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Pulmonary

Last 50 Pulmonary Postings

(Click on title to be directed to posting, most recent listed first, CME offerings in Bold)

September 2019 Pulmonary Case of the Month: An HIV Patient with a
   Fever
Adherence to Prescribed Medication and Its Association with Quality of Life
Among COPD Patients Treated at a Tertiary Care Hospital in Puducherry
    – A Cross Sectional Study
June 2019 Pulmonary Case of the Month: Try, Try Again
Update and Arizona Thoracic Society Position Statement on Stem Cell 
   Therapy for Lung Disease
March 2019 Pulmonary Case of the Month: A 59-Year-Old Woman
   with Fatigue
Co-Infection with Nocardia and Mycobacterium Avium Complex (MAC) 
   in a Patient with Acquired Immunodeficiency Syndrome 
Progressive Massive Fibrosis in Workers Outside the Coal Industry: A Case 
   Series from New Mexico
December 2018 Pulmonary Case of the Month: A Young Man with
   Multiple Lung Masses
Antibiotics as Anti-inflammatories in Pulmonary Diseases
September 2018 Pulmonary Case of the Month: Lung Cysts
Infected Chylothorax: A Case Report and Review
August 2018 Pulmonary Case of the Month
July 2018 Pulmonary Case of the Month
Phrenic Nerve Injury Post Catheter Ablation for Atrial Fibrillation
Evaluating a Scoring System for Predicting Thirty-Day Hospital 
   Readmissions for Chronic Obstructive Pulmonary Disease Exacerbation
Intralobar Bronchopulmonary Sequestration: A Case and Brief Review
Sharpening Occam’s Razor – A Diagnostic Dilemma
June 2018 Pulmonary Case of the Month
May 2018 Pulmonary Case of the Month
Tobacco Company Campaign Contributions and Congressional Support of
   Tobacco Legislation
Social Media: A Novel Engagement Tool for Miners in Rural New Mexico
April 2018 Pulmonary Case of the Month
First-Line Therapy for Non-Small Cell Lung Cancer Including Targeted
   Therapy: A Brief Review
March 2018 Pulmonary Case of the Month
February 2018 Pulmonary Case of the Month
January 2018 Pulmonary Case of the Month
Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia in a Patient
   with Multiple Pulmonary Nodules: Case Report and Literature Review
Necrotizing Pneumonia: Diagnosis and Treatment Options
December 2017 Pulmonary Case of the Month
First Report of Splenic Abscesses Due to Coccidioidomycosis
November 2017 Pulmonary Case of the Month
Treatment of Lymphoma and Cardiac Monitoring during Pregnancy
October 2017 Pulmonary Case of the Month
September 2017 Pulmonary Case of the Month
August 2017 Pulmonary Case of the Month
Tip of the Iceberg: 18F-FDG PET/CT Diagnoses Extensively Disseminated 
   Coccidioidomycosis with Cutaneous Lesions
July 2017 Pulmonary Case of the Month
Correlation between the Severity of Chronic Inflammatory Respiratory
   Disorders and the Frequency of Venous Thromboembolism: Meta-Analysis
June 2017 Pulmonary Case of the Month
May 2017 Pulmonary Case of the Month
April 2017 Pulmonary Case of the Month
March 2017 Pulmonary Case of the Month
February 2017 Pulmonary Case of the Month
January 2017 Pulmonary Case of the Month
December 2016 Pulmonary Case of the Month
Inhaler Device Preferences in Older Adults with Chronic Lung Disease
November 2016 Pulmonary Case of the Month
Tobacco Company Campaign Contributions and Congressional Support
   of the Cigar Bill
October 2016 Pulmonary Case of the Month
September 2016 Pulmonary Case of the Month
August 2016 Pulmonary Case of the Month

 

For complete pulmonary listings click here.

The Southwest Journal of Pulmonary and Critical Care publishes articles broadly related to pulmonary medicine including thoracic surgery, transplantation, airways disease, pediatric pulmonology, anesthesiolgy, pharmacology, nursing  and more. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.

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Friday
Jun222018

Intralobar Bronchopulmonary Sequestration: A Case and Brief Review

Uddalak Majumdar, MD1 

Payal Sen, MD2

Akshay Sood, MD2

1Cleveland Clinic Foundation, Cleveland, OH USA

2Univeristy of New Mexico, Albuquerque, NM USA

 

Abstract

Objective: Bronchopulmonary sequestration is a rare congenital abnormality of the lower respiratory tract, seen mostly in children but often in adults. The term implies a mass of lung tissue that has no function and lacks normal communication with the rest of the tracheobronchial tree.

Case: A 40-year-old man presented with acute onset of left flank pain for 4 hours. He was born in Yemen and emigrated to the US in 1998; at that time, he had been tested for tuberculosis which was negative. In this admission, he met systemic inflammatory response (SIRS) criteria and had basilar crackles in the left lower lobe of the lung. CT scan revealed a cavitary lesion with air-fluid level in the left lower lobe airspace. There was systemic arterial blood supply to this region arising off the celiac axis. He was diagnosed with an infected intralobar bronchopulmonary sequestration and underwent video-assisted thoracoscopic wedge resection. On follow up 3 months later, he was doing well.

Discussion: Pulmonary sequestration is a rare congenital anomaly of a mass of lung tissue, which can have cystic changes and is a very important differential diagnosis of cavities in the lung. Confirmation of diagnosis is by visualization of a systemic vessel supplying sequestrated pulmonary, and this is accomplished by contrast-enhanced CT scan, MRI or invasive angiography. 

Conclusion: The delay in diagnosis in our patient was due to falling prey to anchoring and availability biases and chasing the diagnosis of tuberculosis in a patient from Yemen with a lower lobe cavitation.

Case

History of Present Illness: A 40-year-old man with a past medical history of atrial fibrillation presented to the hospital with acute onset of left flank pain for 4 hours, fevers and chills. The pain was sharp and stabbing, pleuritic, non-radiating, and was severe with an intensity of 10/10. He denied extraneous activity or trauma earlier in the day, denied substernal pain, cough, night sweats, weight loss or change in urinary habits. He was born in Yemen and emigrated to the US in 1998; at that time, he was tested for tuberculosis (TB) which was negative. He was known to have a cavitary lesion in left lower lobe since 2005, and had undergone extensive evaluation (imaging, sputum and PPD) which showed no form of tuberculosis. He denied taking prophylactic TB treatment. Annual PPD testing had always been negative.

