Pulmonary hyalinizing granuloma: Atypical presentation

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(A). A clear chest X-ray without any lung lesions before starting TNF mAb therapy. (B). Bilateral diffuse military lesions on chest X-ray after TNF mAb therapy. (C). Bilateral innumerable micronodular opacities on chest computed tomography after TNF mAb therapy. (D). Resolved bilateral military nodules on chest computed tomography after anti-TB treatment." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C.-R. Wang, W.-C. Lin, Y.-S. Tsai" "autores" => array:3 [ 0 => array:2 [ "nombre" => "C.-R." "apellidos" => "Wang" ] 1 => array:2 [ "nombre" => "W.-C." "apellidos" => "Lin" ] 2 => array:2 [ "nombre" => "Y.-S." "apellidos" => "Tsai" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S253104372100043X?idApp=UINPBA00004E" "url" => "/25310437/0000002700000004/v1_202107020810/S253104372100043X/v1_202107020810/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2531043720302622" "issn" => "25310437" "doi" => "10.1016/j.pulmoe.2020.12.002" "estado" => "S300" "fechaPublicacion" => "2021-07-01" "aid" => "1574" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Pulmonol. 2021;27:359-61" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "The influence of the non-invasive ventilation mask interface on the upper airway of patients with amyotrophic lateral sclerosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "359" "paginaFinal" => "361" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1548 "Ancho" => 1505 "Tamanyo" => 383486 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Clinical data, ventilation details and pharyngeal area measurements. Patient 1 is a 64-year old male, diagnosed with ALS 1.5 years ago, ALSFRS-R of 32 points, Fuctional vital capacity of 69%, ventilated with a ResMed Stellar 150 (ET mode; IPAP 12 cmH2O; EPAP 4 cmH2O; Inspiratory time 0.7-1.2s; Respiratory frequency: 16 bpm; Cycle: medium; Rise time: 250 msec; Fall time: 100 msec). Using an oronasal mask RedMed AirFit F20 he presented a pharyngeal area (squared C2-C4, as proposed by Stokely et al.) of 8.91 cm2 (A) and with an intranasal mask ResMed AirFit P10 of 8.74 cm2 (B). Patient 2 is a 48-year old male, diagnosed with ALS 8 years ago, ALSFRS-R of 6 points, Functional vital capacity of 12%, ventilated with a ResMed Stellar 150 (ET mode; IPAP 17 cmH2O; EPAP 6 cmH2O; Inspiratory time: 0.8-1.5s; Respiratory frequency: 16 bpm; Cycle: medium; Rise time: 300 msec; Fall time: 200 msec). Using an oronasal mask ResMed AirFit F20 he presented a pharyngeal area (squared C2-C4) of 2.29 cm2 (C) and with an intranasal mask ResMed AirFit P10 of 6.21 cm2 (D)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alessandra Dorça, Max Sarmet, Vinicius Maldaner" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Alessandra" "apellidos" => "Dorça" ] 1 => array:2 [ "nombre" => "Max" "apellidos" => "Sarmet" ] 2 => array:2 [ "nombre" => "Vinicius" "apellidos" => "Maldaner" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043720302622?idApp=UINPBA00004E" "url" => "/25310437/0000002700000004/v1_202107020810/S2531043720302622/v1_202107020810/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Pulmonary hyalinizing granuloma: Atypical presentation" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "362" "paginaFinal" => "364" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Â.D. Cunha, N. Melo, S. Guimarães, C.S. Moura, J.M. Pereira, A. Morais" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Â.D." "apellidos" => "Cunha" "email" => array:1 [ 0 => "6979@hstviseu.min-saude.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Melo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Guimarães" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "C.S." "apellidos" => "Moura" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J.M." "apellidos" => "Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Morais" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Pulmonology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pulmonology Department, Centro Hospitalar São João, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pathology Department, Centro Hospitalar São João, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Radiology Department, Centro Hospitalar São João, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Faculdade de Medicina do Porto, University of Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Institute for Research and Innovation in Health (I3S), University of Porto, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3235 "Ancho" => 2925 "Tamanyo" => 1318774 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Chest CT scan showing bilateral peripheral consolidation areas in the lower lobes before (A and B) and after (C and D) complete chemotherapy scheme. (E1) Histology showing hyalinized lamellar collagen tissue surrounded by lymphoplasmacytic infiltrates (hematoxylin and eosin, ×200); and (E2) negative Congo red stain (CR, ×200)." ] ] ] "textoCompleto" => "In 1977, Engleman et al. described pulmonary hyalinizing granuloma (PHG) as a separate entity.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> This disease is rare and is radiologically characterized by multiple and often bilateral nodules with no preferential localization.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Its etiology and pathogenesis remain unclear, and a definitive diagnosis is provided by histopathological study of the lesions describing hyalinized lamellar collagen bundles surrounded by plasma cells, lymphocytes, and histiocytes. This disease usually evolves with a benign course with nodules slowly increasing in size over years. Specific treatment is not usually required, although corticosteroids have demonstrated some efficacy.