Abnormal Chest Roentgenogram Research Articles

Dyspnea and an Abnormal Chest Roentgenogram in an Elderly Housewife

DOI: http://dx.doi.org/10.5915/17-1-12747 A case of dyspnea and an abnormal chest x-ray in a 66-year old housewife is presented as a diagnostic challenge. Asbestos-related pulmonary and pleural changes are discussed with possible relevance to this patient's clinical findings.

Transbronchial lung biopsy in pediatric and adolescent patients.

Since data are unavailable on the role of transbronchial lung biopsy (TBB) in pediatric and adolescent patients, we reviewed our two-year experience in 12 patients (median age, 14.5 years). In all 12, the indication for TBB was a persistently abnormal chest roentgenogram (nine with multilobar infiltrates, two with unilateral infiltrates, and one with a cavitary lesion). Overall, a specific diagnosis was made by TBB in six patients, including three patients with sarcoidosis, one with lymphoma, and two with eosinophilic granuloma. In three additional patients, nonspecific histologic findings on TBB combined with clinical findings, roentgenographic patterns, and supplemental laboratory data helped support a diagnosis. Although the need for general anesthesia and the small size of the biopsy specimens may limit the usefulness of TBB in most pediatric patients, TBB may be a useful alternative in carefully selected patients.

Disseminated Aspergillosis Complicating Hepatic Failure

To the Editor. —In the June 1983 Archives, Walsh and Hamilton 1 reported three cases of disseminated aspergillosis complicating hepatic failure. The patients in all three of these rare cases received corticosteroid treatment. We recently treated a case in which the only predisposing factors were cirrhosis and heavy drinking. Report of a Case. —A 32-year-old man was admitted to the hospital with a three-day history of Jaundice, fever, and obnubilation. He also had an abnormal chest roentgenogram. He had had a previous diagnosis of chronic sequelae of alcohol consumption 15 months before, and he continued to be a heavy drinker. Physical examination showed a temperature of 38.8 °C, icterus, spider nevi, flapping tremor, and confusion. Examination of the thorax disclosed scattered ronchi and basal rales. The patient's liver was palpable 8 cm below the right costal margin. The spleen was not felt and there were no ascites. Laboratory studies disclosed

Isolation of pathogenic bacteria from the nasopharynx of children with respiratory syncytial virus infection. Predictive value of chest roentgen examination and laboratory tests.

Potentially pathogenic bacteria were isolated from the nasopharynx in 33/66 hospitalized infants and children with verified respiratory syncytial virus (RSV) infection. The value of chest roentgenograms and blood counts for the prediction of concomitant bacterial infection was evaluated. Abnormal chest roentgenograms were found in 89% whether pathogenic bacteria were present or not. The most common finding was general hyperinflation of the lungs, with or without infiltrates. This occurred more frequently in the group with isolated RSV infection. Fever, leucocytosis and an elevated ESR were found during the illness in more than half the cases. These findings were more frequent in children who harboured potential pathogenic bacteria, though the difference was not significant. For optimal evaluation of a case all available information about it should be taken into consideration.

Usefulness of Screening Chest Roentgenograms in Preoperative Patients

We proposed that clinical criteria could define a group of patients very unlikely to have abnormal preoperative chest roentgenograms. Nine hundred five surgical admissions were screened for the presence of clinical factors we thought would make those patients more likely to have abnormal preoperative chest roentgenograms. Of these, 368 had no risk factors. One patient (0.3%) of the 368 had an abnormal x-ray film, which did not affect the surgery. No material abnormalities were found in the remainder of the group without risk factors. Five hundred four patients had identifiable risk factors. Of these, 114 (22%) were found to have serious abnormalities on preoperative chest roentgenogram.