The patient worked on a ship, which travelled in the Great Lakes on the US-Canada border. He was a current smoker with a 20-pack-year smoking history. He lived at home with his wife and children. There was no history of IV drug use, prior imprisonment or homelessness. He denied being in contact with anyone with TB while in Yemen. He was sexually active with his wife and had no other sexual partners. He denied history of sexually transmitted infections.

Physical Examination:

Vital Signs: Temp – 38.3 degrees Fahrenheit, Pulse- 111/minute, RR- 18/min, BP- 151/66 mm Hg. Spo2- 90 % on Room Air.

Basilar crackles and rhonchi in the left lower lobe of the lung. No cervical or inguinal lymphadenopathy. Rest of the physical exam was normal.

Significant Laboratory Findings:

WBC elevated at 15,500/mm3 with 65 percent Neutrophils.

Lactate - 1.1 mmol/dL

Radiography:

Chest x-ray was done while in the emergency department, which revealed left basilar sub-segmental atelectasis (Figure 1).

Fig.1. Chest x-ray showing left basilar sub-segmental atelectasis without focal consolidation, large pleural effusion or pneumothorax.

Initial CT scan of abdomen and pelvis was done to rule out renal/ureteral stone. It showed a left lower lobe airspace consolidation with bronchiectasis and bronchiolectasis and a cavitary lesion with air-fluid level (Figure 2). 

Figure 2. Representative images from the CT scan in lung windows showing left lower lobe airspace consolidation concerning for an acute on chronic process.

C-reactive protein and erythrocyte sedimentation rate were normal, CRP and ESR- normal; blood cultures revealed no growth; procalcitonin 0.4 ng/mL (normal <0.15); anti-nuclear antibody – negative; Aspergillus antigen – negative; urine Legionella antigen – negative; Streptococcus pneumoniae antigen – positive.

Sputum Gram stain and acid-fast bacilli culture/stain could not be obtained because the patient did not produce any sputum.

Subsequently CT chest with IV contrast was done which showed findings compatible with a pneumonia within a left lower lobe intrapulmonary sequestration. (Figure 3).

Figure 3. Representative images from the thoracic CT chest with IV contrast. The left lower lobe demonstrates a 69 x 83 mm heterogeneous fluid collection with multiple locules of air. There was systemic arterial blood supply to this region arising off the celiac axis (arrows).

The patient was diagnosed with an infected intralobar bronchopulmonary sequestration. He was treated initially with intravenous fluids and piperacillin-tazobactam. He underwent video-assisted thoracoscopic wedge resection of infected bronchopulmonary sequestration in left lower lobe and ligation of the systemic feeding vessels from the celiac artery. Pathologic examination revealed a fibrotic lung with areas of centrilobular emphysema, bronchiolectasis, mucus pooling and microscopic honeycomb changes. Findings also showed an elastic artery, with features most suggestive of intralobar sequestration. His symptoms completely resolved after his operation.

Discussion

Bronchopulmonary sequestration is a rare congenital abnormality of the lower respiratory tract, seen mostly in children but often in adults, like in our patient (1). In 1946, Pryce coined the term "pulmonary sequestration" to describe a disconnected bronchopulmonary mass or cyst with an anomalous arterial supply (2). The term implies a mass of lung tissue that has no function and lacks normal communication with the rest of the tracheobronchial tree. This mass of non-functional lung tissue receives blood supply from the systemic circulation (3). The exact etiology is unknown and is thought to be an embryologic process error in foregut budding (4), although some have indicated a non-congenital acquired process in intralobar sequestration.

Sequestration may be intra- or extralobar based on its relation with the normal lung lobes. An intralobar sequestration (ILS), like the name suggests, is located within a normal lobe, lacks its own visceral pleura (5) and also has aberrant connections to bronchi, and lung parenchyma, or even the gastrointestinal tract, and often presents with recurrent infections (6,7). Compared to ILS, an extralobar sequestration (ELS) is located outside the normal lung and has its own visceral pleura (8), with the rare occurrence of infectious complications (9). About 75% of BPS is intralobar while 25% is extralobar (10). Bronchopulmonary sequestration is often associated with other congenital abnormalities like congenital diaphragmatic hernia, vertebral anomalies, congenital heart disease, pulmonary hypoplasia, colonic duplication, and congenital pulmonary airway malformation (11). 

Clinically, pulmonary sequestration is latent until infection leads to symptoms (12). Symptoms, like that of any pathological lung condition depend on the type, size, and location of the lesion. Sepsis and extracardiac shunting are common complications of untreated sequestration. Hemoptysis can also be a presentation. The mechanism of pneumonia is post-obstructive and usually recurrence of pneumonia leads to diagnosis. Recurrent pneumonia especially in the lower lobes should always include intralobar sequestration in the differential diagnoses. But the pathophysiology of infection and/or hemoptysis when ILS is not connected to airway is a mystery. Sometimes there is a partial or anatomically abnormal connection to the tracheobronchial tree, which can lead to poor mucus clearance, plugging and recurrent infection.

The mainstay of diagnosis is pre-operative imaging and post-operative histopathology of the resected specimen. The pathognomonic imaging characteristic is systemic vascular supply of the affected area of the lung (intra or extra-lobar), which is seen in about 80% of CT scans. Recurrent infection can lead to cystic areas within the mass (clusters of “ring shadows” on X-ray) (13). The surrounding normal lung may have air trapping and show emphysematous changes. Radiologic signs of BPS are a spectrum and represent the chronic and recurrent inflammation of the sequestrated lung: recurrent focal airspace disease, a parenchymal mass, a cavitary consolidation or mass, cystic lesions, localized bronchiectasis or adjacent emphysema. Bronchoscopy has little role in the management of BPS, which needs to be kept in mind by clinicians investigating cystic lung lesions. Identifying the systemic feeding vessel also helps with surgical planning.  

