Chest Signs Research Articles

Management plan of a paediatric outpatient department during the SARS-CoV-2 epidemic.

With the novel coronavirus (2019-nCoV) infection outbreak and spread, serious cases of infection and neonatal infection have been reported. Moreover, children show milder cases and a better prognosis than adults. The outpatient Department of Paediatrics has played a crucial role in the prevention and control of novel coronavirus (2019-nCoV) infection in children. Based on previous experience and existing diagnosis and treatment guidelines, we present the relevant strategies of this particular paediatric outpatient department when responding to the epidemic. Conclusion: Concurrently, we hope that this article can act as a reference in the fight against SARS-CoV-2 infection. Further modifications will be made in the future with the increase in clinical experience and changes in the disease. This article is protected by copyright. All rights reserved.

Erdheim-Chester Disease: a Rare but Important Cause of Recurrent Pericarditis.

Erdheim-Chester disease (ECD) is a very rare neoplasm of the non-Langerhans cell histiocytes. Pericardial involvement is uncommon, and we aim to review the current knowledge on the epidemiology, clinical manifestations, and management of recurrent pericarditis due to ECD. We also aim to raise awareness of the importance of considering ECD as a differential diagnosis for recurrent pericarditis in the appropriate clinical settings. The prevalence of pericardial involvement in ECD is estimated to be 40% and is getting more recognized recently. Up to 68% of patients carry the BRAFV600E mutation, and targeted treatment with vemurafenib, an inhibitor of BRAF kinase, showed an excellent response in those who carry this mutation. Pericardial disease appears to be the most common cardiac presentation (in 80% of cases). Although pericardial involvement is frequently asymptomatic, patients with ECD can present with typical pericarditis chest pain and signs of right heart failure if constriction is present. The diagnosis of ECD requires a biopsy of the pericardium or another affected organ. If BRAFV600E mutation is absent, limited data exist, and many medications have been tried, like interferon alfa, anakinra, and infliximab.

Evidence about the Chest CT diagnostic performance in the pandemic of SARS-CoV-2 infection: A smooth takeoff and hard landing.

According to all guidelines, the unique criterion for the diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the viral nucleic acid test by reverse transcription polymerase chain reaction (RT-PCR). That should always guide the isolation decision and the management conduction [1]. SARS-CoV-2 related pneumonia may manifest after 2 to 4 days following the coronavirus infection. Typical computed tomography (CT) feature of coronavirus (COVID-19) lung disease is the bilateral , peripheric or diffuse and patchy ground-glass opacities(GGO) with consolidations. Several other signs such as crazy paving pattern , interstitial thickening, reversed-halo or microvascular embolisms are less likely described and may evoke COVID-19 pneumonia in an appropriate context. The chest CT could be initially normal. The GGO have tendency of quick evolution till the seventh day and stabilize later till the 20th day of the COVID-19 infection. Lung lesions in severe cases involve more lung segments with larger sized GGO. the interlobular septal thickening and consolidations are constant. The pleural effusion and pneumothorax were rarely described [2]. The lack of sensitivity, insufficient stability, and relatively long processing time of RT-PCR gave a considerable place for the chest CT in the daily practice of COVID-19 patients. Several reports found exciting the confrontation between the CT and the RT-PCR results. The sensitivity of CT features in highly pandemic areas could reach 97%. The earlier CT chest signs and the improvement of pulmonary lesions before RT-PCR negativity made some authors recommend the CT chest as diagnostic screening tool [3-5]. However, we still believe that the recommendation of the CT as a new diagnostic tool could not be based only on likelihood ratios and temporary concordance with the reference gold standard test. The respect of the basic epidemiologic principles is always mandatory to enhance the conclusion’s value. These recommendations were not born from blinded comparison with the refence test such in controlled randomized trials. To avoid time-lead bias many studies did not consider other potential bias especially the confusion and the selection. Moreover, the CT result did not influence the decision of proceeding to the reference test in all the previous reports. In this pandemic era, a chest CT examination will include not only additional cost for personal protective equipment (PPE) and sterilization but also more risk for the radiology department staff [6]. The chest CT could be used to select patients candidate for RT-PCR. Its value in the management and the follow up of pulmonary lesions cannot be overstated. It could play a role in clinical decision making when the gold standard test is not available in highly pandemic areas. Most of the radiology societies all over the world were not recommending the CT as diagnostic test especially in large scale screening. The few metaanalysis available have discordant conclusions about the topic. Upcoming evidence-based reports should contribute more to that [7,8].