Diagnosis of Disseminated Coccidioidomycosis by Liver Biopsy

The liver is commonly involved at autopsy in disseminated coccidioidomycosis, but it is distinctly unusual to diagnose disseminated coccidioidal disease by a liver biopsy. We describe three patients with hepatic coccidioidomycosis diagnosed by liver biopsy in addition to the four previously reported cases in the literature. Most patients had a hepatitislike illness with pulmonary infiltrates of short duration. Hepatomegaly and/or abnormal liver function test results were present in six of seven patients. All patients had an abnormal chest roentgenogram. Eosinophilia was found in five patients. Every biopsy specimen showed evidence of granulomas containing readily identifiable coccidioidallike spherules. The condition of six of seven patients improved following therapy and only one died. Hepatic coccidioidomycosis is an unusual manifestation of dissemination that is commonly a hepatic-pulmonary syndrome with eosinophilia. The diagnosis is readily made with liver biopsy, and the outcome may be more favorable than other forms of dissemination.

Indications for flexible fiberoptic bronchoscopy in pediatric patients.

Although the availability of flexible fiberoptic bronchoscopy (FFB) has been a major advance in adult pulmonary medicine, the role of FFB in pediatrics has remained less well defined. Therefore, a two-year retrospective study was undertaken to determine the indications for FFB in 95 pediatric patients (mean age, 6.9 years) who underwent 129 FFB procedures. Indications for FFB included stridor (41/129), abnormal chest roentgenogram (38/129), airway evaluation in patients with tracheostomy (13/129), airway obstruction (11/129), hoarseness (9/129), recurrent pneumonia (7/129), chronic cough (4/129), failed extubation (3/129), tracheal injury (2/129), and hemoptysis (1/129). Overall, a specific diagnosis was made in 88% of cases, of which 48% involved a lower airway disorder. A minor complication rate of 2% was observed with no major complications.

Treatment of tuberculosis and other mycobacterial diseases.

In controlled clinical trials, several regimens have proven effective in treating tuberculosis. The drugs must be given in combination to avoid the emergence of resistant organisms. The simplest regimen is based on the administration of isoniazid and rifampin for 9 months. Ethambutol or streptomycin generally is added for an initial 2-8 weeks. Good results also have been reported using twice weekly administration of the isoniazid and rifampin after an initial 1 month of daily treatment. Relapse rates of less than 3% have been reported with these regimens. A table shows the recommended doses for the drugs. If neither isoniazid nor rifampin can be used, the patient needs to be given at least 2 and preferably 3 drugs to which his organisms are known to be susceptible. Additionally, these drugs must be administered for at least 18 months. Several circumstances are associated with a higher rate of drug resistant organisms and call for susceptibility studies: tuberculosis among individuals known to have a higher prevalence of drug resistance such as Asians or Hispanics; previous treatment; persistence of culture-positive sputum after 3 months of therapy; and exposure to drug resistant tuberculosis. The recommendations for the treatment regimen need to be changed in several special situations, including: infection with mycobacteria other than "M. tuberculosis;" tuberculosis in children; disease in organ systems other than the lungs; and the presence of certain patient characteristics, concurrent diseases, or the development of adverse drug reactions. Much scientific data supports the value of isoniazid (INH) in the prevention of tuberculosis. Isoniazid preventive therapy is recommended for several groups, listed in order of priority: household members and other close associates of potentially infectious tuberculosis cases; newly infected persons; persons with significant reactions to tuberculin skin test and abnormal chest roentgenograms; persons with significant reactions to tuberculin skin tests who are in special clinical situations; and tuberculin skin test reactors under age 35 with none of the other risk factors. Prior to administration of INH preventive therapy, it is important to: exclude bacteriologically positive or progressive tuberculous disease; question for a history of prior INH administration to exclude those who have had a adequate course of the drug; check for contraindications to the administration of INH for preventive therapy; and identify patients for whom preventive therapy is not contraindicated but in whom special precautions are indicated. Other drugs might be effective for preventive therapy, but as yet there are currently no data available documenting the efficacy of any drug other than INH.