Symptomatic patients are treated with surgical excision; surgery is curative and is associated with minimal morbidity (14). Surgery is urgent in patients with significant respiratory distress but may be an elective procedure in adults or older children with less symptoms (15, 16). 

For asymptomatic patients of any age, management depends on how ‘high risk’ they are considered for developing complications. High risk patients are those with large lesions occupying >20 percent of the hemithorax, bilateral or multifocal cysts, or those with pneumothorax. In these patients, surgical resection is preferred to observation (17). On the other hand, in asymptomatic patients without these high-risk characteristics, either elective surgical resection or conservative management with observation are reasonable options (18). 

Apart from surgery, even embolization of the anomalous arterial supply has been reported to result in a complete resolution of symptoms and imaging changes to a certain in some cases (19). Since identification of vascular supply during surgery may be difficult during surgery, presurgical embolization may reduce risk of vascular complications (19). Embolization also has a more important role in hemoptysis and heart failure from shunting.

Conclusions

  • Pulmonary sequestration is a rare congenital anomaly of a mass of lung tissue without a normal connection to the tracheobronchial tree and a systemic vascular supply.
  • Presentation in adults is due to complication of the mass, undiagnosed in childhood. 
  • Sequestrated lung can have cystic changes and is a very important differential diagnosis of the cavitation. 
  • Confirmation of diagnosis is by visualization of a systemic vessel supplying sequestrated pulmonary, and this is usually accomplished by contrast-enhanced CT scan, MRI or invasive angiography.

Teaching points

This is a case of adult presentation of congenital pulmonary malformation and represents a delay in diagnosis, even though the patient’s symptoms started 10 years ago. The delay was due to falling prey to anchoring and availability biases and chasing the diagnosis of TB ten years ago in a patient from Yemen with a lower lobe cavitation. 

The feeding vessel from the celiac axis can only be demonstrated via a contrast enhanced CT, and thus, when in doubt, we should always get angiography by contrast-enhanced-CT or MRI or by invasive angiography. Had it been thought of and done 10 years ago, the patient would’ve been diagnosed and treated earlier.

Disclosure Statement

Drs. Majumdar, Sen and Sood have no conflicts of interest or financial ties to disclose.

References

  1. Landing BH, Dixon LG. Congenital malformations and genetic disorders of the respiratory tract (larynx, trachea, bronchi, and lungs). Am Rev Respir Dis. 1979 Jul;120(1):151-85. [CrossRef] [PubMed]
  2. John PR, Beasley SW, Mayne V. Pulmonary sequestration and related congenital disorders. A clinico-radiological review of 41 cases. Pediatric radiology. Pediatr Radiol. 1989;20(1-2):4-9. [CrossRef] [PubMed]
  3. Van Raemdonck D, De Boeck K, Devlieger H, et al. Pulmonary sequestration: a comparison between pediatric and adult patients. Eur J Cardiothorac Surg. 2001 Apr;19(4):388-95. [CrossRef] [PubMed]
  4. Gezer S, Taştepe I, Sirmali M, Findik G, Türüt H, Kaya S, Karaoğlanoğlu N, Cetin G. Pulmonary sequestration: a single-institutional series composed of 27 cases. J Thorac Cardiovasc Surg. 2007 Apr;133(4):955-9. [CrossRef] [PubMed]
  5. Shanti CM, Klein MD. Cystic lung disease. Semin Pediatr Surg. 2008 Feb;17(1):2-8. [CrossRef] [PubMed]
  6. Stocker JT, Drake RM, Madewell JE. Cystic and congenital lung disease in the newborn. Perspect Pediatr Pathol. 1978;4:93-154. [PubMed]
  7. Schwartz MZ, Ramachandran P. Congenital malformations of the lung and mediastinum--a quarter century of experience from a single institution. J Pediatr Surg. 1997 Jan;32(1):44-7. [CrossRef] [PubMed]
  8. Abbey P, Das CJ, Pangtey GS, Seith A, Dutta R, Kumar A. Imaging in bronchopulmonary sequestration. Send to J Med Imaging Radiat Oncol. 2009 Feb;53(1):22-31. [CrossRef] [PubMed]
  9. Houda el M, Ahmed Z, Amine K, Amina BS, Raja F, Chiraz H. Antenatal diagnosis of extralobar pulmonary sequestration. Pan Afr Med J. 2014;19:54. [CrossRef] [PubMed]
  10. Frazier AA, Rosado de Christenson ML, Stocker JT, Templeton PA. Intralobar sequestration: radiologic-pathologic correlation. Radiographics. 1997 May-Jun;17(3):725-45. [CrossRef] [PubMed]
  11. Kravitz RM. Congenital malformations of the lung. Pediatr Clin North Am. 1994 Jun;41(3):453-72. [CrossRef] [PubMed]
  12. Hang JD, Guo QY, Chen CX, Chen LY. Imaging approach to the diagnosis of pulmonary sequestration. Acta Radiol. 1996 Nov;37(6):883-8. [CrossRef] [PubMed]
  13. Hernanz-Schulman M. Cysts and cystlike lesions of the lung. Radiol Clin North Am. 1993 May;31(3):631-49. [PubMed]
  14. Samuel M, Burge DM. Management of antenatally diagnosed pulmonary sequestration associated with congenital cystic adenomatoid malformation. Thorax. 1999 Aug;54(8):701-6. [CrossRef] [PubMed]
  15. Haller JA, Jr., Golladay ES, Pickard LR, Tepas JJ, 3rd, Shorter NA, Shermeta DW. Surgical management of lung bud anomalies: lobar emphysema, bronchogenic cyst, cystic adenomatoid malformation, and intralobar pulmonary sequestration. Ann Thorac Surg. 1979 Jul;28(1):33-43. [CrossRef] [PubMed]
  16. Al-Bassam A, Al-Rabeeah A, Al-Nassar S, Al-Mobaireek K, Al-Rawaf A, Banjer H, et al. Congenital cystic disease of the lung in infants and children (experience with 57 cases). Eur J Pediatr Surg. 1999 Dec;9(6):364-8. [CrossRef] [PubMed]
  17. Parikh DH, Rasiah SV. Congenital lung lesions: Postnatal management and outcome. Semin Pediatr Surg. 2015 Aug;24(4):160-7. [CrossRef] [PubMed]
  18. Singh R, Davenport M. The argument for operative approach to asymptomatic lung lesions. Semin Pediatr Surg. 2015 Aug;24(4):187-95. [CrossRef] [PubMed]
  19. Eber E. Adult outcome of congenital lower respiratory tract malformations. Swiss Med Wkly. 2006 Apr 15;136(15-16):233-40. [PubMed]

