Case Study #2

Infection Secondary to Aspiration:

Initiation of Enteral Nutrition and
Refeeding Syndrome

Sean Servalish
Andrews University
2016-2017
Introduction:
 E.N. is a 73-year-old, white male admitted to Lakeland Regional

Hospital medical/oncology unit after being transferred from Watervliet

Emergency Department with reported anemia and right lung mass.

The patient had complaints of malaise, nausea and vomiting since

starting antibiotics (Azithromycin) 2-month prior for pneumonia treatment.

After a short follow-up patient switched to Levaquin, another antibiotic, and

patient continued to experience the noted symptoms. E.N. also reported mid-

epigastric pain and loss of appetite leading to unintended weight loss with

occasional coughing of blood-streaked phlegm and constipation.

Anthropometrics include a weight of 79.8 kg (176 lbs.) and a height of

1.676 m (5 6). These measurements result in a BMI of 28; an overweight

category BMI. At this height, an ideal body weight for the individual would be

142 lbs. or 64.5 kg; he weighs 124% of his ideal body weight requiring an

adjusted body weight. His adjusted body weight came to 68.4 kg or 150 lbs.;

this was used to calculate his nutrition needs.

This patient was chosen for this study because of his high nutrition

priority due to weight loss, poor intake and advancement of illness requiring

a Percutaneous Endoscopic Gastrostomy (PEG) tube to be placed to help

begin enteral feedings to meet the patients nutritional needs. E.N. also was

high risk for Refeeding Syndrome and began to experience related signs. The

purpose of this study was to identify the situations in which enteral nutrition

is to be initiated vs parenteral nutrition and to define refeeding syndrome

and the patients and signs to look for in people who are risk for this
complication when transitioning to nutrition support. This study began on

1/5/17 and concluded on 1/13/17.

Social History:

E.N. is a married man who lives at home with his wife where he uses a

walker to ambulate at baseline, but is otherwise independent in activities of

daily living. However, he has a paid assistant who helps clean and grocery

shop once a week. Patient reports his wife suffers from bipolar disorder and

is not appropriate to answer medical questions at this point. The son of E.N.

is his primary support system and oversees making medical decisions if

needed. He is a retired man, his past profession unknown. He reports to

never being a smoker but currently consumes alcohol regularly; reports

having 2 shots of liquor per day.

Anatomy and Physiology of Lung Functions affected by Infection

Secondary to Dysphagia Related Aspiration:

E.N. had a lot of aspiration related complications prior to and

throughout his hospital stay. Therefore, it is important to understand the

process of swallowing and the effect of dysphagia and aspiration on lung

function. The swallowing process is broken down into 3 stages, based on the

location of the bolus: the oral phase (oral preparatory and propulsion), the

pharyngeal phase (food passage and airway protection) and esophageal

phase (passageway to the stomach).1 E.N. exhibited dysphagia and

aspiration, receiving a dysphagia diagnosis.

 With many lung complications surfacing while admitted, it is important

to analyze the effect of aspiration on the lungs. Aspiration is defined as the

inhalation of foreign material into the airways beyond the vocal cords. The

content of the aspirate is variable and may comprise of secretions, blood,

bacteria, liquids and food particles. Aspiration may be silent or witnessed.

Aspiration events can also be categorized as aspiration pneumonitis or

aspiration pneumonia (infectious process secondary to an aspiration event).

The course of pneumonitis can be broadly differentiated into 2 clinical

phases. Phase 1 involves intense coughing or bronchospasm that occur

immediately following the aspiration event where as the second phase

characterized by the onset of inflammation in the pulmonary occurs over the

2
next 46 hours. E.N. most likely has suffered from ongoing dysphagia and

aspiration causing inflammation long term, rather than the more commonly

observed short term inflammation from aspiration.

A result of this long-term aspirating/inflammation noted in the patient,

and the cause of many of his symptoms was Bronchorrhea. Bronchorrhea is a

complication of chronic inflammation to the lungs; it is defined at the

production of more than 100 ml of water sputum per day by the bronchioles

in the lungs and can cause serious complications like obstruction of the

airways.

