Bilateral Lung Infiltrates Research Articles

Mycobacterium mageritensePulmonary Disease in Patient with Compromised Immune System

<i>Mycobacterium mageritense</i>Pulmonary Disease in Patient with Compromised Immune System

A prediction rule to identify severe cases among adult patients hospitalized with pandemic influenza A (H1N1) 2009.

The purpose of this study was to establish a prediction rule for severe illness in adult patients hospitalized with pandemic influenza A (H1N1) 2009. At the time of initial presentation, the baseline characteristics of those with severe illness (i.e., admission to intensive care unit, mechanical ventilation, or death) were compared to those of patients with non-severe illnesses. A total of 709 adults hospitalized with pandemic influenza A (H1N1) 2009 were included: 75 severe and 634 non-severe cases. The multivariate analysis demonstrated that altered mental status, hypoxia (PaO2/FiO2 ≤ 250), bilateral lung infiltration, and old age (≥ 65 yr) were independent risk factors for severe cases (all P < 0.001). The area under the ROC curve (0.834 [95% CI, 0.778-0.890]) of the number of risk factors were not significantly different with that of APACHE II score (0.840 [95% CI, 0.790-0.891]) (P = 0.496). The presence of ≥ 2 risk factors had a higher sensitivity, specificity, positive predictive value and negative predictive value than an APACHE II score of ≥ 13. As a prediction rule, the presence of ≥ 2 these risk factors is a powerful and easy-to-use predictor of the severity in adult patients hospitalized with pandemic influenza A (H1N1) 2009.

Diffuse interstitial lung infiltrates in a smoker with human immunodeficiency virus infection

Pulmonary Langerhans cell histiocytosis is a rare interstitial lung disease characteristically affecting middle-aged smokers. It has unpredictable clinical course and may be associated with malignant neoplasms. Opportunistic lung infections are frequently considered when patients with Human immunodeficiency virus (HIV) infection present with respiratory symptoms and an abnormal chest X-ray. Though fiberoptic bronchoscopy with bronchoalveolar lavage is diagnostic for infectious etiologies, surgical lung biopsies are preferred to diagnose noninfectious lung diseases and to help guide appropriate therapy. In the present study, we report a case of progressive bilateral lung infiltrates in a smoker with HIV infection which presented a diagnostic dilemma in view of coexistent HIV infection. Analysis of clinical symptomatology aided by surgical lung biopsy helped in diagnosis.

Diffuse large B-cell lymphoma with lung involvement in a psoriatic arthritis patient treated with methotrexate

Non-Hodgkin lymphoma (NHL) occurs in the setting of methotrexate (MTX) therapy for rheumatoid arthritis. However, it has been very rarely reported in subjects with psoriatic arthritis treated with MTX. We report here a case of a 70-year-old woman with psoriatic arthritis who presented with bilateral lung infiltrates, pleural effusion, splenomegaly, and inguinal lymphadenopathy during treatment with MTX. The diagnosis of diffuse large B-cell lymphoma was made by analysis of the pleural fluid via thoracentesis and biopsy of an enlarged inguinal lymph node. Clinicians should consider the possibility of a NHL complicating psoriasis and with MTX therapy in order to prevent treatment delays.

Idiopathic pneumonia syndrome in mice after allogeneic bone marrow transplantation: association between idiopathic pneumonia syndrome and acute graft-versus-host disease

Objective To explore the association between idiopathic pneumonia syndrome (IPS) and acute graft-versus-host disease (aGVHD) in allogeneic hematopoietic stem cell transplantation. Methods Established acute GVHD model of C57BL/6 → BALB/c mice. Chest computed tomography (CT) scans were dynamically performed in recipient mice after transplant. Lung histopathology and cytokine levels (including TNF-α and IFN-γ) were examined in three experimental groups: mice receiving simple irradiation, syngeneic transplants, and allogeneic transplants. Results All allogeneic transplant mice developed aGVHD. On CT, most aGVHD mice had bilateral diffuse lung infiltrates, while syngeneic transplant mice had normal lungs. On histopathology, aGVHD mice had acute pneumonitis. On immunohistochemistry, the infiltrates were mainly CD4+ T cells during aGVHD onset, but CD8+ T cells predominated during aGVHD progression. Lung TNF-α and IFN-γ levels were higher in the three experimental groups than in normal controls on days + 3 and + 7 post-transplant. On day + 7, TNF-α levels were higher in allogeneic than in syngeneic transplant mice; IFN-γ levels were not different. On days + 12 and + 16, TNF-α levels were higher but IFN-γ levels were lower in allogeneic mice than in syngeneic transplant mice. Conclusions The underlying cause of IPS is aGVHD. T cells and TNF-α may play a role in the pathogenesis of aGVHD-induced IPS. IPS progression may be associated with decreasing lung IFN-γ levels.