Cite as: Majumdar U, Sen P, Sood A. Intralobar bronchopulmonary sequestration: A case and brief review. Southwest J Pulm Crit Care. 2018;16(6):343-9. doi: https://doi.org/10.13175/swjpcc075-18 PDF

Monday
Jun042018

Sharpening Occam’s Razor – A Diagnostic Dilemma

Payal Sen, MD1

Uddalak Majumdar, MD2

Patrick Rendon, MD1

Ali Imran Saeed, MD1

Akshay Sood, MD1

 

1University of New Mexico

Albuquerque, NM US

2Cleveland Clinic Foundation

Cleveland, OH USA

 

Abstract

Objective: Physicians often search for Occam’s Razor, that is, to have a single diagnosis explain all clinical manifestations in an individual patient. Herein, we describe a case which was significant for a dual clinical diagnosis, thus proving that Occam’s razor may not always hold true. 

Case Summary: A 22-year-old Caucasian man presented with 4 days history of fever, and dry cough. Chest x-ray revealed a right middle lobe pneumonia. Mycoplasma IgM antibody titer was significantly elevated (>1:320), using the rapid diagnosis enzyme-immunoassay (EIA) test, and clinical course was complicated by rhabdomyolysis. He was treated with oral azithromycin for 5 days. The patient however returned to the ER in 2 weeks with similar symptoms and repeat chest x-ray revealed a persistent right middle lobe infiltrate. Endobronchial biopsy revealed necrotizing granulomatous inflammation which stained positive for Histoplasma capsulatum. Serum complement fixation antibody test for Histoplasma demonstrated an elevated titer of 1:64. The patient was diagnosed to have an ‘atypical pneumonia due to sub-acute Histoplasma capsulatum and acute Mycoplasma Pneumoniae infections, complicated by rhabdomyolysis.’

Discussion: This case is unusual because the patient had an acute community-acquired atypical pneumonia from Mycoplasma pneumoniae, complicated by rhabdomyolysis, and also had subacute Histoplasma pneumonia. Physicians often search for Occam’s Razor. However, following Hickam’s dictum, we made the unusual diagnosis of concomitant lung infection in an immunocompetent host with Mycoplasma pneumoniae and Histoplasma capsulatum

Conclusion: This was an immunocompetent patient who ran a complex, protracted, and unusual course of community acquired pneumonia. Often, the pursuit of additional or alternative diagnoses may require repeated and multiple invasive diagnostic sampling. Occam’s razor may not always hold true.

Introduction

Occam's razor proposes that the simplest explanation is usually the correct one. However, in the science of medicine, simple solutions may be elusive. Often there is an incredibly complex constellation of symptoms co-occurring with one another, thereby confounding the scientific community. We described the diagnostic conundrums in managing our patient who ran a complex protracted course of community acquired pneumonia.

Case

A 22-year-old Caucasian male college student with no significant past medical history, initially presented to the University hospital in New Mexico, United States, with 4 days’ history of fever, dry cough, and dyspnea. He had recently returned from a family vacation in Illinois and had spent several weeks fishing on the Mississippi river. Review of systems was negative for chest pain, headache, fever, chills, or night sweats. He denied any sick contacts. He did not smoke and did not use recreational drugs. His grandfather, who had been a heavy cigar smoker, had died of lung cancer.

His vital signs were significant for a body temperature of 100.6° Fahrenheit, respiratory rate of 32 breaths per minute, pulse rate of 94 bpm, blood pressure of 130/82 millimeters of mercury, and pulse oximetry of 90 percent on room air. Physical examination demonstrated that he was in mild respiratory distress. Chest auscultation revealed decreased breath sounds over the right mid to lower lung field. The rest of his physical examination was otherwise unremarkable. 

His laboratory tests revealed a normal complete blood count with a hematocrit of 40.5%, white blood cell count of 8,200 cells per microliter, and platelet count of 263,000 per microliter.  His electrolyte levels showed a serum sodium of 136 mEq per liter, potassium of 3.4 mEq per liter, chloride of 100 mEq per liter, bicarbonate of 21 mEq per liter, blood urea nitrogen of 15 mg/dL and creatinine of 0.9 mg/dL. His blood glucose was normal at 98 mg/dL. His urine analysis revealed 3+ blood without red blood cells. His liver function tests demonstrated an elevated aspartate aminotransferase at 244 units per liter, elevated alanine aminotransferase at 72 units per liter, with normal total bilirubin, albumin, and alkaline phosphatase levels. His serum creatinine kinase (CK) was highly elevated at 26,000 units per liter (normal reference range 39-308 units per liter). His arterial blood gas at rest on room air at an elevation of 5500 feet above sea level showed acute respiratory alkalosis with a normal alveolar arterial gradient with a pH of 7.57, PaCO2 of 28 mmHg, PaO2 of 77 mmHg, and bicarbonate of 22 mEq per liter.  His mycoplasma IgM antibody titer was significantly elevated (> 1:320) using the rapid diagnosis enzyme-immunoassay (EIA) test. Anti-mycoplasma pneumoniae IgA was also elevated. The urinary legionella and pneumococcal antigen levels, sputum culture, blood cultures, and urine toxicology screen were negative. Chest radiograph revealed a right middle and lower lobe pneumonia (Figure 1). 

Figure 1. CXR revealed right mid and lower lobe pneumonia.

The patient was diagnosed with sepsis secondary to Mycoplasma pneumoniae infection of the lungs, with the added complication of rhabdomyolysis. He was treated with intravenous followed by oral azithromycin 500 mg daily for 5 days and given intense hydration therapy. Within 48 hours, his low-grade fever subsided, CK decreased to 1000 units per liter, and the patient felt better. He was then discharged on Day 3 of hospitalization.

