107. Fellows’ Case Files: University of Kansas Medical Center KUMC

After a brief hiatus, we are excited to be back today with another Fellows’ Case Files! Today we’re virtually visiting the University of Kansas Medical Center (KUMC) to hear about a fascinating pulmonary presentation. There are some fantastic case images … Continue reading →

Episode Transcript

(00:17):
Hey, everybody. Welcome back to Palm Peeps. Thanks
for tuning in and listening today. Make sure
to like and subscribe wherever you're listening. Sign
on to our website and follow us on
any social media that, yeah, you're still using
for medical things, which is rapidly decreasing.
But we're excited to be back with another
case today and to dive into some interesting
and fun medical issues. Christina, you are recording

(00:39):
live from a hospital, tucked away in a
patient room corner, an unoccupied patient room. But
so this is a little bit of a
rebel podcast and I love it.
I know first. So glad to see you
though. I know this is one of our
favorite types of episodes to do with our
fellows case files, because it really gives us
the opportunity to highlight such amazing educators across

(01:02):
the country,
as well as highlight some fellowship programs as
we go into
fellowship recruitment season here in just a few
weeks. So very excited today, we're going to
be joined by two fantastic guests from the
University of Kansas Medical Center.
And I'd like to introduce our first guest
who's Doctor. Vish Hedge,
who is currently a second year pulmonary and

(01:23):
critical care medicine fellow at the University of
Kansas Medical Center. He completed his I'm residency
at University of Kansas as well. So staying
on for a bit. May or may not
be a lifer fish, but excited for you
that thank you for reaching out to Dave
and I and trying to present this interesting
case, and welcome to Palm Peeps.
Yeah. I'm a longtime fan and a longtime

(01:44):
listener of the show, and I'm beyond thrilled
to be here.
We're excited to have you. We're also very
lucky to be joined by doctor Sahil Pandya.
Sahil is an associate professor of medicine and
the program director of the PCCM fellowship at
KU. One of my best friends did their
training at KUMC. He's gonna be very excited
that we're virtually visiting you guys. Thank you
so much for making the time and coming

(02:05):
on the show, Sahil.
Thank you both for hosting us today. Really
is an honor. And like Vish, I am
also a longtime listener and a huge supporter
of your podcast. And I think you guys
really create a nice environment of inquiry and
curiosity, and it really aligns with our values
here at the University of Kansas. And also,
like, in this world where life is always
on the go, learning on the go is
such a really nice complimentary
So thanks for all the hard work that

(02:26):
you do. I know it's not easy, but
we know that we all benefit from it,
and we're excited to learn from you guys
today as well. Oh, we appreciate it. Flattery
will get you everywhere. So I've learned well.
Pretty good.
And as a reminder, before we dive into
our case, this podcast is not meant to
be used for specific medical advice, but rather
for medical education. The views we express today
may or may not reflect the opinions or

(02:47):
policies of our respective employers. And the case
we present today will be HIPAA compliant, and
some details may have been changed to protect
the privacy of our patient.
Awesome. Thanks so much, Bert. Well, very excited
to go ahead and go into the case
and
oh, I'm so sorry
about that. Let me get back on track.

(03:09):
Thank you so much, David. Really excited to
get into the case. And, Bish, I know
you brought us a really interesting
case that highlights
a few things today that we'll go over,
but also the importance of diagnostic flexibility
in preliminary and critical medicine.
And I'm hoping that you can start by
telling listeners today how your patient first presented.

(03:30):
Absolutely.
So
I have a 26 year old immigrant from
Southwest India
who presented with a six month history of
progressive cough and shortness of breath.
He had no known past medical history and
had immigrated from The United States to immigrated
to The United States two years prior.
He was initially evaluated in the ER, where

(03:51):
imaging revealed bilateral pulmonary nodules.
These were quite impressive, so much so that
the ER picked up the phone and the
first person that they called was infectious disease.
They ordered a set of sputum cultures as
well as a QuantiFERON gold. The Sputum spares
were negative and the QuantiFERON gold was indeterminate.
The plan initially at that admission was to

(04:11):
pursue a bronchoscopy.
However, the patient was very reluctant.
So he given his
given the pretest
a high pretest probability
of tuberculosis given his background,
he was empirically started on anti tuberculous therapy
for presumed malaria TB.
However, his symptoms worsen, and he returns two
weeks later to the emergency department after a

