Explore the vast range of titles available.

Correspondence to Dr Ji Young Park, Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, South Korea; evan007@naver.com Dr Ji Young Park Herd immunity through extensive and rapid vaccination rather than natural immunity acquired by infection is necessary to control a global pandemic like COVID-19. (C) Data of 10 previously reported cases of influenza vaccine-related ILD. *One case each of chronic hypersensitive pneumonitis and idiopathic pulmonary fibrosis. #1, Johnston et al 5 ; #2, Heinrichs et al 6 ; #3, Kanemitsu et al 7 ; #4, Bhurayanontachai 8 ; #5, Umeda et al 9 ; #6, Kumamoto et al 10 ; #7, Watanabe et al 11 ; #8, Hibino and Kondo 12 ; #9, Hibino and Kondo 12 ; #10, Numata et al. 4 BAL, bronchoalveolar lavage; ED, emergency department; FiO 2 , fraction of inspired oxygen; HFNC, high-flow nasal cannula; ILD, interstitial lung disease; MPD, methylprednisolone; n, no; y, yes. [...]the ‘exclusion of other conditions’ criterion was met as infections and CTDs were ruled out based on the radiological findings and microbiological and serological test results. There was a vaccine safety committee’s report of acute deterioration of underlying ILD after influenza vaccinations from the Japanese Ministry of Health, Labour and Welfare (19 cases from 22.8 million doses of H1N1 vaccine in 2009–2010, Japan).9 However, the evaluation of risk factors for adverse reactions should be analysed through prospective studies that can proactively evaluate every vaccinated individual and not through case series or reports from passive safety surveillance. [...]for rare adverse reactions and delayed-onset events, large healthcare databases with standardised definitions and appropriate statistic models are necessary (active safety surveillance).

We present the cases of two laryngectomised patients who were treated for granulomas of the tracheostomy orifice with a silver nitrate pencil. During tracheostomy care, the tip broke off, was aspirated and fell into the bronchial tree. Necrotising ulcerative injuries of the right bronchial tree with clear delineation were found without lesions in the subsegmental division. To prevent the risk of secondary stenosis of the small airways induced by the spread of silver nitrate, we did not irrigate with saline solution as previously reported. Antibiotherapy and endoscopic monitoring were performed. Complete healing in 4–6 weeks was found without stenosis of the bronchial tree or bleeding.

Correspondence to Dr Tom McLellan, Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, CB2 0AY, UK; tom.mclellan@nhs.net Tom McLellan (specialty respiratory registrar) A man in his 30s, with a history of mild childhood asthma only, went to his local hospital with difficulty in breathing. (C) Summary of antibiotic and steroid therapy, change in blood eosinophil and bronchoalveolar lavage (BAL) % and ECMO sweep requirements (necessary to clear CO 2 ). The condition usually responds rapidly to steroid therapy. Pulmonary function testing at 3 months revealed FEV1 2.87 L (73%) FVC 4.07 L (86%), TLCO 73% KCO 103%.

Rosai-Dorfman disease (RDD) is a non-malignant condition mainly manifesting as a proliferation of histiocytes in lymph nodes. Endotracheal RDD (ERDD) with an acute onset presentation is extremely rare. There are few case reports of ERDD mainly concerning its pathology, diagnostics and bronchoscopic treatment, without providing sufficient clinical information from a comprehensive perspective. As a novel and challenging technique, tracheal resection and reconstruction (TRR) with spontaneous-ventilation video-assisted thoracoscopic surgery (SV-VATS) has been reported as feasible and safe in highly selected patients, but few centres have shared their experience with this approach. This case-based discussion includes not only practical issues in the management of a life-threatening ERDD patient, but also specialists’ views on the management of acute obstructive airway, and the surgeons’ reflection on TRR with SV-VATS.

We present two neonates requiring extracorporeal membrane oxygenation for undiagnosed recalcitrant pulmonary hypertension, highlighting the clinical and ethical dilemmas in management of very rare diseases.

