PJ, Sharma S. Iatrogenic tension pneumothorax com¬
plicating outpatient Heimlich valve chest drainage. J Emerg
4 Mariani
Med 1994; 12:477-79
Pseudomesotheliomatous
Adenocarcinoma of the Lung in
a Patient With HIV Infection
Stephanie R. Schreiner, MD; Beth D. Kirkpatrick, MD; and
Frederic B. Askin, MD
Figure 1. The Heimlich valve showing how the flutter valve had
become folded following the insertion of a drinking straw.
The patient's condition deteriorated over the next days, and he
died in respiratory failure on day 15 of hospitalization.
Discussion
This report demonstrates a further case of inadvertent
closure of a Heimlich flutter valve system with consequent
tension
pneumothorax.
Heimlich flutter valves possess a number of advantages
the conventional underwater seal drainage systems,
including greater patient mobility. They also may facilitate
outpatient management of certain selected patients with
persistent air leaks as are encountered with increasing
frequency in association with lung volume reduction
surgery.
Relative contraindications to the Heimlich valve use
include the drainage of large volumes of fluid or viscous
secretions which may cause dysfunction of the flutter
valve.
Disordered mental status, including confusion and ag¬
gressive behavior, is a contraindication for any elective
tube drainage. However, a Heimlich flutter valve could be
considered a better option than underwater seal drainage
in the emergency use of intercostal drains for pneumotho¬
rax in aggressive or confused patients.
over
Conclusion
This case raises certain concerns regarding the current
design of the flutter valve device. First, there is a predis¬
position to inadvertent reversal. Second, such as in this
rare instance, there is a susceptibility to patient tampering.
Modification of the valve, perhaps by inserting a coarse
grid at the exit aperture, would prevent the introduction of
foreign bodies such as drinking straws.
References
1 Heimlich
drainage of the pleural cavity. Dis Chest
Mainini SE, Johnson FE. Tension pneumothorax complicating
small-caliber chest tube insertion. Chest 1990; 97:759-60
Spouge AR, Thomas HA. Tension pneumothorax after reversal
of a Heimlich valve. AJR Am J Roentgenol 1992; 158:763-64
HJ. Valve
1968; 53:282-87
2
3
Clinical and pathologic findings are presented of the
first reported case in the English-language medical
literature of pseudomesotheliomatous adenocarci¬
noma (PMA) occurring in an HIV-infected patient.
PMA is an uncommon variant of peripheral lung
cancer which typically occurs in elderly male pa¬
tients. It mimics a malignant mesothelioma in terms
of its clinical presentation and gross and microscopic
appearance. The occurrence of this rare tumor in a
young HIV-infected patient suggests some associa¬
tion between HIV infection and the development of
(CHEST 1998; 113:839-41)
adenocarcinoma of lung; human immunodeficiency
Key words:
mesothelioma
PMA.
virus;
Abbreviations:
PMA=pseudomesotheliomatous
adenocarci¬
noma
I^T^ eoplastic processes
and
can
demonstrate unusual clinical
presentations exceptionally aggressive behavior in
the setting of HIV infection. A case is reported of an
HIV-infected patient who presented with rapidly progres¬
-*¦
pulmonary symptoms and nodular pleural thickening.
tem examination revealed an uncommon variant of lung
adenocarcinoma classified as "pseudomesotheliomatous."1
This case is especially unusual because of the age of the
sive
He died before a diagnosis could be established. Postmor¬
patient and the aggressive
nature
of his clinical
course.
One similar case, also in a young HIV-infected patient, is
described in the German-language literature.2 Perhaps
there is some underlying association between HIV infec¬
tion and the development of unusually aggressive forms of
lung cancer such as pseudomesotheliomatous adenocarci¬
noma
(PMA).
Case Report
A 33-year-old heterosexual
man
with HIV infection and previ¬
ously diagnosed pulmonary hypertension presented with a 25pound weight loss, pleuritic pain, a dry cough, and progressive
shortness of breath. Four months prior to admission, his pulmo¬
nary hypertension had been diagnosed by Doppler ultrasound,
which demonstrated a right ventricular systolic pressure of 70
*From the Departments of Pathology (Drs. Schreiner and Askin)
and Infectious Diseases (Dr. Kirkpatrick), Johns Hopkins Hos¬
pital, Baltimore.
Manuscript received April 25, 1997; revision accepted July 28.
