Bilateral Pneumonitis Research Articles

Mediastinal histoplasmosis: report of the first two Brazilian cases of mediastinal granuloma

This report documents the first two Brazilian cases of mediastinal granuloma due to histoplasmosis, presenting selected aspects on the diagnosis. Tissue samples revealing histoplasmosis were obtained from each of the patients by mediastinoscopy and thoracotomy. In the second patient, a subcarinal calcified mass eroded into the bronchial tree, leading to secondary bilateral aspiration pneumonitis one week after thoracotomy. Although rare, histoplasmosis should be included in the differential diagnosis of mediastinal granuloma, specially if there are calcifications greater than 10 mm in dimension.

Bronchoplastic and Pulmonary Arterioplastic Procedures in the Treatment of Bronchogenic Carcinoma

Bronchoplastic and pulmonary arterioplastic procedures have become increasingly popular in recent years as an alternative to pneumonectomy, especially for patients with compromised cardiopulmonary reserve. We reviewed our experience with the procedure to determine the operative technique, indication for the procedure and long-term results. From January 1981 to December 2000, 65 bronchoplasties, four pulmonary arterioplasties and three combined broncho-angioplasties were performed for bronchogenic carcinoma. Of the 72 patients, 31 had stage I disease, 29 had stage II and 12 had stage III disease. One patient (1.4%) died of bilateral pneumonitis postoperatively. Atelectasis occurred in two patients (2.8%), empyema in one (1.4%), and bronchial fistula in one (1.4%). There were no bronchial stenoses after bronchoplastic procedures, and no vascular complications after angioplastic procedures. The 1-, 3- and 5-year survival rates for the entire group were 86.0%, 47.0% and 29.8%, respectively. The difference in survival was significant between stage I and II disease (p=0.0001) and between stage I and III disease (p<0.0001), but not between stage II and III disease (p=0.0779). Bronchoplastic, pulmonary arterioplastic and broncho-angioplastic procedures can be performed safely. Bronchoplastic procedures offer patients with bronchogenic carcinoma a long-term result comparable to that with radical lung resection. Angioplastic and combined broncho-angioplastic procedures should only be used in patients who cannot tolerate pneumonectomy due to poor cardiopulmonary reserve.

Combination Treatment with Weekly Docetaxel and Gemcitabine for Advanced Non–Small-Cell Lung Cancer in Elderly Patients and Patients with Poor Performance Status: Results of a Minnie Pearl Cancer Research Network Phase II Trial

The purpose of this study was to evaluate the feasibility, toxicity, and efficacy of the combination of weekly docetaxel and gemcitabine in patients with advanced non–small-cell lung cancer (NSCLC) who are either elderly or have poor performance status (PS). Patients with stage IIIB or IV NSCLC who had received no previous chemotherapy and were ≥ 70 years of age were eligible for this clinical trial. Patients < 70 years of age were also eligible if they had poor PS or were considered poor candidates for standard platinum-based combination chemotherapy regimens. All patients received chemotherapy with gemcitabine 800 mg/m2 and docetaxel 30 mg/m2, both drugs administered by 30-minute intravenous infusions on days 1, 8, and 15. Treatment courses were repeated every 28 days. Patients were reevaluated after completion of 2 treatment courses; responding patients continued treatment until disease progression or for a maximum of 6 courses. Between August 1999 and June 2000, 64 patients (73% with stage IV disease) were treated at 17 participating sites in the Minnie Pearl Cancer Research Network. Eighteen of 64 patients enrolled (28%) had objective response to treatment; an additional 25 patients (39%) had stable disease. Median survival was 7 months, with 1- and 2-year survival rates of 30% and 17%, respectively. Treatment was well tolerated by most patients. Grade 3/4 leukopenia occurred in 7 patients (11%), but no patient required hospitalization for neutropenia/fever. One patient developed fatal bilateral pneumonitis, which was possibly treatment-related. The combination of weekly docetaxel/gemcitabine is active and relatively well tolerated in most patients with advanced age or poor PS with advanced NSCLC. A randomized comparison of this regimen versus singleagent weekly docetaxel is in progress.