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a>The etiology of PHG is not well established, and no relation to occupational exposure has been identified. Due to the frequent association with infectious, autoimmune, and tumoral diseases, an abnormal immune reaction has been proposed to explain the development of PHG.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3,4</a> In the case in the present report, we describe an uncommon association between PHG and a lymphoproliferative disorder. We found only four similar reports of associations with multicentric Castleman disease<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>; diffuse lymphocytic lymphoma of the abdomen<a class="elsevierStyleCrossRef" href="#bib0035">7</a>; and pulmonary small lymphocytic lymphoma<a class="elsevierStyleCrossRef" href="#bib0040">8</a>. The ages of these patients ranged between 43 and 50 years, and the patients were predominantly male (3 males/1 female). All patients presented with multiple and bilateral pulmonary nodules, and diagnosis was made through video-assisted thoracoscopic lung biopsy in three cases and by post-mortem examination in one case. Chemotherapy schemes targeted at lymphoproliferative disease which included corticosteroid were initiated in three cases. In two of these cases, there was a reduction in the lung nodule dimensions.We report a case of a 69-year-old man, former smoker (70 pack-years), with occupational exposure to dust and fumes from metallurgical casting and contact with birds, who presented to the emergency department with a 6-month history of progressive dyspnea. He reported mild fever, anorexia, and weight loss (10 kg over the prior 3 months). A physical examination revealed inspiratory crackles in the lower lungs. Chest computed tomography (CT) scan showed bilateral peripheral consolidation areas, mainly in the lower lobes but also involving the middle lobe and lingula (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> — A and B); the CT also revealed hepatosplenomegaly. Laboratory data demonstrated normocytic and normochromic anemia, and elevated levels of C-reactive protein and erythrocyte sedimentation rate. An autoimmunity study was negative. No endobronchial lesions were detected in the bronchoscopy. In the bronchoalveolar lavage, the total and differential cell counts revealed lymphocytic (47%) and neutrophilic (7.4%) alveolitis, which was negative for microorganisms and malignant cells. An initial pulmonary function test revealed moderate restrictive ventilatory alteration with a forced expiratory volume in one second (FEV1) 2.06 L (72.8% of the predicted value), forced vital capacity (FVC) 2.42 L (65.6%), preserved FEV1/FVC ratio, a total lung capacity (TLC) 4.51 L (68.5%), and carbon monoxide transfer factor (TLCO) 52%. A CT-guided transthoracic core biopsy was subsequently performed, and hyalinized lamellar collagen tissue surrounded by lymphoplasmacytic infiltrates was reported on histological examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E1). No evidence of neoplastic cells was found, and acid-fast, fungal, and Congo red stains were all negative (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E2). These findings were consistent with a diagnosis of PHG. The patient was started on oral corticosteroid therapy (deflazacort in an equivalent dose of 0.5 mg/kg/day of prednisolone, within a weaning scheme) and demonstrated partial clinical and functional but not radiological improvement.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Throughout the investigation, an indolent non-Hodgkin’s lymphoma (NHL) was incidentally diagnosed, supported by a bone marrow biopsy. The clinical case was, therefore, discussed in a multidisciplinary team, and with PHG hypothesized as a paraneoplastic manifestation of hematological disease, a decision to start NHL treatment was made. After completing eight cycles of chemotherapy (rituximab, cyclophosphamide, vincristine, and prednisolone), the patient had significant clinical, functional, and radiological improvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> — B and D). At the time this report was written, the patient was asymptomatic and functional with FEV1 2.88 L (106.5%), FVC 3.66 L (103.1%), TLC 5.83 L (89.7%), and TLCO 68%. No residual disease was found on further bone marrow tests.In summary, PHG is a rare entity with nonspecific symptoms and slow progression. Although isolated or multiple nodular lesions are the most frequent findings, PHG can occaisonally appear as lung parenchymal infiltration or consolidation with irregular or indistinct borders, such as in this case.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> In patients showing a rapid course and significant functional impairment, corticosteroid treatment may be attempted, despite the unclear efficacy of this approach. Due to the frequent association with underlying diseases, a careful investigation should be performed for therapeutic and prognostic implications.Ethical disclosuresThere are no personal details of patient in any part of the paper and in any supplementary materials (including illustrations).FundingNo funding.Conflicts of interestsThe authors have no conflicts of interest to declare." 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(E1) Histology showing hyalinized lamellar collagen tissue surrounded by lymphoplasmacytic infiltrates (hematoxylin and eosin, ×200); and (E2) negative Congo red stain (CR, ×200)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary hyalinizing granuloma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Engleman" 1 => "A.A. Liebow" 2 => "J. Gmelich" 3 => "P.J. 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Letter to the Editor