(04:33):
generalized tonic clonic seizure.
Doctor. Awesome. Thank you. A lot to a
lot, even in this short presentation that we
have to process here and that so many
things in pearls that I wanna bring up.
One of my former mentors from fellowship would
always point out that the original,
name of AJR CCM, one of our, like,
main pulmonary critical care journals was tuberculosis

(04:55):
and that while tuberculosis is often
managed by infectious disease now, especially in The
United States, like, this is really a pulmonary
problem and something we should be very familiar
with. So that's very interesting. And then we
also have a patient now who's undergoing therapy
and comes in with a new generalized tonic
clonic seizure. So that's its own thought process,
his own diagnostic schema, somebody coming in with

(05:16):
a new seizure.
So we have a young man, progressive respiratory
systems, nodular lung disease, maybe a sort of
miliary pattern was referenced,
on empiric treatment for TB who has new
seizures. So that problem representation
is 26 year old, as far as we
know, immunocompetent
man, but with diffuse pulmonary nodules, so we're
wondering about that immunocompetency

(05:38):
and new neurologic symptoms.
Certainly, somebody who has tuberculosis, we know tuberculosis
can be in any compartment in the body,
right? And so if we're empirically treating for
pulmonary tuberculosis
or miliary, which we really think of as
being spread through the blood vessels at this
point, then we're thinking about disseminating ATB. In
one, two, and three, I'm thinking about what
the CNS space is carrying. The patient's also

(06:00):
on new medications. So anytime someone has seizures
and they're on new medications, I always want
to think about the medication effects.
We're also thinking about disseminated or nodular appearance
of lung disease, and
we don't have anything
confirming this. We're doing empiric management. So is
there a different diagnosis that could be responsible
for both CNS and pulmonary finis? Fungal infections,

(06:22):
I'll always remember, I think I probably got
the question wrong, but on my pulmonary boards,
there was a question that was about a
respiratory disease and all it was a CNS
scan and it was a nocardia that you
were supposed to recognize. And nocardia can do
this very commonly and that and so even
to the point that it made it to
pulmonary board. And then non infectious, malignancy,
sarcoidosis,

(06:43):
other inflammatory diseases that we know can be
in the lungs and the brain.
And then finally, we can't forget about just
serendipity, common things being common. Do this person
have a pulmonary process, and then they're also
somebody who drinks alcohol, and they're coming in
with alcohol withdrawal seizures. So they have someone
they're so we're gonna look for a simple,
unifying explanation, but we're also gonna keep our

(07:04):
differential broad.
Christina, anything to add? Any other
thoughts? Yeah. For no. Thanks so much for
doing that. I think such a kind of
a broad differential just on some preliminary information
that Vish has shared with us. But I
think what this is a really I'm hoping
this is gonna be a really great case
where it's so tempting to to say, yes.

(07:24):
This is the imaging fits with this. Given
the history, it has to be TB. But
I really think that we have to think
about the the whole patient and not check
our cognitive biases,
avoid premature closure. I know we've talked about
that before in some of our other episodes.
And as we're, as Vish was talking about
the lung findings as well, just reminded me
about one of our earlier episodes that we

(07:45):
did with Emily Friedemacher with miliary opacities,
and that actually ended up being disseminated histo.
So I'm actually important, and we wanna hear
a little bit more relevant history, any exposures,
some exam findings, Vish. So I'm hoping that
you can share that with us now.
Absolutely.
This patient's past medical history was pretty unremarkable

(08:07):
except for his recent presumed TB diagnosis.
He reported no allergies to us, and he
was recently started on the right regimen consisting
of nifaben, isoniazid,
pyrazinamide,
ethambutol,
and as well as some pyridoxine supplementation.
This patient was a nonsmoker.
He drank alcohol only socially and denied any

(08:27):
illicit drug use.
He lived notably in Ohio
for a very brief time before he returned
to the Midwest.
His vitals were a temperature of 98,
a heart rate of 92, a blood pressure
of one twenty over 75,
a respiratory rate of 24,
and an oxygen saturation of 96% on two
liters of nasal cannula.