CHEST 7113/3/ MARCH, 1998
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839
Figure 1. Chest CT scan showing nodular pleural thickening
the right lung and extending into the fissures and
surrounding
bronchovascular bundles. A lytic lesion is noted within the
vertebral body (arrow).
septal flattening and dilatation of the right
ventricle.
right
During the 3 months prior to his
admission, the patient had also been undergoing outpatient
workup for a persistent right pleural effusion. A thoracentesis and
two pleural biopsies failed to reveal an infectious cause. Cytologic
examination of the pleural fluid showed normal-appearing lym¬
cells. The patient denied
phocytes and reactive mesothelial
exposure to tuberculosis or asbestos. He was a former intrave¬
nous drug user who had a history of heavy alcohol use and a 12
the patient's
pack-year smoking history. At the time of admission,
HIV infection had progressed to a CD4 count of 488 without any
opportunistic infections. His RNA viral load was 53,000 copies/mL blood.
Physical examination revealed tachypnea and tachycardia with a
heart rate of 105 beats per minute. He was hypoxemic with a Po2 of
mm
Hg as well
as
atrium and
Figure 3. PMA of the lung. A:
poorly differentiated tumor cells
loose, delicate stroma with focal papillary formations (hematoxylin-eosin, original X400). B: immunohistoehemical staining
with polyclonal carcino embryonic antigen is diffusely positive
X400). C: LeuMl shows focal nuclear positivity (original
(originalThe
results of these immunostains support the diagnosis
X400).
in
a
of adenocarcinoma rather than mesothelioma.
62 mm Hg while breathing room air. Decreased breath sounds and
dullness to percussion were noted over the right lung field. A soft S4
and loud P2 were also noted. A chest radiograph revealed enlarge¬
ment ofthe main pulmonary artery with a large right pleural effusion
and pleural thickening in a nodular pattern. On a chest CT scan, a
extending into the
large area ofnodular pleural thickening was found
fissures and bronchovascular bundles (Fig 1). There was right hilar
and bilateral axillary adenopathy. A 9-mm lytic lesion was also noted
within a thoracic vertebra.
Open-lung biopsy was planned but before it could be carried
This
the patient suffered respiratory arrest and died.
curred 3V2 months after his initial presentation.
out
lung. Gross photograph of the bivalved
tumor infiltrating the diaphragm (large arrow)
right
lung
showing
and interlobar fissures (small arrow). This pattern of diffuse
infiltration is commonly seen in malignant mesothelioma.
pleural
Several hilar lymph nodes also show gross involvement by tumor.
Figure 2. PMA of the
840
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oc¬
Results of Autopsy
there
was obliteration of die right thoracic
At autopsy,
a
nodular
soft, white tumor mass. The tumor
cavity by
all
involved
diffusely
pleural surfaces on the right side,
resulting in adherence of the right lung to the chest wall, the
and the pericardium. Sectioning through the
diaphragm, revealed
tumor infiltrating along the interlobar
right lung
fissures and parenchymal intralobar septa (Fig 2). Multiple
metastases were present in the liver, the vertebral column,
Selected
Reports
the adrenal glands, and numerous hilar, carinal, axillary,
paraaortic, and peripancreatic lymph nodes.
Microscopically, the neoplasm showed extensive lymareas of tumor
phangitic spread within both lungs. Viable and
solid nests
showed pseudoacini, papillary formations,
of poorly differentiated malignant cells in a loose, delicate
stroma (Fig 3, A). Based on routine stains and gross
examination, the distinction between an epithelial malig¬
nant mesothelioma and a poorly differentiated adenocar¬
cinoma could not be made. Specific histochemical stains
and immunohistologic markers were necessary to further
this tumor. The tumor showed focal intracytoplasclassify
mic mucicarmine positivity and Alcian blue staining which
was resistant to hyaluronidase predigestion. An immunostain for polyclonal carcinoembryonic antigen was strongly
positive, antibodies to LeuMl showed focal nuclear posi¬
tivity, and vimentin stains were negative (Fig 3, B and C).
These results strongly supported the diagnosis of adeno¬
carcinoma over that of mesothelioma.3 The subclassification of "pseudomesotheliomatous" adenocarcinoma was
based on the similarity of this neoplasm by clinical pre¬
sentation and gross and microscopic appearance to a
malignant mesothelioma.1
Discussion
PMA is an uncommon variant of peripheral lung cancer
first described by Harwood et al in 1976.1 The few
reported cases in the English-language literature of PMA
indicate that the lesion occurs predominantly in men in
the fifth and sixth decades of life.4 The majority of these
men had medical histories of heavy cigarette smoking, and
the presenting symptoms most often included chest pain,
dyspnea, and cough. Pleural effusion with or without
pleural masses was the most common radiographic find¬
ing. Similar to mesothelioma, prognosis is poor with an
overall survival of approximately 6 months. In terms of a
similar cause for mesothelioma and PMA, possible or
definitive asbestos exposure was found in 17% of the 30
PMA cases reviewed by Koss et al.4 The patient reported
herein had no known history of asbestos exposure, and on
microscopic examination of several sections of iron-stained
lung tissue, no ferruginous bodies were identified.