Pulmonary hyalinizing granuloma: Atypical presentation

Â.D. Cunhaa,

Corresponding author

6979@hstviseu.min-saude.pt

Corresponding author.

, N. Melob, S. Guimarãesc, C.S. Mourac, J.M. Pereirad, A. Moraisb,e,f

a Pulmonology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal

b Pulmonology Department, Centro Hospitalar São João, Porto, Portugal

c Pathology Department, Centro Hospitalar São João, Porto, Portugal

d Radiology Department, Centro Hospitalar São João, Porto, Portugal

e Faculdade de Medicina do Porto, University of Porto, Portugal

f Institute for Research and Innovation in Health (I3S), University of Porto, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1977&#44; Engleman et al&#46; described pulmonary hyalinizing granuloma &#40;PHG&#41; as a separate entity&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This disease is rare and is radiologically characterized by multiple and often bilateral nodules with no preferential localization&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Its etiology and pathogenesis remain unclear&#44; and a definitive diagnosis is provided by histopathological study of the lesions describing hyalinized lamellar collagen bundles surrounded by plasma cells&#44; lymphocytes&#44; and histiocytes&#46; This disease usually evolves with a benign course with nodules slowly increasing in size over years&#46; Specific treatment is not usually required&#44; although corticosteroids have demonstrated some efficacy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The etiology of PHG is not well established&#44; and no relation to occupational exposure has been identified&#46; Due to the frequent association with infectious&#44; autoimmune&#44; and tumoral diseases&#44; an abnormal immune reaction has been proposed to explain the development of PHG&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> In the case in the present report&#44; we describe an uncommon association between PHG and a lymphoproliferative disorder&#46; We found only four similar reports of associations with multicentric Castleman disease<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#59; diffuse lymphocytic lymphoma of the abdomen<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#59; and pulmonary small lymphocytic lymphoma<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; The ages of these patients ranged between 43 and 50 years&#44; and the patients were predominantly male &#40;3 males&#47;1 female&#41;&#46; All patients presented with multiple and bilateral pulmonary nodules&#44; and diagnosis was made through video-assisted thoracoscopic lung biopsy in three cases and by post-mortem examination in one case&#46; Chemotherapy schemes targeted at lymphoproliferative disease which included corticosteroid were initiated in three cases&#46; In two of these cases&#44; there was a reduction in the lung nodule dimensions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report a case of a 69-year-old man&#44; former smoker &#40;70 pack-years&#41;&#44; with occupational exposure to dust and fumes from metallurgical casting and contact with birds&#44; who presented to the emergency department with a 6-month history of progressive dyspnea&#46; He reported mild fever&#44; anorexia&#44; and weight loss &#40;10&#8239;kg over the prior 3 months&#41;&#46; A physical examination revealed inspiratory crackles in the lower lungs&#46; Chest computed tomography &#40;CT&#41; scan showed bilateral peripheral consolidation areas&#44; mainly in the lower lobes but also involving the middle lobe and lingula &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> &#8212; A and B&#41;&#59; the CT also revealed hepatosplenomegaly&#46; Laboratory data demonstrated normocytic and normochromic anemia&#44; and elevated levels of C-reactive protein and erythrocyte sedimentation rate&#46; An autoimmunity study was negative&#46; No endobronchial