Possible life-threatening adverse reaction to monovalent H1N1 vaccine

The vaccine against H1N1 was initially issued in July 2009 with no doubts regarding its beneficial immunoprotective effect [1,2]. Recent reports have shown that adverse events are few and generally not life-threatening [3]. There fore, a worldwide vaccination program was launched with very strong confidence [4]. Herein, for the accumulative record, I report a possible life-threatening reaction of the monovalent H1N1 vaccine in Thailand. A 38-year-old pregnant woman (gestational age of 25 weeks) was fit and well and had regular antenatal care without any problems. She was given an H1N1 vaccination and the following day developed diffuse myalgia and minimal shortness of breath. Her condition continued to deteriorate, ultimately ending in respiratory failure on day 5 post-vaccination. On arrival at the intensive care unit, she was tachypneic, tachycardic, and hypotensive. Her chest film demonstrated diffuse bilateral lung infiltration. She was eventually intubated and ventilated with high-concentration oxygen and high positive end-expiratory pressure. She was found to have bloody secretions from tracheal aspiration. Acute lung injury with pulmonary hemorrhage was, therefore, suspected. A complete physical examination revealed a severe bilateral subconjunctival hemorrhage. No other abnormalities were detected. Blood labs showed a leucopenia level of 2,600/mm3, mild anemia with hemoglobin of 10 gm/dL, and a platelet count of 40,000/mm3. A coagulation study was normal. She was also suffering from acute renal failure with a creatinine level of 3 mg/dL. Urinalysis demonstrated proteinuria with a quantitative count of around 1.2 gm/L with microscopic hematuria. A liver function test also showed mild transaminitis. Microbiological study and culture were negative. An echocardiogram showed severe pulmonary hypertension, possibly from severe acute lung injury. Overall, she developed multiple organ failure, including acute respiratory distress syndrome (possibly from pulmonary hemorrhage), shock, acute renal failure with possible glomerulonephritis, and thrombocytopenia. Systemic autoimmune diseases, such as systemic lupus erythematosus or systemic vasculitis, were considered in the differential diagnosis, but all vasculitic screens, including anti-nuclear antibody, C3 and C4 levels, 50% hemolytic complement (CH50), anti-neutrophil cytoplasmic antibody, and anti-double-stranded DNA, were negative. The patient's clinical condition slowly improved over the following 7 days with aggressive organ support but no specific management. In conclusion, the diagnosis of this patient remains unclear; however, vasculitis or an autoimmune disease is unlikely, and a severe adverse event following the H1N1 vaccination could not be completely excluded. Physicians should remain alert to possible severe adverse reactions to this vaccine.

The Seven Year Search: Disseminated Gastric MALT Lymphoma in a Patient with Pulmonary Infiltrates of Unknown Etiology