Bronchoplastic and pulmonary arterioplastic procedures in treatment of bronchogenic carcinoma

Objective: Bronchoplastic and pulmonary arterioplastic procedures have become increasingly popular in recent years as an alternative to pneumonectomy, especially for the patients with compromised cardiopulmonary reserve. Our experience with the procedures was reviewed and the operative technique, indication for the procedures, and long-term results were analyzed. Methods: From January 1977 to December 1996, 65 bronchoplasties, 4 pulmonary arterioplasties, and 3 combined broncho-angioplasties were performed for bronchogenic carcinoma. Of the 72 patients, thirty-one had stage I disease, 29 stage II and 12 stage III. Results: One patient (1.4%) died of bilateral pneumonitis after operation. Atelectasis occurred in 2 patients (2.8%), empyema in one (1.4%) and bronchial fistula in one (1.4%). There were no bronchial stenoses after bronchoplastic procedures, and no vascular complications after angioplastic procedures. The one-years, 3-year and 5-year survival rates for the entire group were 86.0%, 47.0%, and 29.8%, respectively. The three-year survival rates for the patients with stage I, II and III disease were 69.4%, 32.3% and 25.0%, respectively. There was no 5-year survival for patients with stage III disease, whereas for patients with stage I and II disease, the 5-year survival rates were 48.6% and 10.8%, respectively. The difference in survival was significant between stage I and II disease (P=0.0001) and between stage I and III disease (P<0.0001), but not between stage II and III (P=0.0779). Conclusion: Bronchoplastic, pulmonary arterioplastic and broncho-angioplastic procedures can be performed safely. Brochoplastic procedures offer patients with bronchogenic carcinoma a long-term result comparable to that for radical lung resections. Angioplastic and combined angio-bronchoplastic procedures should only be employed in the patients who can not tolerate a pneumonectomy due to poor carciopulmonary reserve.

The role of anti-epithelial cell antibodies in the pathogenesis of bilateral radiation pneumonitis caused by unilateral thoracic irradiation

Two cases of bilateral radiation pneumonitis associated with unilateral thoracic irradiation against lung cancer are described. Both patients died of respiratory failure and autopsy was performed. Histologically, bilateral diffuse alveolar damage was demonstrated in both cases, associated with marked organization of hyaline membrane in one case (case 1). In addition, numerous hyperplastic type II pneumocytes which strongly expressed cytokeratins 8, 18 and 19 were observed. In both patients' sera, antibodies against cytokeratin 8, 18 and 19 were demonstrated by a Western immunoblot. The possible association between autoantibodies to cytokeratins and diffuse alveolar damage observed in patients with bilateral radiation pneumonitis are discussed.

A Case of Chemical Pneumonitis Induced by Ingestion of Hydrocarbon

A 33-year-old woman was presented with dyspnea and chest discomfort after indigesting approximately 500ml of oil paint brush washing fluid. Hypoxic symptoms and radiographic infiltrates rapidly progressed. The patient was intubated and received mechanical ventilation. Bronchoalveolar lavage and transbronchial lung biopsies were performed. The CT scan of the lung showed bilateral extensive pneumonitis with necrosis and the lung tissue pathologic findings showed diffuse alveolar damage with extensive necrosis and numerous lipidladen macrophages. After intensive medical care with mechanical ventilation, her symptoms and radiological findings improved.

Kinetic therapy and continuous intra-arterial blood gas monitoring in severe bilateral aspiration pneumonitis: observation of position-related PaO2oscillations

A case of acute respiratory failure due to massive bilateral aspiration is reported. Initial treatment included continuous lateral rotation by a kinetic bed. Simultaneously performed continuous intra-arterial blood gas monitoring showed marked position-dependent changes in oxygenation. Possible underlying pathophysiological mechanisms are discussed.

Kinetic therapy and continuous intra-arterial blood gas monitoring in severe bilateral aspiration pneumonitis: observation of position-related PaO2 oscillations

Kinetic therapy and continuous intra-arterial blood gas monitoring in severe bilateral aspiration pneumonitis: observation of position-related PaO2 oscillations

Herpes simplex pneumonia in a young immunocompetent man

We report the case of a 33 year old man with herpetic bronchitis and bilateral pneumonitis. He presented without mucocutaneous lesions, and his cellular and humoral immunity were not compromised. Diagnosis was established on histological and cytological findings and confirmed by serology. Acyclovir treatment led to a favourable outcome.