Anemia was also an issue in this patient at admission. The etiology of

his case of anemia was unclear by discharge via the doctor, so other causes

of anemia were researched. People with anemia may feel tired because their
blood does not supply enough oxygen to the bodys organs and tissues. If

anemia becomes severe and prolonged, the lack of oxygen in the blood can

lead to shortness of breath or exercise intolerancea condition in which a

person becomes easily fatigued during or after physical activity (which this

patient reported) and eventually can cause the heart and other organs to

fail. Typically, one would think of iron deficiency anemia related to poor iron

intake. However, there are other causes/types of anemia. Anemia of

inflammation and chronic disease is a type of anemia that commonly occurs

with chronic, or long term, illnesses or infections. It is easily confused with

iron-deficient anemia because in both forms of anemia, levels of circulating

iron in the blood are low. Iron in the body is found both circulating in the

blood and stored in body tissues. Circulating iron is necessary for red blood

cell production. Low blood iron levels occur in iron-deficiency anemia

because levels of the iron stored in the bodys tissues are depleted. In

inflammation anemia, however, iron stores are normal or high. Low blood

iron levels occur in inflammation anemia, despite normal iron stores, because

inflammatory and chronic diseases interfere with the bodys ability to use

stored iron and absorb iron from the diet3. There was a diagnosis made in his

history for chronic disease anemia, and this is likely due to his related health

issues and chronic diseases/inflammation.

Enteral nutrition support is nutrition given through surgically placed

tube to help bypass non-functioning areas or areas needing rest (throat,

esophagus etc.) and feed the patient while allowing the remainder of the GI
tract to function normally. Enteral nutrition can help in the recovery process

or for long term nutrition if necessary.

Refeeding Syndrome, a complication of enteral nutrition is important to

identify for this study, as the patient referred to as E.N. was at risk for it prior

to beginning his feedings. Refeeding syndrome is used to describe several

common metabolic alterations that may occur during nutritional repletion in

patients in a starvation or low intake period (patient has poor intake for a

month or more). Basically, the nutrition form of energy in normal diets and in

the enteral feedings (glucose) requires phosphorus to metabolize to energy,

as well as decent amounts of magnesium, potassium and thiamin (these are

the micronutrients we monitor closely in patients on nutrition support and

even more tightly in those at higher risk for refeeding syndrome). When this

phenomenon occurs, serum levels of the nutrients drop and respiratory

function impairment, cardiac arrhythmias, muscle twitching, spasms and

even death can occur5. To avoid refeeding syndrome, we initiate feedings at a

much lower rate than the goal rate for their specific needs. This way, we can

monitor their levels closely as we increase their dosage in increments over

24-48 hours. If these levels start to drop rather suddenly, we lower their

dosage and supplement them with their lacking micronutrient and slowly try

to work them back to goal again.

Past Medical History

E.N. doesnt have an extensive past medical and surgery history. His

medical conditions listed include: hypertension, hypothyroidism, anemia of

chronic disease, severe protein-calorie malnutrition, excessive weight loss,

lung mass, pituitary mass, dysphagia and aspiration pneumonia. His past

surgeries include a cervical disc surgery and a pituitary surgery where he

states he had a part of his pituitary removed.

Present Medical Status and Treatment:

On January 4th, E.N. was admitted to Lakeland Saint Joseph from a

partner hospital Lakeland Watervliet, where he came with complaints of

malaise, nausea and vomiting since he started taking antibiotics in

November (3 months prior). He was taking Azithromycin initially, and later

switched to Levofloxacin with no improvement in related symptoms. He

confirmed that he had been coughing up blood stained phlegm lately. He also

reported a loss of appetite and weight loss, he estimates about 10 lbs. He

was admitted with diagnosed with severe anemia and a right lung mass of

current unknown cause. The anemia was also of an unknown etiology, the

doctor initially suspected possible blood loss or malnutrition. The MD initially

addressed this with a single unit blood transfusion and considered consulting

a GI (gastrointestinal) specialist. The right lung mass is suspected to be

infection or a neoplasm due to lab values related to these diagnoses showing

no abnormalities. These were the two largest issues to be addressed and

followed upon admission. Medication for his nausea and stomach pain were

prescribed to make the patient more comfortable while monitoring the

mentioned concerns as well as a mild renal insufficiency, thrombocytopenia,

low potassium and his malnutrition state. Chest X-ray and Chest CT tests
confirmed this large mass and scarring from damage to the lungs from long-

term or past disease and inflammation.