The patient however returned to the emergency department 2 weeks after discharge with persistent cough, chest discomfort, and loss of wellbeing. Repeat chest radiograph revealed a persistent right lower lobe infiltrate. Computed tomography (CT) scan of the chest revealed a right lower lobe consolidation with surrounding nodular opacities with a possible endobronchial lesion in the right lower lobe (Figure 2).

Figure 2. Panel A: Coronal view of thoracic CT scan showing right lateral basilar segment consolidation. Panel B: Axial view showing consolidation in the right lower lobe with surrounding nodular opacities.

He underwent bronchoscopy which revealed a mass-like endobronchial lesion in the lateral basilar segmental bronchus of the right lower lobe (Figure 3).

Figure 3. Bronchoscopy revealing a mass-like endobronchial lesion in a lateral segmental bronchus of the right lower lobe.

Endobronchial biopsy revealed necrotizing granulomatous inflammation and stained positive for the yeast form of Histoplasma capsulatum.  Serum complement fixation antibody test for Histoplasma demonstrated an elevated titer of 1:64. Acid fast bacilli were not seen on smear or culture and cytology and histopathology tests did not reveal malignancy.

The patient was diagnosed with an atypical pneumonia due to sub-acute Histoplasma capsulatum and acute Mycoplasma Pneumoniae infections, complicated by rhabdomyolysis. The mycoplasma infection and rhabdomyolysis had already been treated and resolved. For the subacute pulmonary histoplasmosis, the patient was treated with 10 weeks of oral itraconazole. Post treatment clinic follow-up revealed resolution of symptoms and radiological abnormalities.

Discussion

Mycoplasma pneumoniae is a common causative pathogen for community-acquired pneumonia in both children and adults (1).  Apart from respiratory tract symptoms, it is associated with a variety of extra-pulmonary manifestations (2). Recognizing this association can lead to timely diagnosis and treatment of both the mycoplasma infection and its complications. In this case report, we also want to highlight the fact that infection with endemic mycoses can often be mistaken for community acquired pneumonias, and thus having a high index of suspicion for fungal infection is very important, even in immunocompetent patients (3), to prevent a delay in treatment. Physicians often search for Occam’s Razor, i.e., to have a single diagnosis explain all clinical manifestations in an individual patient. This case is significant because of a dual clinical diagnosis, thus proving that Occam’s razor may not always hold true in an individual patient.

Mycoplasma infection can cause several unusual extra-pulmonary manifestations such as hemolytic anemia, immune thrombocytopenic purpura, transverse myelitis, Guillain-Barre syndrome, acute hepatitis and arthritis (4). Another lesser known complication of mycoplasma infection is rhabdomyolysis (5). Rhabdomyolysis is a syndrome caused by injury to the skeletal muscles, thereby resulting in leakage of myoglobin into blood (6). The classic triad of mycoplasma infection consists of myalgias, pigmenturia, and generalized muscle weakness, but this classic triad is seen in less than 10 percent of infected patients (7). Acute renal failure due to acute tubular necrosis as a result of mechanical obstruction by myoglobin is the most common complication, in particular if the serum CK level is >16,000 IU/l, which may be as high as 100,000 IU/l (8). In addition to mycoplasma infection, more common causes of rhabdomyolysis are trauma, immobilization, and recreational drug and alcohol use (9). 

Other organisms known to cause rhabdomyolysis are Influenza A and B virus, Coxsackie virus, Epstein-Barr virus, Primary Human Immunodeficiency virus, Legionella species, Staphylococcus aureus, and Streptococcus pyogenes (9). With respect to Mycoplasma pneumoniae infection, a possible mechanism for rhabdomyolysis is the induction of inflammatory cytokines, such as tumor necrosis factor-alfa (TNF-α) and interleukin-1 (IL-1), which may cause proteolysis of skeletal muscles (10). 

The rapid and reliable diagnosis of Mycoplasma pneumoniae (Mp) enables the correct and prompt use of antibiotics. Methods for identifying Mp infection include culture, molecular detection of pathogen specific antigen or nucleic acid, and serological analysis (11). Each of these methods has its pros and cons. Culture is the definitive method for diagnosis and is critical for monitoring trends in epidemiology but is slow and requires specialized media and trained personnel (11). Although molecular methods for nucleic acid or antigen detection have emerged as the primary techniques for identification of MP pneumoniae in surveillance programs, adoption of these methods is still lagging behind in USA.

Serologic analysis can prove to be problematic due to poor sensitivity and specificity, and the inability to characterize the specific Mp strain. Having said that, most physicians in the United States continue to rely on serological testing in concordance with the IDSA guidelines (11). It is well known that a single serologic test is of limited value in the early diagnosis of mycoplasma pneumoniae since there are often no IgM antibodies in the early stage of infection, and these IgM antibodies may persist long after the infection (12). However, if these IgM antibodies are present along with anti-Mycoplasma pneumoniae IgA, it is usually indicative of recent primary mycoplasma pneumoniae infection (13). A single high Mp-specific antibody titer (> 1:320) has been regarded as a diagnostic marker of mycoplasma pneumoniae, although it is present in only about 30 percent of the patients (12). Since our hospital relies on serological testing, we tested for the specific Mycoplasma pneumoniae IgM and IgA, both of which were positive. The MP-specific antibody titer was also greater than 1:320, thus signifying it indeed was early MP infection.

Symptoms of Mp infection generally resolve within 3–4 weeks after disease onset but can be shortened with antibiotic therapy; macrolides and doxycycline are the mainstay of this treatment (14). The mainstay for the prevention of pigment-induced acute kidney injury is the correction of volume depletion, prevention of intratubular cast formation, and the treatment of the underlying cause of rhabdomyolysis (4). This is done by aggressive fluid resuscitation resulting in increased renal blood flow and thus increasing the urinary flow with consequential wash out of partially obstructing tubular casts (4). Physicians will be served well to watch out for mycoplasma associated rhabdomyolysis in patients with atypical pneumonia and manifestations like myalgia, elevated aminotransferase levels, and myoglobinuria. 