Molecular Confirmation of Bacillus Calmette-Guerin as the Cause of Pulmonary Infection Following Urinary Tract Instillation

Instillation into the urinary tract of the bacillus Calmette-Guérin (BCG), a strain of Mycobacterium bovis, is associated only rarely with severe side effects. We report here two cases of culture-proven pulmonary infection due to therapy with BCG. The first patient, who was seropositive for the human immunodeficiency virus, developed bilateral interstitial pneumonitis after instillation of BCG into the bladder. The second patient developed a right-lower-lobe infiltrate and empyema after instillation of BCG into the right renal pelvis. The clinical isolates from these two patients and from a third patient with a psoas abscess following intravesical instillation were analyzed with use of pulsed field gel electrophoresis (PFGE) to resolve chromosomal restriction fragment polymorphisms. The clinical isolates were confirmed to be BCG by comparison with known vaccine strains that differed from M. bovis isolates. We conclude that the potential for subsequent dissemination be considered prior to the intravesical administration of BCG. Analysis with PFGE may be useful for identifying species of the Mycobacterium tuberculosis complex.

Diagnosis of Pneumocystis carinii pneumonia from non-invasive sampling of respiratory secretions.

An infant infected with HIV presented with fever, tachypnoea, hypoxia, and radiological evidence of bilateral pneumonitis. Fluorescent antibody technique identified Pneumocystis carinii within 24 hours from secretions obtained by nasopharyngeal aspiration. This rapid, non-invasive method should be the first line investigation of suspected P carinii pneumonia in immunocompromised patients.

Acute Mercury Vapour Intoxication: Report of Six Cases

In a group of six workers acutely exposed to metallic mercury vapour in a confined space, one patient had acute renal and respiratory failure which required daily haemodialysis and mechanical ventilation, another had acute bilateral pneumonitis with respiratory insufficiency, and the other four had corrosive oropharyngeal mucositis with a 'flu-like syndrome. Serum and urinary mercury showed an obvious correlation with the clinical picture. After removal from the source of exposure and the institution support measures (including chelant therapy in the first two patients), all recovered without evidence of residual damage.

A STUDY ON PULMONARY CHANGES INDUCED BY COMBINED RADIATION AND ANTITUMOR AGENTS

Combined radiotherapy and chemotherapy have been recently carried out effectively to have a good prognosis in malignant lymphoma and small cell carcinoma of the lung. This treatment has been often said to be complicated by bilateral diffuse interstitial pneumonitis, which is sometimes fatal.In this study, bilateral diffuse interstitial pneumonitis was recognized in 10 cases with malignant lymphoma (7 cases) and primary lung cancer (3 cases), treated by combined radiotherapy and chemotherapy. No bilateral diffuse interstitial pneumonitis could be discovered in cases without combined chemotherapy. Mediastinum was irradiated in 8 cases and bilateral supraclavicular region in 6 cases. Radiation doses were ranged from 25 to 60 Gy.Cyclophosphamide (CPM) was given to 9 cases ranging from 1050 mg to 9900 mg. Vincristine (VCR) was given to 9 cases from 1 mg to 9 mg. ACNU was given to one case 100 mg. Antitumor agents were given before or after radiotherapy, or concurrently.This pneumonitis was observed in the period 30 to 130 days after onset of radiotherapy and 25 to 100 days after onset of chemotherapy.These patients had a low grade fever (<38°C), dyspnea and shortness of breath frequently, and rarely had rales or leucocytosis.Chest radiographs were characterized by bilateral diffuse interstitial changes or hazy, homogeneous shadows. Ga-67 scannings were positive in 5 cases performed at the time of development of pneumonitis. Six patients were dead from this pneumonitis without improvement after injection of antibiotics and steroid.Mouse lung induced by combined radiation and antitumor agents was histologically investigated. Mice were irradiated 2000 R or 4000 R to the left hemithorax. CPM, Adriamycin (ADM) and Rinderon (RD) were given to them intraperitoneally.Both CPM and ADM could enhance the lung damage. Histopathologic pictures induced by combined radiation and antitumor agents were characterized not only by alveolar thickening with cellular accumulation, but also by exudate into alveolar lumen. RD was effective in controlling exudate into alveolar lumen at the time of 4 weeks after radiation.In view of the low incidence of pulmonary toxicity and the benefit of improving tumor response, combined radiotherapy and chemotherapy should be carried out. However, it should be kept in mind that fatal pneumonitis could be occurred as a complication of combination therapy.

