Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
How do you approach tapering high dose continuous infusions for status epilepticus in patients experiencing serious medication-related toxicity?
The short answer is as quickly as possible. How you do it will somewhat depend on the need for ongoing continuous infusion of a sedative for treatment of status epilepticus. Probably the most severe toxicity syndrome is Propofol-Related Infusion Syndrome (PRIS), which if not recognized early, can le...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
How do you manage a 3 cm solitary pulmonary cryptococcoma in an asymptomatic, immunocompetent, HIV-negative host?
I will treat it with oral Fluconazole for 6-12 months. Brain MRI to R/O CNS infection.
What policies do you take regarding legalized recreational marijuana or medical marijuana use in transplant patients?
The use of THC and CBD is becoming an increasingly important topic in solid organ transplantation. Recent survey data has demonstrated that daily cannabis use is higher than daily alcohol use in the U.S. (Caulkins, PMID 38775461).Certainly, the legalization of THC use in many states has led to consi...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...