Purpose: Mucosal-associated lymphoid tissue (MALT) derived lymphoma can arise from a variety of extranodal sites, most commonly the stomach. These lymphomas can disseminate to multiple sites. We report the case of a 60-year-old male with a long history of stable pulmonary infiltrates of unknown etiology presenting with hematemesis. A 60-year-old Chinese male with chronic bilateral lung infiltrates presented to our hospital with epigastric pain and hematemesis. The infiltrates were discovered 7 years prior to admission on a CXR ordered for evaluation of a cough. He then underwent 2 bronchoscopies and a CT-guided lung biopsy. These studies were non-diagnostic. Due to his mild symptoms, the infiltrates were followed with yearly CT scans and remained stable. In the months prior to his presentation, the patient noted a 10 lb weight loss and mild dyspnea, but denied other constitutional or abdominal symptoms. On admission to the ICU, an EGD revealed a 1.2 cm deep ulcer with heaped-up margins in the proximal body of the stomach. Biopsies revealed H. pylori infection and extranodal marginal zone B-cell lymphoma consistent with gastric MALT, staged as IE. Further evaluation with PET/CT showed increased uptake in the stomach wall and areas corresponding to the pulmonary infiltrates. Lung biopsy via VATS was consistent with MALT, which upstaged his disease to stage IV. After completing a course of antibiotics and CVP chemotherapy, repeat imaging and EGD revealed stable, unchanged disease at 6 and 12 months. The patient denied further treatment due to minimal symptoms. Gastric MALT with pulmonary dissemination is well described. The pulmonary disease is commonly asymptomatic and often undiagnosed until after the gastric disease reveals itself. Despite the radiologic evidence and a full pulmonary workup in our patient, a definitive diagnosis remained elusive for 7 years. He had no GI symptoms until presenting to us with hematemesis. As a result of the EGD findings, a more aggressive workup was undertaken resulting in the diagnosis of metastatic gastric MALT lymphoma. Our patient's clinical course presents a clear example of the indolent course and resulting diagnostic difficulty that extranodal MALT presents to the clinician. Patients with non-gastric extranodal MALT are often found to have gastric MALT at the time of diagnosis. Since involvement of more than 1 extranodal site has implications for treatment, this case highlights the importance of performing a work-up for gastric MALT when extranodal non-gastric MALT is discovered. As seen in this case, we recommend an EGD be performed in patients with undiagnosed chronic pulmonanry infiltrates to rule out metastatic gastric MALT as the etiology.

Epistaxis y enfermedad sistémica

We report the case of a 77-year-old man who presented nasal obstruction sensation and epistaxis. Otorhinolaryngological examination revealed occupation of the left nasal passage and the left maxillary sinus by an inflammatory tumour, the biopsy results of which were inconclusive. While diagnostic tests where being carried out, the patient presented a severe systemic condition consisting mainly of anaemia, acute renal failure, and cavitated diffuse bilateral lung infiltrates. In the light of the results of anti-neutrophilic cytoplasmic antibodies and renal biopsy, Wegener's granulomatosis was diagnosed and treatment for the disease was instituted with a favourable response. Finally, clinical manifestations of Wegener's granulomatosis are reviewed, with especial emphasis on otolaryngologic complaints.

Human Umbilical Cord Mesenchymal Stem Cells Reduce Fibrosis of Bleomycin-Induced Lung Injury

Acute respiratory distress syndrome is characterized by loss of lung tissue as a result of inflammation and fibrosis. Augmenting tissue repair by the use of mesenchymal stem cells may be an important advance in treating this condition. We evaluated the role of term human umbilical cord cells derived from Wharton's jelly with a phenotype consistent with mesenchymal stem cells (uMSCs) in the treatment of a bleomycin-induced mouse model of lung injury. uMSCs were administered systemically, and lungs were harvested at 7, 14, and 28 days post-bleomycin. Injected uMSCs were located in the lung 2 weeks later only in areas of inflammation and fibrosis but not in healthy lung tissue. The administration of uMSCs reduced inflammation and inhibited the expression of transforming growth factor-beta, interferon-gamma, and the proinflammatory cytokines macrophage migratory inhibitory factor and tumor necrosis factor-alpha. Collagen concentration in the lung was significantly reduced by uMSC treatment, which may have been a consequence of the simultaneous reduction in Smad2 phosphorylation (transforming growth factor-beta activity). uMSCs also increased matrix metalloproteinase-2 levels and reduced their endogenous inhibitors, tissue inhibitors of matrix metalloproteinases, favoring a pro-degradative milieu following collagen deposition. Notably, injected human lung fibroblasts did not influence either collagen or matrix metalloproteinase levels in the lung. The results of this study suggest that uMSCs have antifibrotic properties and may augment lung repair if used to treat acute respiratory distress syndrome.