Pulmonary toxicity of mitomycin.

Six patients with breast cancer developed pulmonary toxicity following mitomycin therapy. The presenting symptoms were shortness of breath and a dry cough. The radiological pictures varied from a normal chest x-ray to extensive bilateral pneumonitis. The histological findings consisted of diffuse alveolar damage progressing to interstitial pulmonary fibrosis. Corticosteroid therapy resulted in complete resolution of pneumonia in one patient. Respiratory symptoms improved in 3 patients following discontinuation of the drug. Two patients with extensive bilateral pneumonitis, who were not treated with steroids, died of respiratory failure. Mitomycin-induced lung toxicity appears to be reversible with the discontinuation of drug and the administration of corticosteroids. Lung biopsy is necessary in order to rule out other diagnoses.

39 THE EFFECT OF THE IN IMMUNOSUPPRESSED CHILDREN WITH LYMPHO PROLIFERATIVE DISEASES

THF, a partially purified Thymic Hormone, was shown to restore the impaired cell mediated immunity (CMI) and reduce the visceral complications in 4 children with acute leukemia and generalized varicella. Twelve children with acute lymphocytic leukemia (ALL) or lymphoma were treated with THF for generalized varicella infection associated with impaired CMI. CMI parameters were studied before, during and post THF therapy. It was found to increase significantly (two- to ten-fold) the number of peripheral blood lymphocytes, E-rosettes, response to ConA, PHA and intracellular cAMP in 11 children. The number of lymphocytes and E-rosettes increased from 700 to 6000 and from 250 to 5500 per Cu.mm respectively. All children recovered from the varicella infection, including two with severe bilateral pneumonitis, and all of them developed antibodies to V-Z virus. Similar results of the above mentioned CMI parameters were obtained in 6 additional immunosuppressed children with ALL & lymphoma, 4 of whom had severe pneumonitis. THF restored positive GVHR and skin tests in 8 out of 10 and 4 out of 9 children studied respectively. These observations suggest that THF may restore the impaired CMI in children with ALL & lymphoma and may be valuable as supportive therapy of severe viral infections.

Pertussoid Eosinophilic Pneumonia: Pulmonary Infiltrates with Eosinophilia in Very Young Infants

This presents four new cases of pertussoid eosinophilic pneumonia in young infants. The 19 previously reported cases have been young infants with bilateral intersitial infiltrates and eosinophilia. The cause of this syndrome is unknown. Cultures from the four patients were negative; however, studies of immunoglobulin levels suggest that the disease has an infectious etiology. The cause of the eosinophilia is also unknown; however, it appears to be associated with a favorable prognosis in young infants with severe bilateral pneumonitis.

Report of a patient with T-cell deficiency and normal B-cell function: A new immunodeficiency disease with response to transfer factor

An 11-yr-old boy had recurrent fevers and pulmonary infections since early childhood and, at age 7, had disseminated varicella with bilateral pneumonitis. A female sibling, age 1, died during this period of time with varicella pneumonia. Two years later, an immunological evaluation showed severe deficits in cellular immunity with skin anergy and very low or poor in vitro lymphocyte proliferative responses to mitogens, allogeneic cells and specific antigens. Quantitation of peripheral T-cells by spontaneous rosette formation was also low—40–45% (normal 61%). On the other hand, B-cell immunity seemed to be completely normal. Serum immunoglobulins and the immunoglobulin receptors on peripheral lymphocytes were normal. The patient produced specific antibodies upon antigen challenge (immunization) and after natural infection. Following transfer factor therapy, conversion of skin reactivity and clinical improvement occurred. No changes were seen in in vitro lymphocyte function with transfer factor therapy. Immunologic reconstitution persisted for 6 mo, after which the patient responded again to the administration of transfer factor. Although this patient has several characteristics in common with Nezelof's syndrome, the patient described in this report appears to represent a distinct clinical entity of primary isolated T-cell deficiency and normal B-cell immunity. The normal B-cell immune system, and the clinical and immunological response to transfer factor therapy, differentiates our patient from the syndrome of thymic dysplasia with immunoglobulin synthesis (Nezelof's syndrome).