Moving on to the second teaching point, endemic mycoses like coccidioidomycosis, histoplasmosis, and blastomycosis are often overlooked causes for community acquired pneumonia, particularly when immunocompetent patients travel out of the endemic zones (15). Often, testing is not even performed until the patient has failed to improve on antibacterial therapy. Delays in recognition, diagnosis and proper treatment may lead to disastrous outcomes (3). Performance of fungal antigen testing on bronchial washings or lavage fluid may improve the sensitivity for diagnosis over microscopic examination and the speed of diagnosis over culture even though isolation of the fungus by culture remains the gold standard method for definitive diagnosis (16). In this case, our patient was previously treated as mycoplasma pneumonia, thus leading to prolonged symptom course from histoplasmosis.

This case is unusual because the patient had an acute community-acquired atypical pneumonia from Mycoplasma pneumoniae, complicated by rhabdomyolysis, and also had subacute Histoplasma pneumonia. Physicians often search for Occam’s Razor, a principle from philosophy that when presented with competing hypothetical answers to a problem, one should select the one that makes the fewest assumptions.  Countering

Occam’s Razor, Dr. John Hickam said “Patients can have as many diseases as they damn well please!” (17). Following Hickam’s dictum, we made the unusual diagnosis of concomitant lung infection in an immunocompetent host with Mycoplasma pneumoniae and Histoplasma capsulatum.

Conclusion

With this case report, the authors wish to highlight two important teaching points. The first being that rhabdomyolysis is a serious but treatable extrapulmonary complication of Mycoplasma pneumoniae infection of the lungs. Having a high index of suspicion can limit treatment delay for rhabdomyolysis caused by mycoplasma infection and will therefore limit consequential morbidity like renal insufficiency. The second point that the authors wish to emphasize is that endemic fungal infection can often be mistaken for bacterial and viral community-acquired pneumonia in an immunocompetent host, particularly when they present with symptoms outside the endemic zone, thus delaying timely management. Hence one should have a high suspicion for fungal infection in immunocompetent hosts with unusual presentations such as history of travel to endemic zone, chronicity of symptoms, lack of response to therapy for community-acquired pneumonia, nodular lung lesions, and endobronchial abnormalities.

References

  1. Hardy RD, Jafri HS, Olsen K, Hatfield J, Iglehart J, Rogers BB, Patel P, et al. Mycoplasma pneumoniae induces chronic respiratory infection, airway hyperreactivity, and pulmonary inflammation: a murine model of infection-associated chronic reactive airway disease. Infect Immun. 2002 Feb;70(2):649-54. [CrossRef] [PubMed]
  2. Kawai Y, Miyashita N, Kato T, Okimoto N, Narita M. Extra-pulmonary manifestations associated with Mycoplasma pneumoniae pneumonia in adults. Eur J Intern Med. 2016 Apr;29:e9-e10. [CrossRef] [PubMed]
  3. Hage CA, Knox KS, Wheat LJ. Endemic mycoses: overlooked causes of community acquired pneumonia. Respir Med. 2012 Jun;106(6):769-76. [CrossRef] [PubMed]
  4. Gosselt A, Olijhoek J, Wierema T. Severe asymptomatic rhabdomyolysis complicating a mycoplasma pneumonia. BMJ Case Rep. 2017 Jul 26;2017. pii: bcr-2016-217752. [CrossRef] [PubMed]
  5. Khan FY, Sayed H. Rhabdomyolysis associated with Mycoplasma pneumoniae pneumonia. Hong Kong Med J. 2012 Jun;18(3):247-9. [PubMed]
  6. Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013 Sep;144(3):1058-65. [CrossRef] [PubMed]
  7. Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de Visser M. Rhabdomyolysis: review of the literature. Neuromuscul Disord. 2014 Aug;24(8):651-9. [CrossRef] [PubMed]
  8. Allison SJ. Acute kidney injury: Macrophage extracellular traps in rhabdomyolysis-induced AKI. Nat Rev Nephrol. 2018 Mar;14(3):141. [CrossRef] [PubMed]
  9. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009 Jul 2;361(1):62-72. [CrossRef] [PubMed]
  10. Giannoglou GD, Chatzizisis YS, Misirli G. The syndrome of rhabdomyolysis: Pathophysiology and diagnosis. Eur J Intern Med. 2007 Mar;18(2):90-100. [CrossRef] [PubMed]
  11. Diaz MH, Winchell JM. The evolution of advanced molecular diagnostics for the detection and characterization of Mycoplasma pneumoniae. Front Microbiol. 2016 Mar 8;7:232. [CrossRef] [PubMed]
  12. Lee SC, Youn YS, Rhim JW, Kang JH, Lee KY. Early serologic diagnosis of Mycoplasma pneumoniae pneumonia: An observational study on changes in titers of specific-igm antibodies and cold agglutinins. Medicine. 2016 May;95(19):e3605. [CrossRef] [PubMed]
  13. Lee WJ, Huang EY, Tsai CM, Kuo KC, Huang YC, Hsieh KS, et al. Role of serum Mycoplasma pneumoniae IgA, IgM, and IgG in the diagnosis of mycoplasma pneumoniae-related pneumonia in school-age children and adolescents. Clin Vaccine Immunol. 2017 Jan 5;24(1). pii: e00471-16. [CrossRef] [PubMed]
  14. Novacco M, Sugiarto S, Willi B, Baumann J, Spiri AM, Oestmann A, Riond B, et al. Consecutive antibiotic treatment with doxycycline and marbofloxacin clears bacteremia in Mycoplasma haemofelis-infected cats. Vet Microbiol. 2018 Apr;217:112-120. [CrossRef] [PubMed]
  15. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, Stoffer T, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Send to Emerg Infect Dis. 2006 Jun;12(6):958-62. [CrossRef] [PubMed]
  16. Wheat LJ. Approach to the diagnosis of the endemic mycoses. Clin Chest Med. 2009 Jun;30(2):379-89. [CrossRef] [PubMed]
  17. Gupta N, Aragaki A, Wikenheiser-Brokamp KA, Benzaquen S, Panos RJ. Occam's razor or Hickam's dictum? J Bronchology Interv Pulmonol. 2012 Jul;19(3):216-9. [CrossRef] [PubMed]

Cite as: Sen P, Majumdar U, Rendon P, Saeed AI, Sood A. Sharpening Occam's razor-a diagnostic dilemma. Southwest J Pulm Crit Care. 2018;16(6):324-31. doi: https://doi.org/10.13175/swjpcc061-18 PDF 

Friday
Jun012018

June 2018 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

 

History of Present Illness

The patient is a 53-year-old man who presented in January 2018 for a second opinion on interstitial lung disease first diagnosed in 2011. He lives in Los Angeles and had one year of increasing dyspnea on exertion prior to diagnosis. He had an outside surgical lung biopsy and was treated with prednisone, then started on azathioprine and the prednisone tapered. He was followed regularly and had limited progression over next 7 years.  However, recently he had increasing shortness of breath.