Acute interstitial pneumonitis following adjuvant tamoxifen therapy

e11637 Background: Tamoxifen is a serum estrogen receptor modulator that is widely used in the treatment of women with breast cancer and has a low incidence of serious side-effects. Although hypersensitivity reactions to tamoxifen have rarely been described, to our knowledge acute lung toxicity has not previously been reported. Objective: To report an unusual case of acute interstitial pneumonitis in a patient with early stage breast cancer treated with tamoxifen. Results: A 66 year old post-menopausal woman with past medical history of type 2 diabetes mellitus, and hypertension noted a lump in the right breast. An excision biopsy revealed 9 mm moderately differentiated invasive ductal carcinoma. Lymph nodes were not involvd by the tumor. The tumor cells were positive for estrogen and progesterone receptors and were negative for ErbB-2 over expression. The post operative course was complicated by wound infection treated with combination of clindamycin and ciprofloxacin. The patient was recommended adjuvant tamoxifen. Her other medication were metformin, valsartan, calcium and vitamin D. One week after the commencement of tamoxifen she noted increasing dyspnea, cough, and intermittent fever. X-ray chest showed bilateral lung infiltrates. She was hospitalized and treated with broad spectrum antibiotic. The patient condition deteriorated. She developed acute respiratory failure requiring intubation and mechanical ventilation. Tamoxifen was discontinued. A CT scan of chest showed bilateral interstitial infiltrates. Bronchoalveolar lavage was performed which was negative for infection. An open lung biopsy was done which showed focal diffuse alveolar damage consistent with interstitial pneumonia. No evidence of an infective agent, malignancy, or granuloma was noted. The patient was treated with high dose steroid. She gradually recovered and was discharge to home with normal lung function. Conclusions: Drug-induced lung injuries are usually idiosyncratic reactions and occur in an unpredictable manner. The presence of a temporal relationship between the lung injury and tamoxifen administration, a rapid clinical improvement after discontinuation of the drug, and absence of other causes strongly implicated tamoxifen as a potential cause of acute lung injury. No significant financial relationships to disclose.

Epistaxis and systemic disease

We report the case of a 77-year-old man who presented nasal obstruction sensation and epistaxis. Otorhinolaryngologic examination revealed occupation of the left nasal passage and the left maxillary sinus by an inflammatory tumour, the biopsy results of which were inconclusive. While diagnostic tests were being carried out, the patient presented a severe systemic condition consisting mainly of anemia, acute renal failure, and cavitated diffuse bilateral lung infiltrates. In the light of the results of anti-neutrophilic cytoplasmic antibodies and renal biopsy, Wegener's granulomatosis was diagnosed and treatment for the disease was instituted, with a favourable response. Finally, clinical manifestations of Wegener's granulomatosis are reviewed, with special emphasis on otolaryngologic complaints.

Delayed severe pneumonia in mycophenolate mofetil-treated patients with IgA nephropathy

Mycophenolate mofetil (MMF), a relatively new immunosuppressant, is widely used in the field of transplantation and also for autoimmune diseases with good tolerance. It has been reported that MMF possesses potent activity against pneumocystis pneumonia (PCP). This study investigated the effects of this treatment on the occurrence of severe pneumonia (SP) including PCP and its risk factors. This was a retrospective cohort study. Of 850 IgA nephropathy (IgAN) patients that were followed up in our renal centre, 32 received MMF (1-1.5 g/day) and 47 were treated with cyclophosphamide (CTX; 50-100 mg/day). All the patients also received prednisone. SP was defined as diffuse bilateral lung infiltrate with respiratory failure, and PCP was diagnosed by detecting organisms in sputum and bronchoalveolar lavage. Patients given MMF or CTX did not differ in their distribution of age, sex, renal function or prednisone dosage. However, 6 of the 32 patients developed SP around the third month after the initiation of MMF administration: 3 were diagnosed with PCP, 2 with suspected PCP and in the other PCP could not be excluded. SP did not occur in patients treated with CTX. Most SP cases (five of six) presented with abrupt onset and rapidly progressed to respiratory failure, from which four died. The deterioration of renal function was strongly associated with the occurrence of SP. Six patients (6 of 16) with chronic renal function impairment (eGFR < 60 ml/min/1.73 m(2)) developed SP while none of the patients with eGFR > 60 ml/min/1.73 m(2) did. Absolute lymphocyte counts decreased significantly in patients with eGFR < 60 ml/min/1.73 m(2) after 3 months of MMF treatment compared to the counts before MMF was initiated (1.71 +/- 0.23 versus 2.43 +/- 0.17 x 10(9)/l, P = 0.04). This effect was more pronounced in patients with SP, which had significantly lower counts than patients without SP (0.22 +/- 0.04 versus 1.91 +/- 0.20 x 10(9)/l, P = 0.001). The occurrence of SP or PCP in patients with chronically impaired renal function was also associated with lymphopenia. This study is the first report of delayed SP including PCP following MMF plus corticosteroids in patients with IgAN. Chronically impaired renal function might be a risk factor for severe infection, and lymphocyte counts may serve as useful and convenient tools for monitoring the intendance of the occurrence of PCP. This finding and its risk factors need to be further evaluated.