Central Bilateral Pulmonary Infiltrates in an Asymptomatic Man

History A 34-year-old asymptomatic man was referred to us for evaluation of an abnormal chest roentgenogram obtained during a preemployment evaluation. He had not suffered from any pulmonary disease in the past, and his family history was unremarkable. No history of drug use or abuse was obtained; he had smoked one pack of cigarettes daily for 15 years. He had done some demolition work in Vietnam from 1965 to 1969, odd jobs in southern California from 1969 to 1979, and less than a year of demolition work in Minnesota just before moving to Wisconsin. He stated that he had had no radiological studies of the chest during the past 12 years. Findings from physical examination, urinalysis, screening blood chemistry studies, and pulmonary function studies (spirometry, lung volumes, diffusing capacity, and arterial blood gases) were normal, as was a complete blood cell count. Posteroanterior (PA) and lateral chest roentgenograms are shown

Toxic shock syndrome: management and long-term sequelae.

Little information is available on the optimal management of toxic shock syndrome and on its sequelae. The most appropriate antibiotic treatment, the efficacy of colloid infusions, and the potential role of gamma globulin preparations have not yet been completely ascertained. Coagulase-positive staphylococci associated with toxic shock syndrome had minimal inhibitory concentrations of 0.06 microgram/mL or less to rifampin, 0.25 microgram/mL or less to gentamicin, and 0.50 microgram/mL or less to both nafcillin and clindamycin. In the 36 patients studied abnormal chest roentgenograms were commoner in those who had received albumin than in those who had not. Radioimmunoassay showed antibody titers to staphylococcal enterotoxin F, a marker protein in toxic shock syndrome, of 1:4000 or more for intravenous gamma globulin (12/15 lots) and 1:40 000 or more for intramuscular gamma globulin. Major sequelae of toxic shock syndrome include late-onset rash, compromised renal function, cyanotic extremities, and prolonged neuromuscular abnormalities.

False aneurysm of the left coronary artery

The case of a 65-year-old white man with a large false aneurysm of the left coronary artery resulting from spontaneous rupture of the circumflex coronary artery is described. An abnormal chest roentgenogram resulted in initial evaluation, and a coronary aneurysm was then suspected on the basis of two-dimensional echocardiography. Cardiac catheterization demonstrated a large, saccular false aneurysm arising from the left coronary artery and diffuse aneurysmal disease of the right coronary artery. The patient underwent surgical resection of the aneurysm and saphenous vein aorta-coronary bypass grafting but failed to survive the postoperative period. Pathological examination documented histologic proof of a false aneurysm. The optimal treatment for coronary artery aneurysms is unknown but must be based on symptomatic associated arteriosclerotic heart disease and the risks of complications related to the aneurysm, including the risk of rupture with formation of a false aneurysm as documented in this case.

Legionnaires' Disease in an Immunologically Normal Child

Legionnaires' disease is being recognized more frequently in children. Recent reports of cases in a child with lymphocytic leukemia 1 and in one with Down's syndrome 2 emphasize the possibility that immunocompromise is an antecedent risk factor. We report a case of Legionnaires' disease in an immunologically normal child. Report of a Case. —A 4-year-old girl was referred to Naval Regional Medical Center, Portsmouth, Va, for fever, dyspnea, and an abnormal chest roentgenogram on March 1, 1980. Her illness had begun five days previously with mild congestion and generalized malaise. Four days prior to admission, a school physical examination had revealed an erythematous throat but with no complaints. A throat culture had been done. During the 72 hours before admission, she had had temperature of 39.5 °C, and right-sided chest and shoulder pain had developed with rapid, shallow respirations. Chest roentgenogram revealed a right middle lung field perihilar infiltrate. She

The effect of mechanical vibration physiotherapy on arterial oxygenation in acutely ill patients with atelectasis or pneumonia.

The effect of mechanical chest vibration on arterial blood gases was studied in 10 patients requiring oxygen therapy who had acute lung disease and an abnormal chest roentgenogram. Eight patients were using mechanical ventilators. For the duration of the study, patients were seated or in a high semi-Fowlers position. No other pharmacologic or physical therapy was given during the study period, nor was there any change in the fraction of inspired oxygen or the respirator settings. The patients ranged from 23 to 89 yr of age. After control blood gas measurements were taken, each patient received 30 min of mechanical vibration to the thorax followed immediately by tracheal suction. Blood gases were re-examined 30 min and 1 h after completion of the physiotherapy. Results showed a significant increase in PO2 at 30 min and 1 h after completion of mechanical chest vibration with no change in PCO2 or pH. This study demonstrated that external mechanical vibration of the chest is a useful therapeutic modality in the management of hypoxemia in patients with atelectasis or pneumonia. This was reflected by the increase in PO2 with no change in alveolar ventilation. We presume the better matching of ventilation to perfusion accounted for our results.