On January 5th, a Pulmonology Specialist completed his assessment

with patient E.N. His impression was that there was necrosis present in the

findings of the CT test from the day prior in the lungs. Dysphagia was

identified as a possible concern for the first time as the doctor was

concerned this was the possible cause of pulmonary issues and mass in the

patient. Speech therapy was consulted for this focus and they recommended

a video-swallow exam to help confirm the dysphagia suggested.

Supplemented oxygen has been used and will continue to take place as well

as aggressive pulmonary hygiene (helps remove mucus and debris from

airways) to help maintain respiratory function. Finally, a bronchoscopy was

planned for the morning to determine internal damage of the lung from the

lobular mass as well as collecting washings from the mass to determine

cause and rule out bacterium and neoplasm. Cause of the severe anemia

remains unclear; two more units of blood were transfused. More scans were

ordered to determine any yet discovered malignancies or disease.

Fluid secretions were found during bronchoscopy around the

consolidated mass as well a good amount of inflammation; pus and fluid

were drained. The washings and samples were sent to lab for evaluation but

the Pulmonologist believed it to be infectious and made plans on antibiotic

therapy pending results.

 On January 9th, a formal video-swallow test was performed by the

Speech-Language Pathologist. Her findings confirmed dysphagia; noting a

poor epiglottis function and upper esophageal sphincter dysfunction. Patient

aspirated on fluids during the test and the recommendation for another route

of nutrition (enteral) to be able to avoid this problematic, poor functioning

area of the digestive system that may be causing chronic inflammation of

the lungs. Labs also shared results of the bronchoscopy; negative for a

malignancy. PEG tube placement and endoscopy referral made to create this

alternative form of nutrition. A percutaneous endoscopic gastrostomy (PEG)

is a procedure for placing a feeding tube directly into the stomach through a

small incision in the abdominal wall with the assistance of an instrument

known as an endoscope6. Nutrition was consulted for the appropriate formula

and feedings as well as flushings for this patient. The EGD scope during the

procedure for the PEG placement found a nose bleed in the rear of one of the

nostrils that may be causing this coughing of blood.

After becoming stable with his enteral feedings, the attending

physician deemed E.N. to be medically stable enough to be discharged to

Royalton Manor, a skilled nursing facility where he can be more closely

monitored. GI, pulmonary and dentist referrals for outpatient follow-ups were

made at this time and the patient was discharged on continuous enteral

feedings on January 13th. Hemoglobin and hematocrit were still very low at

discharge.
Labs: Admission vs Discharge days

Lab: Admission Final Lab Normal Range

Lab values values on for Lab Value:
on 1/12-13/17
1/04/17:
White Blood Cell 3.9 4.5 4.5 - 11
count
Red Blood Cell 2.46 (L) 2.59 (L) 4.0 - 5.2
count
Hemoglobin 6.8 (LL) 7.5 (L) 12.0 -16.0
Hematocrit 20.4 (LL) 22.9 (L) 35.0-47.0%
Mean Corpuscular 83 82.6 80 100 fL
Volume
MCH 27.7 27.0 26-34 pg/cell
MCHC 33.4 32.7 32-37 g/dL
RDW 16.9 (H) 14.5 11.5 14.5%
Platelets 126 (L) 126 (L) 140 440
Random Glucose 107 143 (H) 65-100 mg/dL
Blood Urea 27 (H) 28 8-26, 835 mg/dL
Nitrogen
Creatinine 1.3 (H) 1.1 0.5 - 1.0, 0.7-1.3
mg/dL
BUN/Creatinine 21 25 7-25
Ratio
eGFR 54 (L) >60 >60 mL/min
Sodium 135 (L) 141 136 - 143 mmol/L
Potassium 3.7 4.0 3.6-5.0 mmol/L
Chloride 105 104 96 107 mmol/L
CO2 23 27 22-31 mmol/L
Total Calcium 8.6 8.2 (L) 8.4 10.2 mg/dL
Total Protein 6.9 5.6(L) 6.4 -8.2 g/dL
Albumin 2.8 (L) 2.5 (L) 3.2 4.6 g/dL
AST 10 20 10-42 U/L
ALT 10 (L) 26 17-63 U/L
Alkaline 61 79 38-126 U/L
Phosphatase
Medications:

Drug/Nutrient
Medication Purpose Possible Side Effects
Interaction
PRN:
Absorption of sodium
Indigestion, Poor appetite, fatigue,
phosphate
Maalox upset stomach, weakness, diarrhea,
supplements and
heartburn. constipation
other supplements.
Caffeine and other GI Upset stomach, nausea,
Mild pain relief irritants. K+ vomiting, headache,
Ibuprofen
and fever. supplements for diarrhea, constipation,
coagulation dizziness.
ROUTINE:
It can treat high
Dont take with
Dizziness, drowsiness,
blood pressure orange juice, low Na+
Tenormin fatigue, bradycardia,
and chest pain Low Ca+ diet can
depression.
(angina). help. Avoid ETOH
Avoid ETOH. Avoid Dry mouth, nausea,
natural licorice, abdominal pain, diarrhea,
Cardura Treat High BP
grapefruit. Take 30 constipation, dizziness,
mins post-pran weakness.
Take with water, not Poor taste, diarrhea,
orange juice. 2 hr abdominal pain,
Antibiotic
Levaquin before or after Zn, constipation, flatulence,
infection
antacid, Mg, Ca, Fe, headache, insomnia,
MVI. dizziness, fatigue.
Take on empty
stomach, 30 minutes
before breakfast. Take
supplements with Mg, Poor appetite, weight loss,
It can treat
Synthroid Ca, or Fe 4+ hours nausea, diarrhea,
hypothyroidism
apart from this. Take headache, insomnia.
2-3 hours prior to soy
consumption.

Dry mouth/throat,
It can treat or Limit shakiness, restlessness,
Proventil prevent caffeine/xanthine, nervousness, excitement,
bronchospasm. avoid alcohol, or trouble sleeping

Augmentin Antibiotic for Take with food if GI Nausea, vomiting,

 upset occurs. Food
diarrhea, stomatitis,
infection doesnt affect
glossitis.
absorption.
Take with milk after
meals to avoid GI Taste loss, nausea,
Uric acid
Zyloprim distress. Avoid large vomiting, gastritis,
reducer for gout
dose of Vitamin C. diarrhea, headache, fever.
Limit alcohol.
Constipation, diarrhea,
Nausea and tiredness, weakness,
Zofran None
vomiting headache, dry mouth,
abdominal pain.

Procedures/Tests:

1/4/17 Chest X-Ray

- Findings showed that the previous discovered mass of the right upper

lung has increased in size. Atherosclerosis is present as well as

spondylosis (spinal disc deterioration).

1/4/17 Chest CT

- Findings: confirmed increased in lobe mass size. Enlarged spleen found

(splenomegaly), hepatic lobe cysts. Small pleural effusions, larger on

the right side. Scarring from previous disease.

1/6/17 Bronchoscopy:
 - Findings of fluid secretion and inflammation discovered in the right

lung and washings of the area mass were obtained to determine cause.

Findings returned negative for malignancy.

1/9/17 Chest X-Ray

- Findings mass in lung consolidating (becomes solid)

1/9/17 Video-fluoroscopic Swallow Study

- Findings: poor epiglottis movement, decreased sphincter opening,

aspiration present.
- Dysphagia diagnosed patient recommended to receive nutrition non-

orally

1/11/17 Upper GI Endoscopy & PEG Tube Placement:

- Findings: multiple small polyps with no bleeding and no previous signs

of bleeding were found in the stomach. PEG tube was placed that can

be externally removed if needed. Small bleeding in posterior pharynx

also noted. Believes blood in phlegm is coming from a posterior nose

bleed in one nostril.

1/13/17 Cranial Nerve/Brain MRI

- Enlarged pituitary gland, stroke has been ruled out as cause of

dysphagia.

Medical Nutrition Therapy:

The first encounter with E.N. occurred for a consult made for the poor

appetite and weight loss reported by the patient at time of admission. These

are standard questions that help trigger different aspects of the care team to

make them aware of the patient and to help ensure they are followed by the
appropriate professionals. Patient had difficulty speaking for long periods of

time so questions were kept simple and easy to answer for him. E.N.

