Despite reports of pulmonary toxicity due to styrene, guidelines on acceptable styrene exposure levels have been based on risk of cancer and central nervous system and liver toxicity and not on respiratory effects. Many reports have linked exposure to styrene vapor in occupational settings to various forms of non-malignant pulmonary disorders including bronchiolitis, hypersensitivity pneumonitis, and occupational asthma. We report two cases in which the same tasks performed in a single workplace resulted in exposure to styrene vapor with subsequent development of acute respiratory symptoms associated with impaired gas exchange and imaging and histopathologic findings consistent with bronchiolitis and organizing pneumonia. Both patients gradually recovered once their workplace exposure to styrene was terminated. Clinicians, employers, and insurers should be aware of the potential for pulmonary toxicity from exposure to styrene.

INTRODUCTION: Papillary thyroid carcinoma (PTC) is a follicular type of thyroid cancer most of time has lymphatic invasion and rarely has hematologic spread. This is a rare case leading to diagnosis of PTC from a right sided pleural effusion. CASE PRESENTATION:A 78 year old man with no significant past medical history presented with chief complain of cough with whitish phlegm, shortness of breath for past 3 days associated with choking sensation on eating. He is a former smoker. He was afebrile with normal blood pressure, tachypnic and was requiring 2 liter of oxygen. On physical examination he had poor breath sounds on right side of lung with no wheezes, crackle or rhonchi. On laboratory examination complete blood cell count, basal metabolic panel and pro b-type natriuretic peptide was within normal limit. Chest xray revealed right pleural effusion. Thoracocenthesis was done and 2 liters of serosanginous fluid was removed which was exudative with lymphocytic predominant on differential. He underwent computerized tomography (CT) of chest with contrast which showed mediastinal adenopathy, right sided pleural effusion. Later cytology from right pleural effusion came positive for adenocarcinoma (concern for non small cell lung cancer), with Positive: Pan keratin, CK7, TTF-1, Moc31. Positron emission tomography-PET-CT revealed hypermetabolic activities in cervical adenopathy, mediastinal adenopathy, pleural nodules and thyroid. He underwent left cervical lymph node biopsy which revealed metastatic papillary carcinoma with extra nodal extension and necrosis. Immunostains were positive for TTF-1 and thyroglobulin. Serum thyroglobulin antibody was greater than 500 IU/ml (normal < 4IU) and thyroid stimulating hormone 2.38 mcIU/ml (normal-0.350 3.74 mcIU/ml). Further pleural fluid pathology was correlated with the cervical biopsy pathology and diagnoses was reconsidered as PTC metastasis to lungs. DISCUSSION: PTC accounts for 80% to 90% of all thyroid cancers. Only 2 to 10 percent of patients have metastases beyond the neck at the time of diagnosis (1). Among such patients, two-thirds have pulmonary and one-fourth have skeletal metastases. From pathology standpoint, sometimes it becomes challenging to differentiate primary pulmonary adenocarcinoma (with papillary hisotlogy) from PTC as the histology shows well-differentiated branching papillae that mimics PTC. CONCLUSIONS: Our case based on pleural fluid pathology analysis initial presumptive diagnosis was considered as adenocarcinoma of lung. But later pleural fluid pathology was correlated with the cervical biopsy pathology and patient was diagnosed with PTC metastasis to lungs. Serum thyroglobulin and its antibody level are very helpful in diagnosis. In case of initial dilemma, one should also consider sending thyroglobulin level on pleural fluid analysis.