Criteria for hospitalizing children who have ingested products containing hydrocarbons

The clinical records of 950 children who ingested products containing hydrocarbons were reviewed. Eight hundred children were asymptomatic at the time of the initial evaluation and remained so during a six-to eight-hour period of observation. All had normal chest films, and all were treated as outpatients. One hundred fifty other children were admitted to the hospital; 79 were symptomatic at the time of initial medical evaluation and had abnormal chest roentgenograms. Seventy-one other children were asymptomatic but had roentgenographic evidence of pulmonary involvement (36) or had had pulmonary symptoms before arriving at the medical facility (35). Complications (seven) occurred only in symptomatic children who had roentgenographic evidence of pneumonia. These data suggest that the majority of children who are brought for medical evaluation after ingesting hydrocarbon-containing substances do not experience pulmonary complications and therefore do not require hospitalization. Only children who are symptomatic at the time of initial medical evaluation or who became symptomatic during a six- to eight-hour observation period require hospitalization.

Criteria for Hospitalizing Children Who Have Ingested Products Containing Hydrocarbons

The clinical records of 950 children who ingested products containing hydrocarbons were reviewed. Eight hundred children were asymptomatic at the time of the initial evaluation and remained so during a six-to eight-hour period of observation. All had normal chest films, and all were treated as outpatients. One hundred fifty other children were admitted to the hospital; 79 were symptomatic at the time of initial medical evaluation and had abnormal chest roentgenograms. Seventy-one other children were asymptomatic but had roentgenographic evidence of pulmonary involvement (36) or had had pulmonary symptoms before arriving at the medical facility (35). Complications (seven) occurred only in symptomatic children who had roentgenographic evidence of pneumonia. These data suggest that the majority of children who are brought for medical evaluation after ingesting hydrocarbon-containing substances do not experience pulmonary complications and therefore do not require hospitalization. Only children who are symptomatic at the time of initial medical evaluation or who became symptomatic during a six- to eight-hour observation period require hospitalization.

Chronic Lung Damage Caused by Adenovirus Type 7: A Ten-Year Follow-up Study

Twenty-seven children aged 0.6 to 7.0 (mean 2.1) years were admitted to the hospital in 1967 and 1968 with type 7 adenoviral pneumonia. All ran a prolonged course. Type 7 adenovirus was isolated from 14 children, and in the other 13, the rise in the titer of complement-fixing antibodies to adenovirus was fourfold or greater. The outcome of the disease in these 27 children was reassessed in 1979, 9.6 to 12.1 (mean 10.7) years after the adenovirus type 7 pneumonia. Twenty-two were examined clinically and roentgenographically and all had lung function tests. Twelve had abnormal chest roentgenograms, and of these, six had bronchiectasis. Six of the ten children with normal chest x-ray films and ten of the 12 with abnormal chest roentgenograms had abnormal pulmonary function tests. Of the six patients with bronchiectasis, four showed no discernible cause of bronchiectasis other than the antecedent type 7 adenoviral infection. The other two patients had bronchial asthma, which can be a risk factor for bronchiectasis.

The evolution of pulmonary cryptococcosis: clinical implications from a study of 41 patients with and without compromising host factors.

Over 14 years 41 patients were diagnosed as having pulmonary cryptococcosis. Cryptococcus neoformans remained localized to the lung in 12 cases and disseminated in the remaining 29. Thirty-four patients were compromised hosts. Disseminated disease developed in 28 of these 34, and four of these 28 patients with disseminated disease presented with concomitant pulmonary and meningeal infections. In all the remaining 24 central nervous system involvement developed 2 to 20 weeks after the finding of an abnormal chest roentgenogram. Seven patients were normal hosts, and in six of these cases disease remained localized to the lung. Four important conclusions were drawn from this study: pulmonary cryptococcosis is rarely considered in the differential diagnosis of an abnormal chest roentgenogram, thereby leading to missed diagnoses and therapeutic errors; the natural history of untreated pulmonary cryptococcosis in compromised hosts is extrapulmonic dissemination; compromised hosts with pulmonary cryptococcosis should receive antifungal therapy because of a high propensity for dissemination; and normal hosts in whom dissemination has been excluded generally do not need antifungal therapy.