A Hitherto Unreported Pulmonary Complication in an IV Heroin User

IV heroin use is associated with several well-described complications, including noncardiogenic pulmonary edema, aspiration pneumonitis, ARDS, pneumonia, lung abscess, septic pulmonary emboli, and atelectasis. Foreign-body granulomatosis may develop when drug users inject solutions containing crushed oral tablets in which talc is used as filler and can be complicated by pulmonary fibrosis. The effects are distinct from pulmonary edema, which may occur acutely with heroin injection. We describe the case of a young female patient who was an IV heroin user who also smoked cigarettes, and presented with progressive dyspnea, hypoxia, and bilateral lung infiltrates. The final pathologic diagnosis in this case was one that had not been previously reported in IV heroin users.

Pulmonary Eosinophilia

Eosinophils may infiltrate the lung tissue, thus impairing gas exchange and causing several symptoms as dyspnea, fever, and cough. This process may be secondary to several factors, including drugs or parasite migration, or primary (idiopathic). Acute eosinophilic pneumonia is life-threatening and presents frequently in young smokers as an acute hypoxemic respiratory failure of generally less than a week with bilateral lung infiltrates, frequently misdiagnosed as severe community-acquired pneumonia. This patients present without peripheral eosinophilia but usually have more than 25% eosinophils on bronchoalveolar fluid. Chronic eosinophilic pneumonia is a protracted disease of usually more than a month before presentation, with a predilection for middle aged asthmatic patients. Hypoxemia is mild-moderate, and there are usually more than 1,000 eosinophils/mm3 of peripheral blood. Bronchoalveolar fluid has high eosinophil levels (usually more than 25%). Migratory peripheral infiltrates are seen in the chest x-ray film. Both acute and chronic eosinophilic pneumonia are treated by glucocorticoids and respiratory support as well as avoidance of any recognized trigger.

Diagnostic utility of the soluble triggering receptor expressed on myeloid cells-1 in bronchoalveolar lavage fluid from patients with bilateral lung infiltrates

BackgroundDifferential diagnosis of patients with bilateral lung infiltrates remains a difficult problem for intensive care clinicians. Here we evaluate the diagnostic role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in bronchoalveolar lavage (BAL) specimens from patients with bilateral lung infiltrates.MethodsWe conducted a prospective observational study on 80 patients with bilateral lung infiltrates with clinical suspicion of infectious pneumonia. Patients were categorized into three groups: bacterial or fungal infection, intracellular or viral infection, and noninfectious inflammatory disease. sTREM-1 concentrations were measured, and BAL fluid and Clinical Pulmonary Infection Score (CPIS) were analyzed.ResultsThe sTREM-1 concentration was significantly increased in patients with bacterial or fungal pneumonia (n = 29, 521.2 ± 94.7 pg/ml), compared with that in patients with viral pneumonia, atypical pneumonia or tuberculosis (n = 14, 92.9 ± 20.0 pg/ml) or noninfectious inflammatory disease (n = 37, 92.8 ± 10.7 pg/ml). The concentration of sTREM-1 in BAL fluid, but not CPIS, was an independent predictor of bacterial or fungal pneumonia, and a cutoff value of more than 184 pg/ml yielded a diagnostic sensitivity of 86% and a specificity of 90%.ConclusionThe sTREM-1 level in BAL fluid from patients with bilateral lung infiltrates is a potential marker for the differential diagnosis of pneumonia due to extracellular bacteria.