(08:50):
On exam, he was alert and oriented,
and we did not have any cross neurological
deficits that were noted.
His pulmonary exam showed a normal work of
breathing, and I was able to appreciate some
scattered rolls.
Apart from that was, once again, pretty unremarkable.
Otherwise, his musculoskeletal
exam

(09:10):
showed point tenderness on his lower back. Apart
from
that, the rest of the exam was
essentially normal.
Awesome. Thank you for summarizing that. So we
have a lot of pertinent negatives. We do
have some things that we wanna think about
for social exposures.
I was gonna add a couple other thoughts
here that as you walk us through it.

(09:31):
Certainly, point tenderness in the lower back on
someone you're worried about TB makes us worry
about whether or not we have dissemination of
bones. I will also say, while it definitely
could be right to empirically treat with TB,
I'm not commenting on that decision that was
made prior at all,
we generally make every effort to confirm TB,
right, as we're treating it. And this is
both because it's important diagnosis to confirm, but

(09:53):
also we wanna get resistance testing, right. There
are multiple reasons why we wanna be able
to grow this, and we should be able
to from a biopsy or a sample from
somewhere. And then finally, the last thing I
would just add before we go forward too
is with someone who comes in with new
generalized tonic clonic seizures, and then by the
time you're seeing them, the neuro exam's normal,
they're awake. We always just have to remember
that convulsive

(10:14):
syncope is often confused for seizures. So just
because it looked like someone was shaking doesn't
mean that it was necessarily seizure. Now in
this case, if it's witnessed, then you often
can take it to the bank, but just
always keep that in mind.
Sahil, I wanted to turn to you though.
Now we've got an exam, we've gotten a
little more history. Curious if there are other
things that you're thinking about to add on
to my rudimentary differential? And then additionally, what

(10:35):
you would be thinking about for the first
steps in the diagnostic workup?
Absolutely. So I think this is a great
foundational piece that we can build on. And
so for me, as I think about patients
that really present with pulmonary complaints, I really
find myself using a combination of both subjective
complaints and objective information
really to think about in a schema of
pretest probability for a likely diagnosis. And that

(10:55):
really guides what tasks I'm gonna order, if
the risks outweigh the benefits, and so that
we can really be high yield for our
patient and serving them well. So from the
very start, I really found several of these
aspects of the case atypical,
and I really make notes of these in
my mental scheme of evaluation.
So first of all, this is a young
patient who really presented with a subacute onset
of almost six months of shortness of breath.

(11:17):
I always make the point for all learners
and trainees and also for myself that timing
of pulmonary evolution is so important in narrowing
your differential.
And without even having any imaging, I can
really assume with a reasonable amount of certainty
that there's probably a reasonable amount of parenchymal
burden to have warranted empiric anti TB burden
to begin with. So already, a really atypical
story. I would think that an acute bacterial

(11:38):
or viral process would generally not be present
with such a prolonged prodrome. And so a
strong parenchymal burden plus the bacterial superinfection, for
example, would really have an accelerated course, and
it seems like that's not what was going
on in this case.
Also, the patient provides the history that the
symptoms are worsening, and this was despite what
we would assume to be adequate treatment and
escalating with seizure history. So hearing these complaints,

(11:59):
my mental model thinks about combined pulmonary and
CNS infections that you've already alluded to, Dave.
And that includes things like nocardia,
endocarditis with embolic events, fungal infections like disseminated
crypto, disseminated blasto, maybe some parasitic infection, but
also thinking about noninfectious causes like autoimmune disease
and malignancy.
TB therapy in The United States is generally

(12:20):
pretty effective unless you're running into really drug
resistant cases. So my first thought really jumps
in questioning and verifying the diagnosis, which would
include verifying TB based serologies,
following evolution and parenchymal findings, because I think
that delta is really gonna tell us what
pathophysiologically
is happening at the level of the pulmonary
lobule. And so dedicated CT imaging would be
very helpful. I would ensure that this patient

(12:42):
gets to in broad disseminated fungal serologies,
verifying immunocompetence, so thinking about HIV, thinking about
serum immunoglobulins,
and or is this an atypical manifestation of
a common pathogen? And it would also just
always
reobtain history to ensure that no clues that
can be unmasked to put this atypical picture
together. I often find that just sitting with
patients and not going in with any agenda,

(13:04):
but just hearing their story from start to
finish again often yields the highest information to
help serve them the best. And then depending
on the results of this imaging and serologic
evaluation, I think I would be able to
generate a post test probability of
further diagnostics that would be helpful to pursue.
Because if those
tests are still indeterminate, then the benefits
would outweigh the risk of doing more invasive