INTRODUCTION:Congenital tracheobronchial anomalies are a rare occurrence, but if present, their associated conditions and complications can cause significant morbidity and mortality in children and sometimes even in adults. CASE PRESENTATION:An elderly gentleman with a history of smoking, chronic obstructive pulmonary disease and pulmonary fibrosis, had a CT scan done for lung cancer screening, which showed a cavitary lesion measuring 14 mm in diameter in the right upper lobe and multiple enlarged mediastinal lymph nodes. A follow-up PET-CT scan showed increased uptake in the lymph nodes. He then underwent bronchoscopy, endobronchial ultrasound and biopsy of the mediastinal lymph nodes, given his extensive smoking history and concern for malignancy. Bronchoscopy findings: The main carina had a small opening present, that when entered led to a "blind pouch" with areas where 2 bronchi showed divided off but were sealed. Area resembled a "second carina". DISCUSSION:The prevalence of congenital bronchial branching anomalies, often referred to as the tracheal bronchus is approximately 0.1-2% in the general population (Chassagnon et al., 2016). Types 1 and 2 of the tracheal bronchus arise more than 2 cm from the carina, with and without narrowing of the distal trachea respectively, whereas type 3 tracheal bronchus arises less than 2 cm from the carina (Jamil & Soos, 2020). Commonly referred to as the pig bronchus, the tracheal bronchus almost always arises from the right upper lobe (Setty & Michaels, 2000). This patient's tracheal bronchus was a supernumerary bronchus that ended as two blind bronchi or a tracheal divertica, while his right upper lobe bronchus had a normal trifurcation. CONCLUSIONS:Often associated with tracheal bronchus are other congenital malformations such as congenital heart disease, VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb anomalies), and other airway malformations (Chassagnon et al., 2016). Most patients are asymptomatic and I incidentally diagnosed on bronchoscopy, but given the variability in the origin extent of the bronchus, symptoms can include recurrent aspiration pneumonia, atelectasis, or respiratory failure. Based on symptomatology, management varies from observant watching, symptomatic management, to surgical treatment.

A woman in her 70s with a history of chronic minocycline use presented with complaints of a non-tender posterior neck mass. A thyroid gland ultrasound showed a highly suspicious right thyroid nodule. A total thyroidectomy revealed darkened discolouration of the thyroid gland and tracheal cartilage. The pathology report showed dark brown granules representing melanin. Chronic minocycline usage is known to cause pigmentation of nails, teeth, bones and the thyroid gland. Our case highlights the importance of recognising that long-term use of minocycline can cause discolouration of the thyroid and tracheal cartilage. Current case studies do not show any adverse health effects associated with black thyroid and tracheal cartilage. For patients who are to undergo neck surgery, physicians need to be aware of this side effect, and that further intervention, such as surgical resection, may not be required.

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INTRODUCTION:Pembrolizumab is a humanized monoclonal antibody that targets the programmed cell death-1 receptor in T-cells and is becoming more widely utilized. Immunologic checkpoint inhibitors have revolutionized cancer treatment but can be associated with systemic toxicities, including pyrexia, chills, infusion reactions, and rarely immunologic phenomena such as sarcoid-like reactions [1]. CASE PRESENTATION:We present a case of an 81-year-old female with a history of hypertension, hyperlipidemia, and urothelial carcinoma of the renal pelvis metastatic to the retroperitoneal lymph nodes. She had undergone a right nephrectomy and completed adjuvant chemotherapy with carboplatin plus gemcitabine. Afterward, the oncology team initiated Pembrolizumab IV 200 mg every three weeks for maintenance therapy. Follow-up imaging done four months after starting immunotherapy showed a solid pulmonary nodule in the right lower lobe measuring 3.7 x 2.1 cm. Due to concern for metastasis, she underwent a percutaneous biopsy which revealed non-caseating granulomas. She lacked signs of sarcoidosis such as arthritis, rash, visual change, and mediastinal adenopathy, and a detailed workup for fungal and mycobacterial diseases was negative. Given the recent initiation of pembrolizumab, a medication-induced reaction was considered. DISCUSSION:The differential diagnosis for pulmonary granulomatous disease includes non-infectious etiologies such as sarcoidosis or hypersensitivity pneumonitis, infectious etiologies such as fungal or mycobacterial diseases, and drug-induced reactions. Pembrolizumab is an immune checkpoint inhibitor used in the treatment of malignancy, and it acts by blocking PD-1 located on lymphocytes. Some reports have discussed concerns that pembrolizumab could exacerbate or manifest autoimmune disease [2, ]. Additionally, a few reports have described the development of non-caseating granulomas (referred to as sarcoid-like reaction), 3-6 months after treatment with Pembrolizumab and other checkpoint inhibitors such as ipilimumab and nivolumab [2,3]. The sarcoid-like reaction is primarily T-cell mediated and is a localized process (affecting either the lungs, skin, or kidneys), unlike sarcoidosis, which is more of a systemic disease. However, as it manifests as a new nodule or lymphadenopathy, a biopsy is often required to rule out metastatic disease.CONCLUSIONS: This case highlights the importance of understanding the relationship between immunologic therapies and their range of toxicities. While pembrolizumab is an effective treatment in malignancy, clinicians should be aware of the unexpected immunologic consequences of sarcoid-like reactions or flares of pre-existing autoimmune disease.