BACKGROUND Nonunion of a rib fracture can cause chronic pain, and pharmacological pain management may lead to medication dependence. This report describes a 54-year-old man with a chronic cough and painful nonunion fracture of the left posterior 8th rib, managed with minimally invasive surgery and a rib splint. CASE REPORT A 54-year-old man presented with chronic cough-induced left chest wall pain. Three-dimensional chest computed tomography (CT) scan showed a nonunion of a fracture of the left posterior 8th rib. After medical management failure, we proposed a surgical approach with the aim to remove the tissue comprising the nonunion, release the nerve, and stabilize the bone stumps. To avoid the adverse effects of a large incision, we designed a minimally invasive strategy based on ultrasound fracture localization and the use of an intramedullary splint. The pain disappeared immediately after surgery. The patient was discharged in 24 hours. At 6-week follow-up, he was still asymptomatic, and a new CT scan reconfirmed the correct splint position. From the immediate postoperative evaluation until the last follow-up visit, he consistently reported full satisfaction. CONCLUSIONS This report has highlighted the challenges of management of chronic pain in nonunion of a rib fracture, and has described the use of a minimally invasive surgical approach. In this single case, our tailored surgical strategy achieved definitive success in pain management, minimizing postoperative complications/adverse effects and avoiding the addition of pain medications despite a 24-hour hospital stay. Our goal is to share an alternative solution for colleagues facing similar cases.

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This report describes a 42-year-old female patient who presented with an intensive nocturnal dry cough persisting for over six months. Subsequent to the prolonged cough, she developed shoulder and neck discomfort, leading her to seek chiropractic care. The patient received cervical chiropractic adjustments combined with the Koren Specific Technique (KST) emotions protocol. The patient was mainly treated for her musculoskeletal complaint. However, after two treatment sessions, the patient\'s chronic cough showed significant improvement. Two weeks later, the cough had completely ceased, and her shoulder and neck discomfort had also improved. The cough symptoms did not reappear during the six-month follow-up. The mechanism of cough improvement remains unclear, whether it is due to spinal adjustments, the KST emotions protocol, their combined effects, or merely a placebo response. This report discusses the potential underlying mechanisms of the case improvement, suggesting a non-pharmacological adjunctive therapeutic approach that could be investigated further in future research.

Vanishing lung syndrome (VLS) also known as type I bullae disease or idiopathic bullous disease is characterized by giant emphysematous bullae that commonly develop in the upper lobes, occupying at least one-third of a hemithorax. It is a progressive and irreversible condition that involves pulmonary parenchymal destruction and alveolar dilation. It is commonly associated with middle-aged tobacco smokers, habitual marijuana users, and those with alpha-1-antitrypsin deficiency. This case involves an incarcerated male in his 30s with chronic marijuana smoking who presented with a three-month history of right-sided chest pain accompanied by cough, hemoptysis, fever, and weight loss. The patient reported month-long atypical chest discomfort associated with a cough productive of bloody sputum and was brought to the ED after developing acutely worsening right-sided chest pain. The patient underwent a chest X-ray that revealed a large pneumothorax on the left. Subsequently, CT chest imaging showed extensive bilateral bullous disease, left upper lobe consolidation, and enlarged mediastinal lymph nodes. This case illustrates a rare presentation of VLS in the setting of a young patient who other than reported regular marijuana use had no other risk factors and a negative workup for possible etiologies that could cause his severe bullous emphysema, including alpha-1 antitrypsin, HIV, Sjogren\'s syndrome, pulmonary Langerhans cell histiocytosis, two sputum Mycobacterium tuberculosis tests, and acid-fast bacteria sputum cultures, which were all negative. Identifying and assessing the degree of disease early in this progressive disease helps guide treatment while preventing further deterioration of lung parenchyma.

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Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH), a rare disease previously overlooked, is gradually being recognized as an important precursor state to pulmonary neuroendocrine tumors. The very insidious onset of symptom presentation makes early diagnosis of DIPNECH almost impossible in clinical settings. In this report, we present a case of persistent and worsening cough for over five years with waxing and waning lung nodules of varying sizes which were eventually diagnosed as DIPNECH on biopsy. However, due to the location and the multiplicity of these nodules, surgical resection was not an option in this case. The diagnostic workup including imaging and biopsy, management options, and possible prognosis of DIPNECH are discussed in detail. This report highlights the growing recognition of DIPNECH as a clinical entity to be aware of during the formulation of a differential diagnosis for patients presenting with chronic unrelenting cough and associated lung nodules.