Lung carcinoma, in general, is uncommon in HIV-infected
persons.56 Reviews of the cases uhat have been reported,
however, suggest a specific clinical profile for diose patients in
whom lung cancer develops.6 They tend to be male, to be
young, and to have a history of intravenous drug use. Patients
also tend to be at an advanced clinical stage with widespread
metastases at the time of presentation. Adenocarcinomas are the
predominant subtype found in these patients.
As far as is known, there is only one reported case, in the
German-language literature, of PMA occurring in an HIVinfected patient.2 That patient, who similarly was in his early
30s, had late-stage HIV infection. His presenting symptoms
were dyspnea and a dry cough. A subsequent chest radio¬
gram showed a right-sided pleural effusion and broad pleural
deposits. His condition deteriorated rapidly and he died only
6 weeks after the reported onset of symptoms.
The occurrence of such a rare tumor in unusually young
patients, without other obvious risk factors, suggests that
there is an association between HIV infection and devel¬
PMA. Like other neoplasms occurring in
HIV-infected persons, the PMAs in these two cases
behaved very aggressively and resulted in shorter survival
times than previously reported for this tumor in non-HIVinfected persons. Continued case reporting is necessary to
determine (1) if there are other variables, such as smoking
or intravenous drug use, that might make an HIV-infected
individual more susceptible to developing such a tumor
and (2) what protocols would be optimal in the future for
treating this tumor in HIV-infected patients.
opment of
References
1 Harwood TR, Gracey DR, Yokoo Y. Pseudomesotheliomatous
carcinoma of the lung: a variant of peripheral lung cancer.
Am J Clin Pathol 1976; 65:159-67
2 Brunner-La Rocca HP, Schlossberg D, Vogt P. Pseudome¬
sotheliomatous carcinoma in a patient with HIV infection.
Dtsch Med Wochenschr 1995; 120:1312-17
PR, Legier J, Wright GL Jr. Immunohistochemical
evaluation of seven monoclonal antibodies for differentiation
of pleural mesothelioma from lung adenocarcinoma. Cancer
3 Wirth
1991; 67:655-62
M, Travis W, Moran C, et al. Pseudomesotheliomatous
adenocarcinoma: a reappraisal. Sernin Diagn Pathol 1992;
4 Koss
9:117-23
5 Fraire AE, Awe
RJ. Lung cancer in association with human
immunodeficiency virus infection. Cancer 1992; 70:432-36
6 Karp J, Profeta G, Marantz PR, et al. Lung cancer in patients
with immunodeficiency syndrome. Chest 1993; 103:410-13
Orbital Herniation Associated
With Noninvasive Positive
Pressure Ventilation*
Daniel Lazoivick, DO; Thomas J. Meyer, MD, FCCP;
Mark Pressman, PhD; and Donald Peterson, MD, FCCP
diagnosis of severe obstructive sleep apnea was
a 52-year-old hypertensive man devel¬
a
oped large intracraniai hemorrhage. Therapeutic
noninvasive positive pressure ventilation (NPPV) for
obstructive sleep apnea and hypoventilation was
complicated by transient unilateral orbital hernia¬
tion. As best as can be determined, this represents a
new, potentially deleterious side effect of NPPV.
A
made after
(CHEST 1998; 113:841-43)
Key words: CPAP; noninvasive ventilation; orbital herniation
Abbreviation: NPPV=noninvasive positive pressure ventilation
oninvasive positive pressure ventilation (NPPV) is the
Tyf
-L ^
of
mechanical ventilation to
the
delivery positive pressure
lungs without endotracheal intubation.
Intermittent
*From the Division of Pulmonary and Critical Care Medicine,
Department of Medicine, and Sleep Disorders Center, The
Lankenau Hospital and Medical Research Center (Drs. Lazowick, Meyer, Pressman, and Peterson), Wynnewood, Pa, and
Department of Medicine,
Jefferson Medical College (Drs.
and Peterson), Philadelphia.
Meyer, Pressman,
Manuscript received February 20, 1997; revision accepted Au¬
gust 28.
CHEST / 113 / 3 / MARCH, 1998
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841