No abstract

A 30-year-old man was admitted to hospital for the management of massive hemoptysis. He had a long history of childhood cutaneous infections and recurrent pneumonia complicated by empyema, and thoracic and pulmonary abscesses that required prolonged intravenous antibiotics and surgical decortications. His family history was unremarkable. A previous sweat test was negative. Further investigations revealed marked eosinophilia and grossly elevated serum immunoglobulin (Ig) E levels of 2510 IU/L (normal range 0 to 100 IU/L), but normal IgA, IgG and IgM levels, which led to the clinical diagnosis of Job's syndrome. Despite prophylactic oral antibiotics (predominantly ampicillin-based), he suffered from further bouts of severe pneumonia with massive hemoptysis and the subsequent development of a large right upper lobe cavitating abscess that required lobectomy. Interestingly, the abscess culture grew Stenotrophomonas maltophilia, which was successfully treated with sulperazone (cefoperazone and sodium sulbactam).During the current admission 10 years later, he again presented with dyspnea and life-threatening hemoptysis. Multiple scars were noted from previous skin abscesses of the face and limbs, as well as from bilateral thoracotomy incisions. Breath sounds were reduced bilaterally, especially over the right side. A complete blood panel revealed leukocytosis (white blood cell count 16.4×10 9 /L [normal range 4×10 9 /L to 11×10 9 /L]), predominantly neutrophils (85.1%) and eosinophils (9.5%). A chest radiograph showed consolidative changes and cavitations over the right lower zone. Computed tomography revealed multiple pneumatoceles (Figure 1), the largest being 5.5 cm in size, with fluid levels in the right lower lobe. Urgent angiography was performed and two culprit hypertrophic bronchial arteries supplying the right main and right lower lobe bronchi ( Figure 2A) were successfully occluded by microsphere embolization (500 µm to 700 µm) ( Figure 2B), with subsequent resolution of hemoptysis. In addition, percutaneous drainage of the dominant lung abscess was performed. Both sputum and abscess fluid cultures grew Penicillium marneffei, which produces a characteristic soluble red pigment at 30°C (Figure 3). The patient was treated with amphotericin B and the prophylactic antibiotic cefepime. Despite appropriate antifungal and antibiotic therapy, his contralateral lung also rapidly became infected and he finally succumbed to respiratory failure. DisCussionThe term Job's syndrome was coined in 1966 by Davis et al (1), who described a rare condition characterized by recurrent staphylococcal skin infections, sinusitis, otitis media and pulmonary infections. Other clinical manifestations described since then include candida endocarditis, keratitis and corneal perforation, craniofacial and dental abnormalities, and skeletal deformities (2). Pulmonary complications such as recurrent pneumonia, pneumatocele formation and lung abscesses caused by bacterial and fungal infections are also common (3-7) ( Table 1).The mode of inher...

Aim:To assess the feasibility of simultaneous video-assisted thoracoscopic surgery (VATS) lobectomy and mastectomy via the same incision in patients with synchronous primary carcinoma of the ipsilateral breast and lung. Methods: The patient was first positioned supine and modified radical mastectomy for the breast carcinoma was carried out in the standard way. After that, the mastectomy wound was partially closed and the patient was then turned into a full right decubitus position. Camera and instrument ports were inserted and a utility thoracotomy was made through the mastectomy wound. VATS lobectomy was then carried out. Results: From December 2007 to December 2008, three patients with synchronous primary breast and lung tumour received simultaneous mastectomy and VATS lobectomy through a single mastectomy incision in our institute. There was no operation-related mortality. The median operation time was 253 min (range 246-345 min) and the median blood loss was 250 mL (range 110-300 mL). All except one patient had uneventful postoperative recovery and deep vein thrombosis was noted in one patient. Conclusion: Simultaneous lobectomy through the mastectomy incision is a safe and feasible treatment option for ipsilateral pulmonary and breast lesion with encouraging outcome.

Atrial myxoma, especially the papillary subtype, is known to be friable and gelatinous. Manipulation of an atrial myxoma during surgery can be very difficult, and not uncommonly results in fragmentation and embolization of part of the tumor. The conventional method using a metallic spoon to manipulate the tumor is widely practiced because alternatives are sparse. We describe a novel home-made suction device to aid the excision of friable atrial myxomas.