(13:26):
testing. And that would include things like endobronchial
ultrasound, if there was adenopathy that was amenable
to do so, bronchoscopy with BAL, and potentially
a trans bronchial biopsy or cryobiopsy depending on
the post test probability that we generate. So
those are my initial thoughts moving forward in
this really interesting and atypical case.
Oh, it's wonderful. So many pearls there. I
I really love that Bayesian approach to your

(13:47):
diagnostic reasoning process because it's so tempting sometimes
to just jump to, let's look at what
the old scan was. We really have to
have this question of how how much is
it gonna change my management? Am I gonna
do a lung biopsy no matter what? Or
if I don't see any lymphadenopathy,
is this really not gonna be worth it
to go look and see if I can
ultrasound in the media side? And that was
that that was great. Thank you so much.

(14:07):
I was gonna add that I was gonna
say that for me, I always talk about
this as physicians. We're also human beings at
best, and we really wanna just do the
best by our patient. We always worry about
missing something or not doing the right thing.
And I think the thing that I've learned
over time and that my mentors have taught
me is all we can do is the
best with the information that we have at
the time. And so we think about what
could serve a patient the best with the

(14:27):
information that we have, and we will always
do the best if we are using that
information in a high yield way. So I
appreciate that commentary, and that's I think at
a humanistic level, we just do the best
we can with what we know at the
time. Totally. And I think that is one
of the most unique aspects of medicine is
that we're almost always acting with incomplete information.
We have to we have to be making
some diagnostic and treatment decisions before we have
the entire picture.

(14:48):
So really interesting.
So, Vish, can you share with us what
the next steps ended up being? What was
the relevant lab work, any imaging, and how
this influenced the diagnostic process for this patient?
Absolutely.
His initial labs were notable
only for a mild leukocytosis
and some lymphopenia,

(15:09):
but, otherwise, his chemistries were unremarkable.
Initially, he did have HIV testing that was
negative.
They did end up pursuing
repeat
sputum cultures for AFB and fungal pathogens,
and as well as getting a repeat quantiform
goal, as well as broad fungal serologies.
At the time when we're in this case,
the testing was still negative or indeterminate for

(15:31):
all these.
So we got repeat CT scans.
So his initial CT scan showed diffuse bilateral
milliary nodules that were in random in distribution,
more so in the lower lobes.
However, when we got a repeat CT scan,
which is from this admission, we we saw,
once again, these diffuse bilateral mill ray nodules

(15:54):
in a random distribution, but now some had
developed central cavitation,
some were now more confluent,
especially so in the right upper lobe. And
at the basis, we saw more interlockingal septal
thickening that was noticed.
Also, with for a seizure, we had a
CT scan that was performed, which revealed

(16:15):
intercranial
ring enhancing lesions with surrounding basogenic edema in
the frontal lobes, cerebellum, and PONS.
Thank you, Ish. It's super helpful to kinda
get the patterns and bring us to our
next phase of things. Monty, what do you,
what are you thinking?

(16:35):
Yeah, thanks for, for what I was gonna
say, I know that you alluded and feel
alluded as well with this new onset here.
I'm surprised, but seeing it and hearing Vish
talk about this intracranial ring enhancing lesions,
I think is an interesting finding. Probably wasn't
expected when the first patient first presented, but
I think this is interesting to consider. And
I know we already talked about abscess formation,

(16:58):
tuberculosis,
but definitely metastasis has to be on our
differentials. We think about that, but I really
think this is an important opportunity.
I know we we like to,
you know, find radiology teaching points with everything.
And I think, Visha, you mentioned some great
things with how the anilary nodule from their
initial appearance to their interval follow-up appearance. But

(17:19):
one of the things that you mentioned was
kind of this random distribution
of nodules.
And I think that's really important to think
about, and something that I try to recognize
is when I see this pattern of small
nodules
that are in random formation or nature, that
really does
lead me to think of some type of
hematogenous
spread. So the major considerations, and we've talked

(17:39):
about some of these already, is this miliary
tuberculosis.
Is it the disseminated fungal infection, which I
think we've all talked about and working up
serum fungal markers, trying to understand
immunocompromised
status, but as well as metastatic disease. And
I think all of us are probably still
thinking that we still have to have this
on the table. That's how I tend to
think of these random distribution of nodules, but