Fulminant Klebssiella Pneumoniae Pneumonia in Immunocompetent Non Alcoholic Patient

We describe a case of fulminant community acquired bacteremic K. pneumoniae pneumonia in non alcoholic (<20 gr/day) patient. A previously healthy 36-year-old man presented with fever (39 C), malaise, dyspnea and a nonproductive cough. On physical examination, he had tachycardia (120/min), tachypnea (31/min) and hypotension (85/67 mm Hg). A chest radiograph displayed symmetric bilateral and voluminous hyperdense lung infiltrates with bulging interlobar fissure.

Diffuse Pulmonary Meningotheliomatosis

Minute pulmonary meningothelial nodules are rare lesions histologically composed of small nests of epithelioid cells located within the interstitium of the lung. These nodules are generally asymptomatic and are usually found incidentally at autopsy or in surgical specimens resected for unrelated causes. The lesions are most often single, although multiple lesions with unilateral involvement of one or even all lobes of the same lung have been described. To our knowledge, cases of meningothelial nodules with disseminated bilateral pulmonary involvement associated with clinical symptoms of restrictive pulmonary disease and radiologic evidence of diffuse reticulonodular pulmonary infiltrates have not been previously documented. We have studied 5 patients presenting with diffuse bilateral pulmonary involvement by numerous minute pulmonary meningothelial nodules. The patients were 4 women and a man aged 54 to 75 years who presented clinically with dyspnea and shortness of breath and the lesions were discovered on open lung biopsies performed for the evaluation of diffuse bilateral interstitial lung infiltrates found on chest x-rays and computed tomography scans. In 3 patients, there was a previous history of malignancy and the radiologic findings were suspected of representing diffuse metastatic disease. Histologically, the lesions were composed of small clusters of epithelioid cells with round to oval nuclei devoid of atypia and surrounded by abundant eosinophilic cytoplasm. Immunohistochemical studies showed positivity of the tumor cells for epithelial membrane antigen and vimentin, and negative staining for cytokeratin, actin, S-100 protein, CD34, chromogranin, and synaptophysin. Electron microscopic examination in 1 case confirmed the ultrastructural features of meningothelial cells, including complex cytoplasmic interdigitations joined by well-developed desmosomes and abundant intracytoplasmic intermediate filaments. The diffuse bilateral involvement of lung parenchyma in the present cases can lead to confusion on clinical and radiologic grounds with a variety of interstitial pulmonary processes, including idiopathic interstitial pneumonia and lymphangitis carcinomatosa. Diffuse pulmonary meningotheliomatosis should be considered in the clinical differential diagnosis of diffuse interstitial pulmonary infiltrates.

An 18-Year-Old Man With Persistent Cough and Bilateral Lower Lung Infiltration

An 18-Year-Old Man With Persistent Cough and Bilateral Lower Lung Infiltration

An 18-year-old man with persistent cough and bilateral lower lung infiltration. Epstein-Barr virus-positive lymphoproliferative disorder consistent with lymphomatoid granulomatosis.

An 18-year-old man with persistent cough and bilateral lower lung infiltration. Epstein-Barr virus-positive lymphoproliferative disorder consistent with lymphomatoid granulomatosis.

A Case of Acute Fibrinous and Organizing Pneumonia

Acute fibrinous and organizing pneumonia (AFOP) is a histological pattern consisting of prominent intra-alveolar fibrin and organizing pneumonia, with out hyaline membranes or prominent eosinophilia. The clinical manifestations of AFOP resemble those of acute lung injury such as acute interstitial pneumonia (AIP). However, the classic histological patterns of AFOP differ from diffuse alveolar damage (DAD), bronchiolitis obliterans with organizing pneumonia (BOOP) or acute eosinophilic pneumonia (AEP). The characteristic intra-alveolar fibrin ball and lack of classic hyaline membrane are the predominant histological features of AFOP. Although some reports suggest that its clinical course is less catastrophic than DAD, the clinical entity that distinguishes AFOP from DAD has not been established. We present a case of pathologically demonstrated AFOP in a 79-year-old man. The radiological findings of our case were similar to those of DAD, presented with diffuse bilateral lung infiltrations. However, despite the rapid development of respiratory failure, the patient had a better response and outcome to steroid therapy than what would be expected for DAD.