In this case report, we discuss the case of a 64-year-old woman who presented with an unusual complaint of a chronic cough associated with pleuritic chest pain of 15 years following a saline-filled breast implant surgery. Initially, these were minimally abated by acid reflux medications. However, her cough worsened despite other interventions. In the work-up to determine the etiology of her complaints, the most common causes of a chronic cough were considered. The history ruled out post-nasal drip, and pulmonary function tests excluded asthma and chronic obstructive pulmonary disease (COPD), although she had a family history. An IgE allergy panel and an Aspergillus antibody test were also normal. However, an esophagram revealed a significant finding of mild to moderate Gastroesophageal reflux disease (GERD). Ultimately, the subsequent removal of the implants led to a dramatic resolution of her symptoms. It is worth noting that breast implants, like any other medical device, carry certain risks. Complications such as infections, implant rupture, capsular contracture, and changes in breast sensations are known risks associated with breast augmentation surgery.

Cough is a frequent symptom accompanied by lung cancer. More potent antitussive treatment for this complex and distressing symptom is required, but anti-cancer chemotherapy cannot fully manage the cough. Inhibition of vagal nerves might control coughing in patients with troublesome lung cancer-related cough and P2X3 inhibitory therapy may be useful for targeting neuronal function. We report the case of a woman in her late 70s who never smoked and had advanced lung cancer. She visited our hospital complaining of serious deterioration of a non-productive cough. She was diagnosed with relapse of lung cancer, but she requested 2-week anti-tussive therapy before second-line chemotherapy. Gefapixant (P2X3 antagonist) add-on at a dose of 90 mg/day (45 mg twice daily as the usual dosage in Japan) improved her cough as indicated by an improvement in the visual analog scale for cough from 70 to 20 mm and in the Japanese version of the Leicester Cough Questionnaire from 8.2 to 16.3, despite a deterioration in lung cancer after 2 weeks. There are no current guidelines for cough accompanied by lung cancer; however, our findings suggest that P2X3 inhibition is a potent therapeutic option for lung cancer-related cough.

Pulmonary nodular lymphoid hyperplasia (PNLH) is a rare non-neoplastic disease that presents with mass lesions in the lung. It is radiologically difficult to differentiate it from adenocarcinoma of the lung or pulmonary lymphoma. There has been no consensus regarding the treatment of PNLH; however, in many case series, patients usually undergo surgical resection for diagnostic and therapeutic purposes. Here, we present the case of a 60-year-old Chinese male who presented with cough and hemoptysis. A computed tomography scan of the thorax revealed a mass-like lesion. A biopsy was performed which showed lymphocytic pneumonitis. He was treated with a tapering dose of corticosteroids with good clinical and radiological outcomes. Upon a subsequent review of the case, a diagnosis of PNLH was made. This case report suggests that corticosteroids may be an alternative therapy to surgical resection. They have the advantage of being non-invasive and can be used in patients who are otherwise not surgical candidates due to other comorbidities. However, further research is required before we can recommend corticosteroids as a treatment for PNLH.

BACKGROUND: Pertussis is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis, characterized by paroxysms of severe coughing, and predominantly affects children. We report the first case of multiple fractures in the ribs, lumbar spine, and sacrum associated with severe coughing caused by Bordetella pertussis infection in an adult.
METHODS: A 49-year-old female presented with acute-onset chest wall pain for 3 weeks. Imaging results revealed multiple fractures in the ribs and vertebrae, as well as bilateral pleural effusion, pericardial effusion, right pneumothorax, and enlargement of the left parapharyngeal and subclavian lymph nodes. The patient\'s bone density scan, autoimmune antibodies, bone marrow biopsy, and sacral bone biopsy all came back normal. Imaging test results found no evidence of solid tumors or active TB infection. The patient later recalled having violent coughing prior to the onset of chest pain and several family members having similar symptoms. Her blood sample was sent to the CDC, revealing Bordetella pertussis toxin (PT) IgG titer of 110.68 IU/mL. The patient was diagnosed with pertussis and multiple stress fractures from violent coughing. Symptomatic treatments were administered, and the patient\'s symptoms improved. The patient was followed up 8 weeks later, she reported no more coughing or chest pain.
CONCLUSIONS: Pertussis is not just a pediatric disease, but diagnosis in adults is challenging as patients may present with a myriad of confusing symptoms, such as multiple stress fractures due to violent coughing. Medical and epidemiological histories are key to reaching the correct diagnosis, which is essential for appropriate treatments to avoid further complications. Adult immunization should be suggested both for the protection of the adult population and to prevent transmission to children.