(18:01):
I know that there's other nodular patterns that
we should be thinking. And so I'm wondering
if you can talk about your approach to
teaching your fellows and other trainees,
specifically other types of nodular patterns, perilymphatic
or versus centronobular,
and if you have a good schema to
to think about all three.
Yes. And definitely, it's one of my favorite
topics to talk about actually. And I always

(18:21):
think about radiology
and how it often adds a story to
the patient's clinical picture that is not represented
anywhere else. And it is true with
discussing with patients. I think to get the
right thing out of radiology, you have to
ask the right questions. And so when I'm
thinking about nodular patterns,
I always ask myself three questions. And the
first, is there a craniocaudal distribution?

(18:44):
Because an upper lobe disease that's predominant can
represent specific pathology, such as sarcoidosis,
tuberculosis,
an acute phase of hypersensitivity,
pneumonitis,
respiratory bronchiolitis, and even occupational lung diseases like
silicosis.
Basilar findings, on the contrary, can represent other
things like septic emboli, metastatic disease,
aspiration related nodularity, or even autoimmune disease. And

(19:06):
this really speaks to the pathophysiology
of the process itself, really hinging on our
ventilation lung zones, which are upper lung zones
and more of our vascular mediate zones in
the lungs that are the lower lung zones.
The second question I ask myself, is the
nodule distribution symmetric or asymmetric?
Because, for example, if you have a geographic
location that is just isolated to one area,
perhaps it's more an infectious process. Whereas something

(19:28):
like a granulomatous disease process that's non infectious
like sarcoid, for example, may give you a
more symmetric distribution
along with an upper lobe distribution.
I also asked my myself this question, which
is number three, is there a peripheral or
central distribution? Because things that originate in the
center of the chest that may be related
to the hilum, I really think about a
paral lymphatic distribution.

(19:48):
And I asked myself along with this, do
the nodules have a specific characteristic? Are they
well defined? Are they ill defined? Are they
calcified? Or are they non calcified? Because this
can give us insight into chronicity. So all
kind of those nonspecific cues that can add
to the layer of story that we're helping
to try to help this patient the best.
And then I organize myself as to whether
these nodules involve the pleural surfaces or not

(20:10):
because that's just a nice relationship between the
secondary pulmonary lobule, your artery venous system, and
your lymphatic system. So if they do not
involve the pleural surface, then I think about
central lobular nodules first. And And so those
spare the subpleural surfaces.
They spare the fissures, and they're often evenly
spaced from one another because they really respect
the secondary pulmonary lobule and often related to

(20:31):
an airway centered process.
The other thing in the non pleural surface
interface is tree and bud. And so that
often has a characteristic appearance and then is
associated with mucus plugging. And I'm always finding
myself looking at the airways as well. Are
they thickened? Is there mucus along the airways?
Because often, this is an acute and chronic
process and can be a result of an
atypical infection like nontuberculous

(20:52):
mycobacterium
or Pseudomonas, for example.
If it does involve the pleural surface, I
categorize
one example would be parilymphatic with nodules that
involve the fissures that are running along the
inferior aspect of the interlobular septum. Are they
subpleural in nature at the periphery? And those
things can include things like sarcoidosis
or even thickening of the interlobular septum, which

(21:12):
is lymphangitic spread of malignancy.
And then the other pattern that falls into
this category is the random or diffuse. And
this often represents a systemic process that's often
hematogenously
spread. It allows us to really appreciate all
the vasculature beds in all the aspects of
the lung and the secondary inflammatory or infectious
process that's causing a diffuse
pattern to be represented in those spaces. So

(21:35):
those are just my general approaches and thoughts
on how I categorize nodularity.
Oh, I love that. And I love the
respect into the secondary pulmonary labula. I don't
think this is something we think about that
much. It's always a picture who I drop
and that we've shared on Palmpeeps for how
to interpret a CT scan, but, really, whether
or not it's violent or respecting those borders
is a helpful paradigm for this. And then

(21:56):
I think we should also mention it'll be
less in our wheelhouse, but something as intensivist
generalists that we'll also think about is that
ring enhancing CNS lesions have their own pattern
and differential that can help us. And certainly,
you know, we can think about the things
that we have commonly mentioned. We've already talked
about a lot of these, septic emboli, abscesses,
nocardia, fungal infections,