Past Medical History, Social History, Family History

He has no significant past medical history. He is a nonsmoker and denies any significant occupational exposures.

Physical Examination

Physical examination was unremarkable without rales or clubbing.

Which of the following should be obtained at this time? (Click on the correct answer to proceed to the second of five pages)

  1. Prior chest x-rays, CT scans, pulmonary function testing and lung biopsy
  2. Repeat CT scan, pulmonary function testing
  3. Rheumatological serologies
  4. 1 and 3
  5. All of the above

Cite as: Wesselius LJ. June 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(6):296-303. doi: https://doi.org/10.13175/swjpcc063-18 PDF 

Tuesday
May012018

May 2018 Pulmonary Case of the Month

Kenneth K. Sakata, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

 

History of Present Illness

A 70-year-old man was referred because of new anemia and a heme-positive stool. Esophagogastroduodenoscopy (EGD) was performed which revealed gastritis. Ascites developed and a chest x-ray noted a left pleural effusion. He was managed with weekly high-volume thoracentesis and paracentesis. He was referred to pulmonary medicine.

Past Medical History, Social History and Family History

He has a history of coronary artery disease having undergone coronary bypass grafting in 2016. He also has type 2 diabetes mellitus managed by diet and recently diagnosed orthostasis. He smokes about ½ pack of cigarettes per day but does not drink alcohol. He denies any inhalational exposures. He is Native American and works as a judge. There is no family history of any similar disorders.

Physical Examination

  • No acute distress
  • Slight bruise to left eye
  • No lymphadenopathy
  • Decreased breath sounds on left
  • Protuberant distended abdomen
  • Significant left leg edema
  • Discoloration of a few nails

A point of contact ultrasound is performed (Figure 1).

Figure 1. Image from the point of contact ultrasound.

What should be done next? (Click on the correct answer to proceed to the second of seven pages)

  1. Needle biopsy of pleural mass
  2. Thoracentesis
  3. Thoracic surgery consultation for video-assisted thorascopic surgery (VATS)
  4. 1 and 3
  5. All of the above

Cite as: Sakata KK. May 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(5):237-44. doi: https://doi.org/10.13175/swjpcc059-18 PDF 

Monday
Apr302018

Tobacco Company Campaign Contributions and Congressional Support of Tobacco Legislation

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

 

Abstract

Although it is widely held that campaign contributions influence Congressional support for legislation, the impact of these contributions is unclear. Three bills involving tobacco regulation were introduced into the 2017-8 Congress and were co-sponsored in both the House of Representatives and Senate. One was pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act). The association between tobacco political action committee (PAC) campaign contributions with sponsorship of these bills was examined. Tobacco PAC contributions to sponsors of pro-tobacco HR564/S294 were significantly larger [$18218, 95% confidence interval (CI) $15077-$21359, p<0.01] than to non-sponsors ($8730, 95% CI, $6959-$10501). Sponsors of the anti-tobacco HR4273/S2100 received significantly smaller contributions ($2114, 95% CI $0-$4833, p<0.01) than non-sponsors ($12048, 95% CI, $10289-$13707). Similarly, sponsors of the anti-tobacco HR2878/S1341 also received significantly smaller contributions ($2500, 95% CI $0-$5284, p<0.01) than non-sponsors ($12097, 95% CI $10429-$13765). These data demonstrate a significant correlation between campaign contributions and legislative support of pro- and anti-tobacco legislation.

Introduction

Previously, it has been shown tobacco contributions influence state legislators in terms of tobacco control policy-making and support by Southwest US Members of Congress of The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441, aka the "Cigar Bill") (1,2). Although it is widely held that campaign contributions influence elected legislators, Powell (3) notes "political scientists have had great difficulty determining whether and how much influence contributions have on the legislative process". Studies have been inconsistent, with some demonstrating a linkage between campaign contributions and influence while others do not, suggesting that there are other influences in addition to contributions. Powell (3) has pointed out that the influence of donations is likely to occur early in the legislative process, such as during sponsorship for legislation or by directing that funds should be spent on a specific project (earmarks).

During the current 115th Congress, the pro-tobacco “The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” was reintroduced (HR564/S294) (4). In addition, two anti-tobacco bills were introduced (HR4273/S2100 and HR2878/S1341) (4). Tobacco PAC contributions were examined for their association with sponsorship of these bills.

Methods

Tobacco Bills

The website Congress.Gov (4) was searched with the key word tobacco. Three bills were identified that had reached sufficient maturity to be introduced into the House of Representatives and the Senate and had co-sponsors listed in both the House and Senate. One was the pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act) (Table 1).

Table 1. Tobacco related legislation introduced during the 115th session of Congress.

Sponsors and cosponsors were identified as listed on Congress.Gov.

Campaign Contributions

Tobacco company political action committee (PAC) contributions to members of Congress were obtained from the Campaign for Tobacco-Free Kids website (5). Contributions from the years listed (2006-18) were summed and no effort was made to separate recent from more past contributions.

Statistics

The relationship between sponsorship of the tobacco-related bills and tobacco PAC campaign contributions was done by Fisher's exact test using a 2X2 contingency table. Amounts of campaign contributions were expressed as means with 95% confidence intervals. The Mann-Whitney U test was used to calculate comparisons of the amounts of campaign contributions.