Correspondence to Dr Rishi Pabary, Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK; r.pabary@rbht.nhs.uk Learning points It is necessary and important to reassess and re-evaluate diagnoses throughout childhood, particularly when the symptoms and findings no longer fit, and to remain open minded about possible alternative diagnoses. PARN encodes the ribonuclease responsible for telomere mRNA turnover, maturation and stabilisation, and pathogenic variants reported in the literature are known to be associated with shortened telomere length and adult-onset pulmonary fibrosis.1 2 Parental genetic testing showed maternal inheritance of the same PARN variant. The initial 12 gene chILD panel was extended to 38 genes and now detected a heterozygous frame shift mutation in the Regulator of Telomere Elongation Helicase 1 (RTEL1) gene, that encodes a DNA helicase responsible for maintaining telomere length, playing a role in DNA repair and replication.1 4 This mutation is recognised as pathological, autosomal dominantly inherited and leads to loss of function of the telomere length regulator. In adults, it is associated with ILD including idiopathic pulmonary fibrosis, chronic HP and extra-pulmonary conditions including autoimmune disease, bone marrow failure and liver disease.4 Her circulating telomere length was tested and found to be <10th percentile for age matched healthy controls (figure 1F).

Correspondence to Professor Paolo Palange, Department of Public Health and Infectious Diseases, University of Rome La Sapienza, 00185 Rome, Lazio, Italy; paolo.palange@uniroma1.it Clinical case Maria Luisa Nicolardi (specialty respiratory fellow) A 19-year-old male smoker presented in the emergency room after accidental aspiration of an unquantifiable amount of Pyrofluid, a liquid mixture of high-boiling aliphatic/paraffin aromatic free hydrocarbons, during a fire-eating performance. [...]clinical stability was achieved in the next days. Microbiological tests showed a positive nasal swab for methicillin-resistant Staphylococcus Aureus, positive blood cultures for Staphylococcus haemolyticus and positive Aspergillus galactomannan in the sputum. [...]I decided to switch antibiotic therapy to meropenem, ciprofloxacin and vancomycin and to continue isavuconazole.

There was no history of venous thromboembolism, cancer, gastro-oesophageal reflux disease, asthma, allergic rhinitis or other allergies.At presentation, the patient’s temperature was 36.7 ℃ with a heart rate of 74 bpm, blood pressure of 110/60 mm Hg, respiratory rate of 21 bpm and oxygen saturation of 89% on room air. Fajiu Li, pulmonologist and pulmonary vascular interventional radiology specialist Right atrial myxoma is a rare benign tumour of the heart with an incidence of 0.0017% in the general population.1 Meanwhile, this is the first report in the literature of an atrial myxoma with pulmonary artery myxoma embolisation after percutaneous atrial septal repair, in this case, 8 years later. Many cases were reported in the literature of thrombus formation after percutaneous atrial septal repair as far as 10 years later.2 The case we presented was undergone percutaneous closure of the atrial septal defect 8 years ago, which led us to delude ourselves into thinking that the pulmonary embolism was caused by an atrial septal sealer before the acquired mucus-like items from the patient’s pulmonary artery. Large clots or mucus dislodged into the pulmonary artery or/and systemic circulatory systems, such as the brain, the liver, the spleen, the kidneys or the coronary arteries, may lead to sudden death or target organ dysfunction.5 It is well documented that chronic pulmonary obstruction caused by myxoma emboli can lead to irreversible pulmonary hypertension.

Blood tests showed elevated white cell count (WCC) 26.5×109 /L and C-reactive protein (CRP) 295 mg/L and an acute kidney injury (creatinine 113 µmol/L). Lemierre’s syndrome is characterised by septicaemia and internal jugular vein (IJV) thrombophlebitis secondary to an oropharyngeal infection, which extends into the lateral pharyngeal space.1 The formation of a septic thrombus within the IJV can lead to the dissemination of infection via metastatic septic emboli, with multiple organ involvement. The most common causative organism is Fusobacterium necrophorum, a gram-negative anaerobic bacillus, but other organisms such as methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis and various Streptococci have also been implicated.2 The initial symptoms of oropharyngeal infection may not be the presenting feature of the syndrome; metastatic complications of septic emboli can take up to 3 weeks after the primary infection to manifest, and at this stage of presentation the initial infection can be overlooked.3 RN: The diagnosis of Lemierre’s syndrome could have been confirmed by a contrast-enhanced CT of the neck, which could have been done at the same time as the initial CT scan in ED, or a Doppler US scan of the neck, to detect IJV thrombosis.4 It would also be prudent to exclude bacterial endocarditis by performing an echocardiogram, as this is another cause of septic emboli which could account for the bilateral lung lesions.