(22:17):
parasitic infections, malignancy,
vasculitis,
sarcoid.
But I would also get on the phone
with my neuroradiologist
and say,
what does this pattern or distribution or size
or the different the different locations mean anything
to you? Does it make your raise a
differential for any of these to have that
more informed pattern recognition for the CNS imaging

(22:37):
to help inform our decisions as well?
This is a really interesting case. At this
point, it sounds like this patient's getting worse,
had presumed TB. We definitely have confirmed worsening
of pulmonary process based on the progression of
CT scans, and then now clearly,
CNS process along with it. So it seems
like we're leaning towards needing to get some
more tissue from somewhere to help confirm a

(23:00):
diagnosis.
So, Vish, what happened? What did the what
did you guys decide? What was
the best, the next step for the patient
and how did it turn out?
As the old adage goes, tissue is indeed
the issue. At this point, there was still
a reasonable suspicion for infection,
as well as a growing concern for malignancy
as well.
So after reviewing the imaging, it was determined

(23:21):
that the lungs offered the least invasive route
and probably the highest yield side for sampling.
At this point, the patient was clinically stable,
required only millimeter oxygen,
and he was likely to tolerate bronchoscopy
pretty well.
So our initial plan was to perform ABL
and EBS with tBMNA of one large mediastinal

(23:41):
lymph nodes that we saw on the CT,
and do a trans bronchial biopsy.
An additional wrinkle here is to consider whether
to pursue a four step spiropsy or cryo
biopsy. I'm interested in IP and this is
something that's been rapidly expanding.
And there are some case theories and some
studies that would suggest that in this case,

(24:02):
when the suspicion from malignancy
is high,
the cryo biopsy generally offers a higher diagnostic
yield. It gives you larger tissue samples.
And more importantly, it also gives you better
adequacy for molecular testing, which will be more
and more important as we have all these
new therapies that are coming down the line.
It also has an added benefit of avoiding
the crush artifact,

(24:22):
although all this comes at the slight cost
of higher complications
in terms of slightly higher rates of bleeding
and pneumothorax.
So interestingly, I left doctor Pandya had to
be the proceduralist on for the case.
So initially, the first part of the case
was the EDIS tRNA.
So in the room, we had rapid on-site
psychology or ROS,

(24:43):
and
when we initially gave them the sample, the
first thing that they told us is that
this looked very consistent or very concerning for
malignancy.
So what we did is we obtained initial
samples of the room
and
after confirm confirming that
sufficient material had been attained for molecular testing,
we didn't really end up taking more biopsies.

(25:05):
I'm gonna stop you there, Vishvay. I have
a couple follow-up questions if that's okay. Because
this is so important.
So my first one is, because this is
comes up from Pompey's listeners a lot about
choosing the right procedure. And this seems like
the procedure that this patient was gonna be
headed for that I probably would have chosen
too. But the question that comes up often
if people say, what about Avats? He's young.

(25:25):
He has this diffuse process.
What what factors go into deciding about that
of choosing,
less invasive, but biopsy this way or thinking
about getting our thoracic surgery,
colleagues involved to think about the Vats?
So, generally, you could make an argument in
good faith that this gentleman was relatively healthy

(25:46):
and would tolerate a procedure such as Avats
very well.
Additionally, if there's a high pretest probability or
suspicion for something like, interstitial lung disease or
a diffuse parenchronic process such as that, I
think Vats would definitely provide,
much better specimen.
But there are two things in this case
that led us towards maybe pursuing a cryo

(26:07):
biopsy in this case as well. One was
the patient reference. He was somebody that would
have appreciated
a less invasive
approach. And when we presented him with options,
this is what he ended up leaning towards.
And the second is, in in this case,
it looks like we were dealing with a
diffuse parenchymal process.
And while,
once again, you could say that when IOD

(26:29):
could have been on the differential,
the suspicion for malignancy was higher. And when
you have a diffuse process like this, the
diagnostic yield is fairly reasonable from a cryoboxie
alone, somewhere from 70 to 80% based on
whichever trial that you read. They thought it
was very reasonable to pursue a cryobopsy
in this case and would probably provide a
good answer.
Yeah. I totally agree. And also, it seems

(26:50):
like maybe, like, the overall architecture
is less of the question
endobranchial ultrasound is I think as malignancy was
atypical but rising in terms of pretest probability,
I think our desire to stage the mediastinum
also in doing this procedure was also one

