELINES FOR PULMONARY
REHABILITATION AND FORGOT TO
INCLUDE TUBERCULOSIS MAJOR CAUSE
OF RESPIRATORY IMPAIRMENT IN THE
WORLD NOW AND [INDISCERNIBLE]
AND BRUCE AND I WROTE THIS
REVIEW AND CALLED ATTENTION TO
THAT AND IS IFEANYI HERE? I
DON'T THINK HE IS HERE. IF YOU
KNOW DR. ANIDI, HE IS CURRENTLY
CONDUCTING A STUDY HERE TO TRY
TO BETTER UNDERSTAND THE IMMUNE
RESPONSE IN THE LUNG VERSUS
BLOOD.
WE WOULD LOVE TO HAVE YOU
VOLUNTEER FOR THAT STUDY IF YOU
ARE SO INCLINED.
SO THIS IS A PICTURE OF OUR
PATIENT AT HIS GOING AWAY PARTY
AND NINE MONTHS AFTER LIVING AT
CLINICAL CENTER HE HAD OBVIOUSLY
IN-PATIENT PULMONARY REHAB AND
PHYSICAL DEPARTMENT AND
OCCUPATIONAL THERAPY AND DR.
CARR IS SAYING WHOLE TEAM HERE
HAD BEEN AMAZING AND MICHAEL
WHEN WE SAW HIM HAD FOOT DROP
FROM SEVERE MOTOR NEUROPATHY AND
FROM DRUGS FOR TB AND IS NOW
WALKING ON OWN DOING GREAT AND
YOU CAN SEE FEELING WELL AND
THIS HAS BEEN ONE OF MOST
GRATIFYING CASES OF MY CAREER.
IT HAS BEEN MY PLEASURE AND
PRIVILEGE TO HAVE WORKED WITH
DR. CA ARE, R AND HIS AMAZING
TEAM AND INCLUDING DR. LORRAINE.
AND KAREN FOREST IS PART OF THE
LONDON SCHOOL OF HYGIENE AND
TROPICAL MEDICINE AND STAFF IN
THE GAMBIA HAS BEEN IN
COMMUNICATION WITH US ON A
REGULAR BASIS.
I WON'T GO THROUGH ALL THESE
PEOPLE.
YOU CAN SEE IT REALLY TAKES A
VILLAGE AND TAKES THE ENTIRE
GROUP.
IT WAS VERY GRATIFYING TO BE
HERE.
ONE OF THE REALLY AMAZING THINGS
FOR ME WORKING AT NIH IS THE
EXCELLENCE AND PRIDE PEOPLE TAKE
IN THEIR WORK.
AND HELPING.
AND LAST BUT NOT LEAST IS
ACTUALLY OUR PATIENT AND HIS
FAMILY THAT WERE INCREDIBLY
SUPPORTIVE.
YOU KNOW, HELPED HIM GET HERE.
I DON'T KNOW IF IT WAS CLEAR TO
YOU.
HE ARRIVED WITH A CHEST TUBE
HANGING OUT OF HIS CHEST
CONNECTED TO A HIEM LICK VALVE
MAKING LONG TRIP FROM AFRICA TO
HERE IS BAD ENOUGH IN ECONOMY.
AND HE -- HE ARRIVED IN -- WENT
-- WENT THROUGH A REALLY TOUGH
COURSE AND HAS DONE WELL.
WITH THAT, I WILL WRAP IT UP AND
SEE IF THERE ARE QUESTIONS FOR
OUR TEAM.
>> [OFF MIC]. LET ME SEE IF
THERE ARE ANY QUESTIONS ONLINE.
>> THERE IS SILENCE.
>> WE ACTUALLY DO HAVE A
QUESTION FROM THE ONLINE
AUDIENCE.
THE QUESTION IS IS THE BCG
VACCINE NOT AVAILABLE IN THE
GAMBIA.
>> NO. THE QUESTION IF THOSE
DIDN'T HEAR IT IS BCG VACCINE
AVAILABLE IN GAMBIA? IT IS
AVAILABLE IN GAMBIA AND MOST OF
THE SUB IS A HAIRANT WORLDED AND
IN WORLD WHERE HIGH RATE OF
TUBERCULOSIS HAVE BCG GENE AND
IT IS PREVENTIVE IN REACTIVATION
OF TB IN ADULTS.
>> I'M CURIOUS ABOUT FLUID IN
LUNG THAT YOU LEFT WITH
ANTIBIOTICS AND WHAT HAPPENS TO
IT OVER TIME. THANK YOU.
>> GO FOR IT.
>> IT ACTUALLY STAYS.
SO WHAT HAPPENS IS THE MRPLURA
SPACE WILL CONTINUE TO PRODUCE A
PROTEIN RICH FLUID.
IT CHANGES THIS NORMAL SALINE.
OVER TIME IT ESSENTIALLY NOT TO
DISSUADE ANYBODY FROM EATING
JELL-O ANYMORE IT TURNS INTO A
JELL-O MOLD INSIDE OF THE CHEST
AND PROTEIN IS LEECHED IN AND
STAYS AND OVER TIME FORMS WHAT
WE CALL A FIBRO THORAX THAT
SHOULD BE A JELL-O MOLD INSIDE
OF THE CHEST.
>> LET ME ADD A COMMENT THAT
LOTS WENT ON IN CASE OVER NINE
MONTHS WE CAN'T POSSIBLY ADDRESS
EVERY BIT OF.
YOU -- SOME MAY KNOW THAT THERE
IS A KIND OF CULTURE HERE OF NOT
USING NAMMO CASEIN OR
GLYCOCRIEDS AND SOMETHING I HAVE
BEEN VERY COMFORTABLE WITH AND
WHEN STARTING TO DO PLURAL
WASHES WITH AMMI CASEIN LEAVING
IT IN FOR A WHILE DR. CARR'S
TEAM DID NICE STUDIES AND GOT
LEVELS DONE AFTER EACH OF THE
AMACACIN TREATMENTS
DEMONSTRATING SYSTEMIC LEVELS
WERE VERY LOW AND FOLLOWED
HEARING TEST ALL THROUGH THE
COURSE.
HIS HEARING HAS BEEN UNAFFECTED
AND IS 100% NORMAL.
>> THIS IS FROM REBECCA CROOK.
I WORKED WITH THIS CHAP. WE
KNEW HIM BY HIS NICKNAME ISRAEL
FOR MOST OF JOURNEY IN GAMBIA.
WE CAN'T THANK YOU ENOUGH FOR
ALL YOU HAVE DONE FOR HIM IT IS
NICE TO SEE HIM UP AND WITH
WEIGHT AND IT IS AN ACHIEVEMENT
AND GOOD WORK, TEAM.
>> THANKS SO MUCH. THAT IS FROM
GAMBIA? THAT IS RIGHT IF
ANYBODY IN THE GAMBIA CAN STILL
HEAR US YOU ARE MORE THAN
WELCOME. IT WAS REALLY OUR
PLEASURE TO HELP.
>> THANK YOU FOR STARTING OFF.
THANK YOU FOR STARTING OFF THE
YEAR WITH THIS FANTASTIC
PRESENTATION.
AGAIN, I WOULD ENCOURAGE
EVERYONE TO GIVE FEEDBACK VIA
THE LINK THAT YOU WILL RECEIVE
IF YOU COMPLETE YOUR CME. IF
YOU TEXT OR IF YOU ACTUALLY SCAN
THE CODE, THERE WILL BE A LINK
THERE AS WELL TO PROVIDE
FEEDBACK TO US AND THANKS AGAIN.
TAKE CARE!
>> AUDIENCE: [APPLAUSE]