Clinical determinants of tuberculosis screening.

Because of declining prevalence of tuberculosis in the United States, standard laboratory tests detect fewer actively infected patients. Of 6,884 cultures for Mycobacterium tuberculosis (MTB) in three years at our hospital, only 2% were positive. To select other effective screening variables, we retrospectively reviewed patients in whom cultures were ordered. Charts of 79 patients with active tuberculosis and 226 patients whose cultures were negative were reviewed for 45 signs, symptoms, and laboratory tests determined at the time of initial contact. Those variables which distinguished the MTB-active from the nonactive were: history of weight loss, prior exposure, night sweats, fever, abnormal chest roentgenogram, positive skin test (PPD) (at P less than .001), and cough and abnormal pulmonary examination (at P less than .05). An algorithmic analysis suggests that weight loss and/or cough, followed by abnormal chest x-ray film and/or positive PPD, would detect 77% of the MTB-infected persons in whom these tests were done. The classic signs and symptoms of pulmonary tuberculosis continue to be excellent screening variables. When combined with the chest x-ray film and PPD, they may allow use of the culture as a confirmatory test, rather than its current inappropriate use as a screening test, for a disease of low prevalence.

Clinical and roentgenographic features of nosocomial pulmonary disease due to Mycobacterium xenopi.

We describe 19 cases of pulmonary disease due to Mycobacterium xenopi, a nosocomial infection related to the hospital water system. Pre-existing lung disease and prolonged environmental exposure during previous hospitalizations were apparent predisposing factors. Twelve patients had respiratory symptoms, including three with hemoptysis, at the time an abnormal chest roentgenogram was obtained. The predominant radiographic presentation of lung diseases caused by M. xenopi was a nodular or mass shadow, but cavitary disease and multiple nodular densities were also frequently observed. One subject had a solitary pulmonary nodule, and surgical resection was performed. In 12 patients who were skin tested with both M. xenopi sensitin and PPD-tuberculin, induration was consistently greater with M. xenopi. Initial isolates of M. xenopi were uniformly sensitive in vitro to 2.0 microgram of streptomycin, 1.0 microgram of isoniazid, and 10.0 microgram of para-aminosalicylic acid. In general, disease due to M. xenopi was successfully treated with standard antituberculosis drugs.

Exercise performance of the survivors of hyaline membrane disease

We measured the cardiopulmonary response of 62 school-aged survivors of hyaline membrane disease to the stress of submaximal steady-state exercise on a cycle ergometer. The children represented a 48% follow-up of infants with HMD who-survived in our hospital in the years 1968 to 1974. They had incidences of wheezing, pulmonary infections, and abnormal chest roentgenograms after discharge similar to those in groups reported by other investigators. The first group required only supplemental oxygen or continuous positive airway pressure; the second required oxygen and CPAP plus mechanical ventilation with intermittent positive pressure; and the third, half of whom had been treated with positive pressure, developed pulmonary air leaks. Children in all groups had normal heart rates and oxygen consumptions for their heights and work rates. Ventilation was normal in all but three subjects. These three patients had had air leaks and one had severe bronchopulmonary dysplasia, requiring 36 months of oxygen therapy; the other two were only 5 years of age. All three developed hypercarbia during moderate exercise. There was no difference in the tidal volumes, respiratory rates, dead space, or the distribution of ventilation between the three groups and the normal subjects. The alveolar-to-skin oxygen tension gradient decreased in all groups and the normal subjects during light exercise, implying that the match of ventilation to perfusion improved. Most survivors of HMD appear to have normal cardiopulmonary function by school age.