(27:12):
of our utmost priorities. And so it balanced
kind of risk benefit for the patient, but
also having the highest stage for a potential
malignancy to offer the dedicated treatment in that
moment was another reason we were thinking about
this. Yeah. That's wonderful. And then I was
gonna ask you as a one more follow-up
question because I don't think we have touched
on this topic in full dates. Rose, so
helpful, so interesting.
How does it change you as the proceduralist

(27:34):
in the room to have the rapid on-site
there? What do you what technique are you
changing? How does it change the way you're
gonna proceed with the procedure like you did
in this case? Absolutely. So, Vish, you and
I can tag team this. I'll start. What
I really like about Rose is, overall, I
think there is a lot of verbal feedback
in terms of what material we're getting. Is
it adequate material? And is there any sort

(27:55):
of diagnostic certainty in the room that would
dictate how many samples that we need to
get? And then also, do we need to
change our technique from certain times? So oftentimes,
in the room, I'm finding myself saying there's
I'm seeing there's a little amount of material
or there's necrotic tissue. Perhaps endoscopically, I can
see that there's a different area of the
lymph node that I may be able to
attack so that I'm not getting that type
of material. And then also plus or minus

(28:17):
the utility of suction depending on the amount
of material that you're getting. And then also,
I think, oftentimes, we find ourselves, we want
to provide the highest stage and make sure
that we're completely staging in the procedure.
But oftentimes, I'm sure we've all been there
as procedureless where we're taking samples. We've done
it. We know we're in the node, but
we're getting nothing. And so then in that
way, we can make sure that we've

(28:39):
done our due diligence, but then also think
about pivoting to alternate sites that can give
us similar answers, but also are we're not
just hopelessly doing the same thing over and
for the long period of time because then
the patient is exposed to longer amounts of
anesthesia for the risk of complications.
So it allows us to just maintain a
mental model of staying on track,
our yield in the moment, and then also

(29:00):
real time communication about what we're receiving is
actually adequate for the patient. Vish, do you
agree? Anything else that you would add on
that?
No. The only thing I would add is
based on the CT, there were some of
the areas, some of these nodules that we
were intending to sample did look necrotic. What
can often happen, and I think you alluded
to this, is that you can get samples,
but it might be from the necrotic area.
Having somebody that would give you real time

(29:21):
feedback as in, doesn't look like a great
sample. This all looks like chronic material. It
can be very invaluable to prevent further from
future procedures. So I think in some of
those cases, it can actually be very helpful
and valuable.
Yeah. Thank you guys so much. I think
that's really valuable insight for all of us,
especially people who may be less familiar with
the EBIS process. So what'd you find? What
came up?

(29:42):
So on the pathology report, they saw that
there were tumor cells that are positive for
TTF-one, CK-seven, and APPCN, which is probably most
consistent with the diagnosis of millillary adenocarcinoma.
So, the patient had additional molecular testing,
which showed the presence of a fusion gene.
And based on that, he he was started
on a targeted therapy

(30:04):
called crizotinib,
which is a tyrosine kinase inhibitor.
Once again, the images that this patient have
are quite impressive,
and I'd encourage everyone to look at the
images after treatment.
And, in fact, what was diffuse malarial disease
seems to have almost disappeared
with treatment of his target treatment that is
directed towards his therapy. It is a very

(30:26):
nice set of images
after all and a very good outcome for
the patient overall.
That's great to hear. We'll definitely share the
images and make sure that people can see
it on our website. Maybe we'll even lead
with those. And such an interesting, maybe unexpected,
to 27 years old, I would certainly have
this low end differential, but great that we
got there and got them to a good
outcome.
This is a really amazing case. Thank you

(30:47):
both so much for coming on. One thing
that Monty and I love about
this series is not hearing great cases, meeting
fellows who are on the on the front
lines taking care of these patients, and then
also just spreading this network of people interested
in medical education and sharing insights. And everybody
just always has great pearls for us. So
we would love for you guys to share
a little bit more about KU and what

(31:09):
you like about training there. And I think
you're in interview season right now. So what
do you want your people who are interviewing
to know about your time there? Vish, I
guess we can start with you.
And that's a little cliche, but, my favorite
part about the program is similarly with co
fellows. They really do make the journey of
fellowship so much more enjoyable, and it's nice
to learn from them. The other thing I