confirmed weight loss recently related to a poor appetite. A concern noted

was that the calculated weight loss for time period was 7% over a week

(from 12/27/16 to 1/4/17), which is a very severe loss; however, his weight

prior to admission and for several months prior, which came from his

doctors office appointments was the same exact number with the note

patient states he weighs himself at home, uses wheel chair, these are

reported weights. The issue with this is that his weight may have not been

the same for those months, which could affect the severity of this patients

nutrition risk/priority here at the hospital, nutritionally speaking, and an

intervention or diagnosis could have taken place or been made at an earlier

time, benefitting his prognosis. E.N. stated at this time he had been

experiencing nausea, vomiting and occasional constipation recently and that

he agrees to address his recent weight loss with a calorie and protein-dense

supplement. Upon a thorough nutritional focused physical exam, it was

determined that the patient had experienced very little muscle or fat

wasting, and had a normal grip strength. However, the reported weight loss

and poor appetite required a severe malnutrition diagnosis. A 24-hour diet

recall was unable to be obtained from the patient at said time due to obvious

distress and lack of ability to speak for required periods of time. Plans to

obtain one at a follow-up assessment were made by dietetic intern who

completed this nutritional assessment. With E.N. at 124% of his ideal body
weight (142 lbs. ideally, 176 lbs. actual) an adjusted body weight of 68.4 kg

was used to calculated needs. The patients estimated nutrition needs were

as follows:

Calories 1710-2052 kcals based on 25 30 kcal per kg to

help maintain his weight while he is ill and losing weight.
Protein: 68-82 g based on 1 1.2 g per kg which is an
increase from baseline needs to help replete muscle loss
and encompass need for recovery.
Fluid: 1710-2052 based on 1 milliliter per kcal to meet
baseline hydration needs.

At this initial assessment, a nutritional diagnosis was assigned. It was

as follows:

Inadequate oral intake related to physiological causes increasing

nutrient needs as evidenced by a severe weight change of 7% in a week and

poor appetite for over 1 month.

While on a general diet at the time of initial assessment, which was

appropriate for his diagnosis, a goal of meeting >75% of his recommended

needs via oral intake over on 3-5 days was established for E.N.

The nutrition prescription at this time with the corresponding

intervention for this 1/5/17 assessment reads as follows:

1. General diet Recommend this diet to promote oral intake

to meet greater than 75% of his recommended needs.
2. Boost Plus Strawberry Order this commercial beverage
twice daily to increase protein and calories with recent
 weight loss and poor appetite. This supplement, twice a day
provided 720 kcal and 28 grams of protein.

Following a 3-5-day policy requirement for follow-ups in patients with

higher nutritional risk, the patient was encountered again on 1/10/17 by the

dietetic intern. The Speech-Language Pathologist had done an assessment

and video-swallow test on recently due to coughing, choking and swallowing

issues reported by patient. She gave the recommendation that the patient

not eat/drink anything orally (NPO) and that another route of nutrition intake

be investigated. Patient was in even more distress at time of follow-up and

the nurse reported he was struggling to form words and sentences recently

so a 24-hour recall was still unable to be obtained. Now NPO, a 24-hour recall

will not be necessary moving forward due to a different route of nutrition

needed, likely to be long-term. Enteral nutrition recommendations were

included in the follow-up prescription for use at any time. The diagnosis and

calorie needs were unchanged. The prescription and corresponding

interventions for this follow-up were as follows:

1. Isosource 1.5 at goal rate of 60 ml/hr for 22 hours a day

(must hold one hour before and one hour after Synthroid
administration) - Recommend this hyper-caloric, high
protein, fiber containing formula to meet patients
nutritional needs with a low volume, and fiber to maintain GI
tract function. Pending initiation of enteral feedings. This
will provide 1980 kcals, 89 g of protein and 1630 ml fluid per
day.
2. Tube flushes: 100 milliliters every 4 hours once IV fluids are
stopped. - Recommend this to hydrate patient adequately
and maintain tube cleanliness.
 To avoid Refeeding Syndrome in this patient, the rate began at 15 ml

per hour and increasing by 15 ml/hour every 6 hours (only if tolerated) to

eventual goal of 60 milliliters per hour. After not meeting the initial

assessment goal, a more appropriate nutrition goal was assigned: Timely

initiation of nutrition support over the next 2-3 days.

Following the procedure to place the Percutaneous endoscopic

gastrostomy (PEG) tube, a consult was placed mostly as formality to let us

know initiation of feedings was beginning soon in the patient. The

recommendations were reiterated in a note by the following RD.