Purulent Pericarditis and Pneumopericardium by Streptococcus Anginosus

We report a case of Purulent pericarditis and pneumopericardium by Streptococcus angiosus in 35-year-old man detained in prison, history of ischemic cerebrovascular event due to cocaine, with no recent surgical or traumatic history who had subacute clinical course of chest pain and signs of systemic inflammatory response. He was empirically treated with vancomycin and cefepime with subsequent pericardiotomy and drainage. The patient has a poor clinical evolution after the procedure, presents septic shock and dies. This is a rare case, a serious infection, the second reported in world, however in comparison to the first case the clinical course was different.

A study on role of chest X-rays in children above 5 years admitted with asthma exacerbation

Context: Asthma is a heterogeneous disease characterized by chronic airway inflammation that causes airway hyperresponsiveness. The diagnosis of asthma is mainly clinical, and chest X-rays are not required for the diagnosis or grading of severity of disease. Aim: The aim of this study is to look at the frequency of abnormalities and the pattern of abnormalities in chest X-rays done in children above 5 years admitted with acute asthma and to analyze if chest X-ray reports altered the ongoing treatment plan. Settings and Design: It was a retrospective study done in a tertiary care hospital. Methods: Data were collected from case records of children above 5 years admitted with acute asthma between November 2014 and October 2017. Statistical Analysis: The statistical analysis was done using Chi-square and Fisher's exact test. Results: A total of 114 children were included in the study, and 84 (74%) had chest X-rays performed of which 88% were normal. Nineteen (22.6%) complied with standard guidelines, and the reason for performing chest X-rays in these children was the presence of focal clinical chest signs. When there were focal clinical findings, the possibility that chest X-ray would be abnormal was 47.37%. When there were no focal clinical findings, the possibility that chest X-ray would be normal was 98.46%. The sensitivity of chest X-rays with clinical correlation was 90% and specificity was 86.48%. Hence, routine chest X-rays in the standard treatment of acute asthma are not necessary, especially when there are no focal clinical findings. Conclusion: Chest X-ray is not required in the management of acute asthma in children above 5 years responding to standard treatment. Chest X-rays should be ordered in the management of acute asthma only when indicated, thereby reducing unnecessary exposure to radiation.

Large Aorto-Pulmonary Window (APW) associated with severe pulmonary hypertension: A case report

Background: APW is a rare congenital cardiac abnormality, accounting for 0.2% to 0.6% of patients. Hence the reported surgical experience is minimal. It is a communication b/w pulmonary artery (PA) and the ascending aorta (Ao), in the presence of two separate semi lunar valves. Heart failure and irreversible pulmonary hypertension are the fearsome outcomes of untreated APW. Therefore, surgical closure is the first-line curative choice. We present a case of young boy who presented late in age (his second decade of life) with severe signs and symptoms. Case Presentation: A 12-year-old male patient from Baluchistan (balochi) presented with complaints of high grade fever for one week, palpitations since 12 days, along with past history of shortness of breath. On examination patient was anemic, cyanosed with raised JVP. On precordial examination apex beat was localized at the 6th intercostal space shifted to mid-axillary line. S1 was normal but S2 was loud with prominent pulmonary component. Grade IV/VI continuous murmur was heard in the left upper sterna border. Chest X-ray showed cardiomegaly with prominent pulmonary artery (PA) and bilateral lung congestion. Echocardiography showed enlarged and hypertrophied right ventricle associated with dilated PA and a large APW was seen with severe pulmonary artery pressure (PAP) of 102 mmHg. Diagnosis of APW was confirmed on cardiac catheterization. Furthermore, cardiac CT was performed which showed type I APW with severe PH and large patent PDA (patent ductus arteriosus). Patient then underwent repair of APW associated with reactive pulmonary hypertension that had a complete repair utilizing a trans-aortic approach. PDA was also ligated during the same procedure. Patient symptoms remarkably improved with a reduction PAP (40mmHg) after surgery and at 6 weeks follow-up. Follow-up echocardiography showed complete closure of the APW, and pharmacological therapy was no longer required in the patient. Conclusion: APW should be suspected in any child, who comes with repeated chest infections and signs of congestive heart failure. It should be surgically corrected early, in order to prevent the development of obstructive pulmonary vascular disease. There is conflict of interest.

Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions.

