A 45-year-old man presents with acute respiratory failure. Imaging revealed a left mainstem endobronchial mass with subcarinal lymphadenopathy, but no other evidence of a primary tumour. An incidental laryngeal nodule was found during bronchoscopy. Biopsies of this lesion by nasopharyngoscopy and subcarinal lymph nodes via mediastinoscopy were performed. Histopathological and immunohistochemical examination showed evidence of melanoma in both samples. Mutational analysis identified the presence of a BRAFV600E mutation. The patient underwent bronchoscopic ablation of the left mainstem endobronchial tumour with laser therapy followed by initiation of encorafenib and binimetinib combination therapy. The patient remains alive at 4 months after initial presentation of disease. This case adds to the body of literature highlighting the clinical heterogeneity and challenges of the management of metastatic pulmonary melanoma. To the best of our knowledge, this simultaneous constellation of metastasis has not been described before.
A 70-year-old man presented with acute respiratory failure, alveolar infiltrates and haemoptysis requiring supplemental oxygen. Flexible bronchoscopy with bronchoalveolar lavage identifies diffuse alveolar haemorrhage. Clinical and serological evaluations do not identify a precise aetiology and histopathology establishes the diagnosis of isolated pauci-immune pulmonary capillaritis. The patient received induction therapy with high dose methylprednisolone at 1000 mg/day for 5 days and weekly rituximab at 375 mg/m2 scheduled over 4 weeks. Although the patient demonstrated clinical improvement after the first week, he experienced a rapid relapse requiring mechanical ventilation. His induction rituximab regimen was continued and plasma exchange was initiated. Despite these therapies, the patient’s condition deteriorated and passed away. Our case adds insight to the management of this rare entity and describes the use of plasma exchange as salvage therapy.
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