Results

Tobacco PAC Contributions

Sixty-five percent of the members of Congress have received a tobacco PAC contribution since 2006 (Appendix 1). The average reported was $11,637. Ten members received over $80,000, of which the largest was to Sen. Richard Burr (R-NC)($124,022); all but three were from what is referred to as the deep South. Over $6 million was donated in total; 82% of the donations went to Republicans.

Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (HR564/S294)

Ninety-four percent of the members of Congress who cosponsored the pro-tobacco "Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (aka Cigar Bill)" had received tobacco PAC campaign contributions (Appendix 2). In contrast, 53% of who were not cosponsors had received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was larger for those who had cosponsored the bill larger ($18218, 95% CI $15077-$21359) than non-sponsors ($8730, 95% CI, $6959-$10501, p<0.01 by Mann-Whitney U test).

Tobacco to 21 Act (HR4273/S2100)

Eighty-two percent of the members of Congress who cosponsored the anti-tobacco " Tobacco to 21 Act" had not received tobacco PAC campaign contributions (Appendix 3). In contrast, 35% of who were not cosponsors had not received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2114, 95% CI $0-$4833) than non-sponsors ($12048, 95% CI, $10289-$13707, p<0.01 by Mann-Whitney U test).

Children Don't Belong on Tobacco Farms Act (HR2878/S1341) 

Data were similar with the anti-tobacco “Children Don't Belong on Tobacco Farms Act”. Seventy-eight percent of the members of Congress who sponsored the bill had not received tobacco PAC campaign contributions (Appendix 4). Thirty-five percent of the members of Congress who had not cosponsored the bill did not receive contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2500, 95% CI $0-$5284) than non-sponsors ($12097, 95% CI $10429-$13765), p<0.01 by Mann-Whitney U test).

Discussion

This manuscript shows an association between tobacco PAC campaign contributions and sponsorship of both pro- and anti-tobacco legislation. More members of Congress who supported the pro-tobacco “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017” had received tobacco PAC campaign contributions and the contributions were larger compared to those not sponsoring the legislation. The data was the opposite for the anti-tobacco “Tobacco to 21 Act” and “Children Don't Belong on Tobacco Farms Act”. The percentage of the members of Congress who had not received tobacco PAC contributions was higher for those who sponsored the legislation compared to those who did not. Taken together these data suggest an influence of campaign contributions on the sponsoring of tobacco legislation in the US Congress.

The data in this manuscript confirms and extends the previous observations that tobacco contributions to state legislators and Southwest Members of Congress influence support of tobacco legislation (1,2).  The Southwest US is not a major tobacco growing or manufacturing region (7). Furthermore, tobacco consumption tends to be low in Southwest US (7). The Southwest is a good area to study the influence of campaign contributions because of the lack of confounding influences from a constituency that makes a living by tobacco growing or manufacturing or has a high prevalence of smokers. Reexamination of the correlation between tobacco PAC contributions and Congressional sponsorship of the "Cigar Bill" shows similar results with the data in 2016 (1, Appendix 1). The present study shows that association occurred in Congress as a whole and extended to anti-smoking legislation.

The title of HR564/S294 is deceiving. The “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” is titled to conjure up images of small businesses hand-rolling premium cigars. However, many of the cigars affected by the legislation are not the large, thick, and expensive ones manufactured with fine tobacco but rather small, thin, cheap cigars that are often flavored (8).

There is no doubt that smoking tobacco is harmful including cigars where the risk can be as high as or exceed those of cigarette smoking (9). Cigarette consumption in the United States is decreasing, compelling US tobacco companies to search for new markets (10). The cigar market, especially the flavored cigar market, represents one strategy to increase tobacco consumption and profits. Flavored cigar use is increasing in US middle and high school students (11). Therefore, tobacco companies support of the "Cigar Bill" is not surprising. By removing regulation, the tobacco companies can increase advertising to children and grow the candy-flavored cigar market (8).

The amount of money donated by the tobacco PACs is quite large and would seem to exceed anything that anti-tobacco smoking organizations could muster. Sixty-five percent of the members of Congress have received contributions totaling over 6 million dollars since 2006. The influence of these contributions may make regulation of tobacco quite difficult.

This manuscript has several limitations. Receiving tobacco PAC contributions and sponsoring pro-tobacco legislation does not necessarily represent cause and effect. It seems likely that tobacco companies would be more likely to support legislators that they perceive as sympathetic. It also seems likely that the tobacco PACs would be less likely to donate to supporters of anti-tobacco legislation.

References

  1. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legislative behavior? Am J Public Health. 1998 Jun;88(6):918-23. [CrossRef] [PubMed]
  2. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
  3. Powell LW. The influence of campaign contributions on legislative policy. The Forum: A Journal of Applied Research in Contemporary Politics 2013;11(3):339-55. [CrossRef]
  4. Congress.gov. Available at: https://www.congress.gov/ (accessed 3/26/18).
  5. Campaign for Tobacco-Free Kids. Tobacco company political action committee (PAC) contributions to Federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions  (accessed 3/26/18).
  6. Statistica. Statistics and facts about the tobacco industry. Available at: http://www.statista.com/topics/1593/tobacco/ (accessed 3/26/18).
  7. Campaign for tobacco-free kids. Key state-specific tobacco-related data & rankings. Available at: https://www.tobaccofreekids.org/assets/factsheets/0176.pdf (accessed 3/26/18).
  8. American Thoracic Society. ATS Joins Letter Opposing Cigar Exemption. October, 2017. Available at: https://news.thoracic.org/washington-letter/2017/ats-joins-letter-opposing-cigar-exemption.php (accessed 3/26/18).
  9. Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015 Apr 24;15:390. [CrossRef] [PubMed]
  10. Centers for Disease Control. Current Cigarette Smoking Among Adults in the United States. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm (accessed 3/26/18).
  11. King BA, Tynan MA, Dube SR, Arrazola R. Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. J Adolesc Health. 2014 Jan;54(1):40-6. [CrossRef] [PubMed]

Cite as: Robbins RA. Tobacco company campaign contributions and congressional support of tobacco legislation. Southwest J Pulm Crit Care. 2018;16(4):232-6. doi: https://doi.org/10.13175/swjpcc053-18 PDF 

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