This Viewpoints article details our recommendation for the World Health Organization Integrated Management of Childhood Illness guidelines to consider additional referral or daily monitoring criteria for children with chest indrawing pneumonia in low-resource settings. We review chest indrawing physiology in children and relate this to the risk of adverse pneumonia outcomes. We believe there is sufficient evidence to support referring or daily monitoring of children with chest indrawing pneumonia and signs of severe respiratory distress, oxygen saturation <93% (when not at high altitude), moderate malnutrition, or an unknown human immunodeficiency virus (HIV) status in an HIV-endemic setting. Pulse oximetry screening should be routine and performed at the earliest point in the patient care pathway as possible. If outpatient clinics lack capacity to conduct pulse oximetry, nutritional assessment, or HIV testing, then we recommend considering referral to complete the evaluation. When referral is not possible, careful daily monitoring should be performed.

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-analysis

Patients with COPD experience episodes of increased inflammation, so-called acute exacerbations of COPD (AE-COPD). In 30%of AE-COPD cases, no clear cause is found. Since there is well-known cross talk between inflammation and thrombosis, the objectives of this study were to determine the prevalence, embolus localization, clinical relevance, and clinical markers of pulmonary embolism (PE) in unexplained AE-COPD. A systematic search was performed using MEDLINE and EMBASE platforms from 1974 to October 2015. Prospective and cross-sectional studies that included patients with AE-COPD and used pulmonary CT-angiography for diagnosis of PE were included. The systematic search resulted in 1,650 records. The main reports of 22 articles were reviewed, and 7 studies were included. The pooled prevalence of PE in unexplained AE-COPD was 16.1%(95%CI, 8.3%-25.8%) in a total of 880 patients. Sixty-eight percent of the emboli found were located in the main pulmonary arteries, lobar arteries, or interlobar arteries. Mortality and length of hospital admission seemed to be increased in patients with unexplained AE-COPD and PE. Pleuritic chest pain and cardiac failure were more frequently reported in patients with unexplained AE-COPD and PE. In contrast, signs of respiratory tract infection was less frequently related to PE. PE is frequently seen in unexplained AE-COPD. Two-thirds of emboli are found at locations that have a clear indication for anticoagulant treatment. These findings merit clinical attention. PE should receive increased awareness in patients with unexplained AE-COPD, especially when pleuritic chest pain and signs of cardiac failure are present, and no clear infectious origin can be identified.

Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance

Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted. Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management. Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation. Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.

Percutaneous drainage of splenic abscess in a renal transplant recipient – A case report

Splenic abscess is a rare clinical entity with an incidence of 0.2–0.7% in autopsy-based studies.1,2 Moreover, abscess of the spleen is a very rare entity in post-renal transplant recipients. We encountered a rare case of this life-threatening infection in a 32-year-old gentleman who had undergone live related renal transplant 8 months ago. He presented with fever, malaise, left upper quadrant pain and non-productive cough. Computed tomography (CT) of the chest taken to assess the lower chest signs and ultrasound abdomen taken to assess the left upper quadrant pain revealed a large thick walled abscess (8cm×7cm×7.5cm) in the spleen. He made a complete recovery after percutaneous pig tail catheter drainage of splenic abscess and intravenous antibiotics for 3 weeks.

Clinical profile of culture proven enteric fever in children at university teaching hospital, Nepal

Introductions: Enteric fever is one of the major public health issues in Nepal. The present study was designed to analyze the clinical profile and antibiotic sensitivity pattern in the cases of culture positive typhoid fever.Methods: This was a cross sectional study done by reviewing the hospital record files of children admitted in paediatric ward of Patan Hospital with culture positive enteric fever over a period of seven years from January 2007 to December 2013. The mode of presentation, sensitivity pattern of isolates from blood culture, response to therapy and the complications were recorded and analyzed.Results: There were total of 119 culture positive enteric fever admitted to children ward during this period, 64 (53.7%) males and 55 (46.3%) females. Common symptoms were fever (100%), vomiting 37 (31.09%), diarrhea 27 (22.68%), abdominal pain 31 (26%) cough 24 (20%), and constipation six (5%). Common clinical signs were hepatomegaly 41 (34.4%), splenomegaly 25 (21%), and chest signs 10 (8.4%). Sensitivity to ceftriaxone was 96.6% in this study. Ninety four percent of salmonella typhi in 2013 were resistant to quinolones.Conclusions: Fever, vomiting, abdominal pain, diarrhea and cough were major manifestations and encephalopathy was common complication of enteric fever in this study. Resistance to many of the drugs are emerging. An appropriate antibiotic has to be initiated only after culture sensitivity in typhoid fever.Journal of Patan Academy of Health Sciences. 2014 Dec;1(2):42-45

Complex evaluation of left atrial dysfunction in patients with type 1 diabetes mellitus by three-dimensional speckle tracking echocardiography: results from the MAGYAR-Path Study.