Opportunistic pathogens in the immunologically hyperresponsive host: Pneumocystis carinii infection in a patient with allergic bronchopulmonary aspergillosis

Pneumocystis carinii is recognized widely as a cause of rapidly lethal diffuse bilateral pneumonitis in immunologically compromised adults and debilitated infants. We describe the clinical course and pathologic features of a 20 year old man with classic allergic bronchopulmonary aspergillosis and chronic localized pulmonary pneumocystosis in the absence of demonstrable immunologic deficiency. Marked roentgenologic and clinical improvement occurred following pentamidine therapy. This unusual presentation reinforces earlier observations that Pneumocystis carinii is a true opportunist, with low virulence for the intact host.

Aids-related kaposi’s sarcoma in a four year old child: the challenge of a missed opportunity

Background: AIDSrelated Kaposi’s sarcoma (KS) is an AIDS-defining illness and is now increasingly recognized in children infected with HIV. Many of these cases are missed due to low index of suspicion. Vertical transmission of HIV is the commonest route of transmission in children and this is preventable by early maternal antenatal diagnosis, early commencement of HAART by the mother and adoption of the safest possible mode of delivery. The index case did not benefit from these services, making her acquire HIV and then develop AIDS-defining illness (KS) at a tender age of 4 years.Aim and objective: The study is aimed at emphasizing the need for all pregnant women to have antenatal screening as soon as pregnancy is confirmed so as to prevent vertical transmission of HIV to the unborn child. It is also aimed at creating awareness in clinical practice so as to increase index of suspicion among clinicians when evaluating chronically ill children.Case Description: GG was a 4year old girl who presented at 108 Nigerian Air force Hospital, Abuja with non-itchy skin rashes of two weeks duration, generalized body swelling, cough and haematochezia of one week duration, and fever of four days duration. She was a paternal orphan having lost her father a year prior to presentation to Acquired immunodeficiency syndrome (AIDS)-related illness. Her mother also tested positive to Human Immunodeficiency virus (HIV) and has been on highly active anti-retroviral therapy (HAART) for a year. Physical examination revealed moderate pallor, bilateral pitting pedal oedema, and matted non-tender peripheral lymphadenopathy. There were papular and nodular skin lesions with a reddish solid lesion on the hard palate. She tested positive to HIV. Abdominal ultrasound scan revealed moderate hepatomegaly with ascites, while chest x-ray showed bilateral interstitial pneumonitis, right hilar lymphadenopathy, right pulmonary nodule and ipsilateral pleural effusion. Excisional biopsy of one of the skin nodules confirmed the diagnosis of Kaposi’s sarcoma. She was commenced on HAART and antibiotics, with a unit of blood transfused. Her condition deteriorated, which necessitated referral to university of Abuja Teaching Hospital where she eventually died after a day of admission.Conclusion: Paediatric AIDSrelated KS is becoming increasingly common in Nigeria and as such, high index of suspicion is required while evaluating pediatric patients. This, coupled with early commencement of HAART is required to avert the pitfalls observed in this case; bearing in mind that childhood AIDSrelated KS is lethal.Keywords: Generalized lymphadenopathy; Kaposi’s sarcoma; Missed opportunity; Paediatric AIDS; Skin rashes

Bilateral radiation penumonitis, a complication of the radiotherapy of bronchogenic carcinoma. (Report and analysis of seven cases with autopsy).

Bilateral radiation penumonitis, a complication of the radiotherapy of bronchogenic carcinoma. (Report and analysis of seven cases with autopsy).