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Clinical cases

Non-invasive ventilation for the treatment of acute respiratory failure following ovarian hyperstimulation syndrome: report of two cases and a brief review of the literature

The ovarian hyperstimulation syndrome (OHSS) is a serious but rarely fatal complication of medical interventions that seek to induce fertility; it is typically encountered in women who undergo controlled ovarian hyperstimulation, but there are very rare patients who have genetic defects who present with OHSS. In recent years, its pathogenesis has been elucidated; this knowledge will decrease the frequency of this syndrome.
Clinical signs may include any or all of the following: rapid weight gain, ascites, oliguria, hemoconcentration, leukocytosis, along with intravascular hypovolemia, hyponatremia, and hyperkalemia. If the patient is not diagnosed early, ascites, pleural and more rarely pericardial effusions, severe respiratory failure and ARDS, hypercoagulability with tromboembolism and multiple organ system failure can occur. Due to the increased use of therapeutic strategies for infertility (particularly those using human chorionic gonadotropin), the systemic, particularly the pulmonary, complications of this syndrome must be identified early to allow appropriate diagnosis and management.
We describe two cases of women with extremely severe OHSS presenting bilateral pleural effusions, and severe respiratory failure (paO2/FiO2 < 200) treated with non-invasive ventilation (NIV). The severe form of OHSS varies between 0.5% and 5% , depending on the population studied: intensive care may be required for management of tromboembolic complications, renal failure and severe respiratory failure. The diagnosis of severe OHSS was made, largely based on bedside ultrasonography showing increased ovarian size, mild ascites and bilateral pleural effusions. Owing to severe respiratory failure the patients were admitted to Respiratory Intermediate Care. Pulmonary intensive care may involve thoracentesis, oxygen supplementation and in more severe cases assisted ventilation.
There are only a few studies in English that describe severe respiratory failure treated with non-invasive ventilation, but all of them have had good outcomes.
Keywords: ovarian hyperstimulation syndrome, severe respiratory failure, non-invasive ventilation

Interstitial lung disease as first clinical manifestation within the antisynthetase syndrome dermatomyositis

Diffuse interstitial pneumopathies within the diseases of the connective tissue are often a diagnosis challenge, sometimes being the initial or dominant manifestation of the underlying autoimmune disease.
The case of a young man shall be presented with relatively quick dyspnoea which has appeared under the conditions of an efficient physical status and without any notable pathological history. The cause of the dyspnoea is found to be a interstitial lung disease with radiological and histopathological pattern of non-specific interstitial pneumonia. The disease screening system discovers Ac anti Ro-52 which commits research in the direction of an autoimmune disease, confirmed by highlighting Ac anti PL-7 as being an antisynthetase syndrome. Subgroup of idiopathic inflammatory myopathies, the antisynthetase syndrome is a rare chronic autoimmune disease, which is characterised by the presence of antibodies directed against aminoacyl-t-RNA-synthetases (family of intracytoplasmic enzymes with a vital role in the protein synthesis).
Shortly after specifying the relevant immunological status, the consistent clinical expression with dermatomyositis is also configured. The treatment is commenced with systemic corticoid and azathioprine; despite the treatment we are witnessing a slowly progressive clinical and functional deterioration.
Keywords: interstitial lung disease, antisynthetase syndrome

Synchronous primary lung cancer and controlateral pulmonary renal cell carcinoma metastases

Synchronous malignant lesions will always entail treatment related difficulties which would ideally require discussions within a multidisciplinary committee in such a way as to reach the optimal solution for the patient. Presented herewith are two patients suffering from lung cancer and clear cell renal carcinoma contralateral metastases and the treatment alternatives that I have opted for.
Keywords: pulmonary metastasectomy, renal cell carcinoma, synchronous lung tumors

Pulmonary hypoplasia with associated cardiac and skeletal malformations

Patients with mild pulmonary hypoplasia typically use to have minimal respiratory symptoms. Nonetheless, other associated anomalies such as cardiac, gastrointestinal, genitourinary, or skeletal defects may be seen. We report the case of a 17-year-old male patient with hypoplastic right lung with secondary cardiac dextroposition, an ostium secundum atrial septal defect, a hypoplastic right pulmonary artery arising from the posterior wall of the left pulmonary artery with a retrocava course, vertebral bone fusion and pollicization due to right congenital thumb absence.
Keywords: Congenital pulmonary venolobar syndrome; atrial septal defect; skeletal; congenital thumb absence.