On 1/12/17 dietetic intern followed up with patient again, as he is an

even higher priority for nutrition with a newly initiated enteral feeding. E.N.

was in an even more noticeable state of confusion and expressed inability to

speak well. The nurse present explained he was tolerating feedings well and

displaying little to no residuals; which is the remaining feeding amount that

is pulled back out of the GI tract via a syringe in the PEG tube to determine

absorption and gut motility. At this point in his admission, Synthroid was

discontinued from his plan of care and therefore, feedings were adjusted to

55 ml per hour and made continuous at 24 hours a day instead of the

previous 22 hours which gave time for this medication to work properly.

Magnesium and potassium levels were low at the time of this encounter. To

correct this, a rider (supplemented to his normal feeding) of potassium and

magnesium were ordered. With a medically identified infection, protein

needs were adjusted to 1.4-1.6 g/kg from previously noted

recommendations; this formula at this rate still encompassed that need as

well as caloric and fluid requirements. Patients new goal after meeting

previous goal: meet >75% recommended needs via enteral nutrition over 3-

5 days.

A sudden discharge order was discovered on 1/13/17 as patient was

deemed medically stable. Upon review of labs on that day, magnesium and

potassium had normalized, but phosphorus levels had dropped suddenly.

This is another sign of refeeding syndrome. An order for rider prior to

discharge was ordered and patient safely transferred to a skilled nursing

facility with orders to monitor labs, especially those related to refeeding

syndrome daily, and to eventually advance his feedings to bolus; where large

amounts of feedings are given 3-5 times daily to improve quality of life vs.

continuous around-the-clock feeding.

Prognosis:

The prognosis of this patient is unclear at this time. Instead of

returning to home, he is going to a skilled nursing facility, which indicates

the doctor believes E.N. needs continued monitoring of his labs, treatment

and response to therapies used to intervene. With reoccurring and minimally

resolved severe anemia from a cause that has been difficult to diagnose, a

pulmonary mass that continuously secretes fluid making respirations

difficult, a newly placed PEG tube with experienced refeeding syndrome

symptoms and given the patients old age and recent malnutrition, it is

difficult to give a positive prognosis. His health will vary day to day and
pending his bodys response to continued drug, nutrition and physical

therapy. He should benefit from reduced aspirating events, which may have

caused ongoing inflammation and damage to the pulmonary system. Patient

has stabilized during his stay at Lakeland in terms of lung function (oxygen

saturation), calorie intake and therefore weight and his pain level. A large

goal for the patient is to continue to receive adequate nutrition to maintain

his weight and aide in recovery from an anemic and fatigued state.

Improving his strength and lung capacity with medication, treatment to drain

fluid as needed and a physical/occupational team will be crucial in his overall

health.

Post timeline of this study, the patient was readmitted with severe

anemic lab values from the skilled nursing facility. A blood transfusion was

done again and a few medications were adjusted and changed for similar

ones, specifically antibiotics. Unfortunately, this patient passed away from

causes unable to be attained from the records available. This occurred 3

weeks after the initial admission mentioned.

Summary:

Studying this patient and his journey and progress through his

specific disease process has taught me many new aspects of clinical nutrition

and care. The first aspect is the complications that can occur in the

pulmonary system from chronic aspiration and inflammation and their

relationship to one another. The medical, drug and nutritional interventions

to treat complications like insufficient respirations, low oxygenation in the

blood and anemias relation to this were something I learned as well. I also

observed the process and procedures by professional healthcare team

members to help determine if a patient should be recommended for nutrition

support. These members include, but are not limited to, the Speech-

Language Pathologist, Medical Doctor, specialists, and the dietitian.

Refeeding syndrome was another aspect I experienced with this patient and I

further educated myself on the signs/symptoms of patients experiencing this

phenomenon and the factors that put a person more at risk for refeeding

syndrome when initiating enteral or parenteral nutrition. Aside from clinical

definitions, procedures and medications, I learned that not every patient can

improve and get through an illness. Death is a real thing and sometimes is

inevitable for those with serious health concerns; I am beginning to accept

that as a future health care professional. E.N. was a very interesting subject

to study and his cooperation was much appreciated.

References:

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and rehabilitation clinics of
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2. Raghavendran, Krishnan et al. Aspiration-Induced Lung Injury. Critical
care medicine 39.4 (2011): 818826. PMC. Web. 3 Feb. 2017.
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as a Significant Clinical Presentation of an Invasive Mucinous
Adenocarcinoma of the Lung. University of Tennessee Health Science
Center. American Thoracic Society Journals. 2015. Web. 3 Feb. 2017
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Feb. 2017.
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