(31:30):
really like about KU is about how collegial
the atmosphere he is. I remember texting doctor
Pandya maybe at seven or eight in the
at night about a new trial that had
come out, and what were his thoughts about
it? It's a great atmosphere to learn and
thrive, and it's something that I've really enjoyed
for the past couple of years.
Yeah. I'll pick you back up on that.
Yeah. I wanna thank you guys all for

(31:50):
the opportunity to speak today. It was a
really a fun and exciting time to chat
about these things. Here at the at KU,
we're really proud of our fellowship program because
I think, like Vish said, it really prioritizes
the fellow's voice to be the strongest. We
really hinge on real time and dynamic feedback.
We always say that if we are not
changing, then we are behind, and it is
so fun to be innovative with our fellows.
We will leverage really being creative, being innovative,

(32:13):
and really creating an environment where challenging the
status quo is welcome and celebrated.
And I think even more than that, we
value all of our fellows as human beings
and clinicians. And so we really wanna know
what they're doing at work, what they're doing
outside of work because who they are as
a whole is so important to us. And
we really focus on growth because all of
our fellows leave feeling confident and competent and
really being leader leaders in pulmonary and critical

(32:36):
care. So that's what we love about KU.
That is
it. That's awesome. That's yeah. So great to
hear and definitely Vishnath cliche.
Right? I was telling a trainee the other
day. I was like, the work that we
do is really hard. The training that you
go through is really hard and told me
you're in critical care medicine. So having that
supportive network
around you is so important. And that's from

(32:56):
co fellows to fellowship leadership. And just being
with y'all for the last twenty minutes, it
really seems that such a great and supportive
and collaborative environment. So excited that you have
that and excited for y'all to be able
to share that with us today.
This was really a fantastic case, and I
think some really nice points that we got
to share today and highlight. I know Dave
and I always end the episode with a

(33:17):
take home point. So I think for mine
today, Hill, I really liked how you went
over the distribution of pulmonary nodules and really
to think about that. And we talked about
the random distribution, the perilymphatic,
as well as the central distribution. So thanks
for sharing your approach and schema for that.
Bharath, what about you? What are you taking
away from today's case?
Oh, I had so many. I read with

(33:38):
the nodules. I I also thought that thinking
about EBIS in its multiple different facets of
both being able to obtain tissue, but actually
doing a visual inspection and being able to
try to stage things in the highest level
possible.
And then also, I appreciate that Vish bringing
up the fact that, when thinking about the
right procedure, a lot of this has to
do with what's gonna get you the best

(33:58):
answer, but then having that conversation with the
patient and laying out the options and what
the positive benefits are gonna be because you
can't really get to the next stage without
going through that.
Vish, any takeaway points you have from this
case?
Good. My takeaway
point from this was
really
how much of a great outcome this was.
We've all had that sense of dread where

(34:19):
we see something on imaging that might portend
a really poor prognosis,
but it's really remarkable to me that this
patient did so well after having imaging findings
that looked so terrible, if I'm being frank.
So it really speaks to the progress in
medicine that we've seen and gives meaning to
all the things that we do inside the
hospital and the clinic every day. So it
gives me a little bit more energy to

(34:39):
go back and do that again. So that's
that's that's my takeaway point from this.
Awesome. And I I think I would echo
that a 100%. And I think for me,
a big takeaway from this case being part
of it and seeing it come through of
all of our time is just the importance
of keeping the patient at the center. I
think the patient came in with a fair
amount of fear and was worried, and it

(35:00):
would have been so ideal for us to
have tissue in the beginning and be able
to expedite the process. But I think the
patient wasn't ready, and I think that's okay.
And I think we were able to gather
information. And so I think the patient really
appreciated that patient approach to allowing us to
justify the recent benefits of procedural intervention. And
I think it's easy to forget that part
that patients do have a lot of fear
with all the things that we do in

(35:21):
medicine, and meeting them where they are and
allowing them to partake in their decision making
really allows for the best outcome. So that
was a big takeaway for me in this
case.
Absolutely. Thank you both so much again for
coming on the show. Thank you all for
listening. Make sure to join us in a
couple weeks for our next episode. This episode
was edited and produced by myself and Christina
Montemayor, music's original music by Eric Rogers, and

(35:42):
we will see you next time.