lesions were detected in the bronchoscopy&#46; In the bronchoalveolar lavage&#44; the total and differential cell counts revealed lymphocytic &#40;47&#37;&#41; and neutrophilic &#40;7&#46;4&#37;&#41; alveolitis&#44; which was negative for microorganisms and malignant cells&#46; An initial pulmonary function test revealed moderate restrictive ventilatory alteration with a forced expiratory volume in one second &#40;FEV1&#41; 2&#46;06&#8239;L &#40;72&#46;8&#37; of the predicted value&#41;&#44; forced vital capacity &#40;FVC&#41; 2&#46;42&#8239;L &#40;65&#46;6&#37;&#41;&#44; preserved FEV1&#47;FVC ratio&#44; a total lung capacity &#40;TLC&#41; 4&#46;51&#8239;L &#40;68&#46;5&#37;&#41;&#44; and carbon monoxide transfer factor &#40;TLCO&#41; 52&#37;&#46; A CT-guided transthoracic core biopsy was subsequently performed&#44; and hyalinized lamellar collagen tissue surrounded by lymphoplasmacytic infiltrates was reported on histological examination &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E<span class="elsevierStyleSup">1</span>&#41;&#46; No evidence of neoplastic cells was found&#44; and acid-fast&#44; fungal&#44; and Congo red stains were all negative &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E<span class="elsevierStyleSup">2</span>&#41;&#46; These findings were consistent with a diagnosis of PHG&#46; The patient was started on oral corticosteroid therapy &#40;deflazacort in an equivalent dose of 0&#46;5&#8239;mg&#47;kg&#47;day of prednisolone&#44; within a weaning scheme&#41; and demonstrated partial clinical and functional but not radiological improvement&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Throughout the investigation&#44; an indolent non-Hodgkin&#8217;s lymphoma &#40;NHL&#41; was incidentally diagnosed&#44; supported by a bone marrow biopsy&#46; The clinical case was&#44; therefore&#44; discussed in a multidisciplinary team&#44; and with PHG hypothesized as a paraneoplastic manifestation of hematological disease&#44; a decision to start NHL treatment was made&#46; After completing eight cycles of chemotherapy &#40;rituximab&#44; cyclophosphamide&#44; vincristine&#44; and prednisolone&#41;&#44; the patient had significant clinical&#44; functional&#44; and radiological improvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> &#8212; B and D&#41;&#46; At the time this report was written&#44; the patient was asymptomatic and functional with FEV1 2&#46;88&#8239;L &#40;106&#46;5&#37;&#41;&#44; FVC 3&#46;66&#8239;L &#40;103&#46;1&#37;&#41;&#44; TLC 5&#46;83&#8239;L &#40;89&#46;7&#37;&#41;&#44; and TLCO 68&#37;&#46; No residual disease was found on further bone marrow tests&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In summary&#44; PHG is a rare entity with nonspecific symptoms and slow progression&#46; Although isolated or multiple nodular lesions are the most frequent findings&#44; PHG can occaisonally appear as lung parenchymal infiltration or consolidation with irregular or indistinct borders&#44; such as in this case&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In patients showing a rapid course and significant functional impairment&#44; corticosteroid treatment may be attempted&#44; despite the unclear efficacy of this approach&#46; Due to the frequent association with underlying diseases&#44; a careful investigation should be performed for therapeutic and prognostic implications&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical disclosures</span><p id="par0030" class="elsevierStylePara elsevierViewall">There are no personal details of patient in any part of the paper and in any supplementary materials &#40;including illustrations&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">No funding&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Article information

ISSN: 25310437
Original language: English

DOI:10.1016/j.pulmoe.2020.09.002

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