Objective:Changes in left atrial (LA) function can be observed in type 1 diabetes mellitus (T1DM). Three-dimensional (3-D) speckle tracking echocardiography (STE) seems to be a promising tool for volumetric and functional evaluation of LA. The objective of the present study was to compare 3DSTE-derived LA volumetric and strain parameters between T1DM patients and matched healthy controls.Methods:This prospective study consists of 17 subcutaneous insulin pump-treated non-obese patients with T1DM (mean age: 33.5±8.2 years, 8 males). To exclude possible cardiovascular disease, patients with complaints of chest pain, dyspnea, or signs of cerebrovascular disease or peripheral artery disease were not included. Their results were compared with 20 age-matched and gender-matched healthy controls (mean age: 36.9±11.0 years, 9 males). Independent sample Student t-test and Fisher’s exact test were used for comparisons. Bland–Altman method was used for evaluating intraobserver and interobserver correlations.Results:Anemia and impaired renal function were not confirmed in T1DM patients. Calculated LA maximum and minimum volumes and LA volume before atrial contraction were significantly increased in T1DM patients. Total atrial stroke volume was increased (23.6±6.9 mL vs. 19.6±4.6 mL, p=0.04), whereas mean segmental circumferential peak strain was decreased (28.9%±11.4% vs. 37.3%±12.5%, p=0.04). Segmental basal longitudinal and area strains were increased, whereas segmental superior circumferential and area strains and midatrial 3-D strain were decreased in T1DM.Conclusion:Both 3DSTE-derived volumetric and strain analysis confirmed alterations in LA function, suggesting early LA remodeling in patients with T1DM. (Anatol J Cardiol 2016; 16: 587-93)

Guideline on the management of acute chest syndrome in sickle cell disease.

1. Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust 2. Lane Fox Respiratory Unit, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust 3. Department of Haematology, North Middlesex Hospital 4. Department of Paediatric Haematology, Bristol Royal Hospital for Children 5. Department of Haematological Medicine, King’s College Hospital 6. Department of Haematology, Whittington Hospital

Community-acquired pneumonia as medical emergency: predictors of early deterioration

BackgroundEarly organ dysfunction determines the prognosis of community-acquired pneumonia (CAP), and recognition of CAP as a medical emergency has been advocated.ObjectiveTo characterise patients with ‘emergency CAP’ and evaluate predictors for...

Issues of respiratory pathology in the writings of Abu Ali Ibn Sino

Abu Ali Ibn Sina (Avicenna) was the great scientist of the medieval East, whose writings have provided an active influence on development of the Eastern and European science and culture over several centuries. His medical opinion was based on a philosophical approach. In his main medical work The Canon of Medicine, Ibn Sina described the chest structure, signs and treatment of respiratory diseases. He paid special attention to inflammation and pulmonary edema, purulent lung diseases, asthma, pleuritis and pulmonary tuberculosis. His diagnostic and therapeutic approaches described long ago has been still actual and could be applied in the current medicine. Abu Ali Ibn Sina laid the basis for the current pneu

Chest auscultatory signs in infants presenting to A&amp;E with bronchiolitis

Anecdotally it has been noted that the traditional chest signs associated with bronchiolitis appear inconsistently in infants clinically diagnosed with bronchiolitis. We wished to explore this more formally. The aim of this study was to assess whether the auscultatory chest signs at presentation in infants with bronchiolitis were influenced by age or by the underlying pathogen. We conducted a prospective opportunistic cohort study, recruiting infants less than 12 months old who presented with bronchiolitis to the Emergency Department of the Royal Hospital for Sick Children in Edinburgh. Eighty-six infants were recruited. Infants who presented with wheeze were significantly older [26.6 (±1.9) weeks] than those without wheeze [17.3 (±2.1) weeks] (analysis of variance, P=0.002). Those who presented without any chest signs on auscultation were younger than those with chest signs [15.1 (±2.6) weeks compared with 24.4 (±1.7) weeks] (analysis of variance, P=0.006). We did not detect any difference in any of the auscultatory chest signs (crackles, wheeze or absence of signs) depending on the virus responsible for bronchiolitis. Clinical signs associated with bronchiolitis vary according to age. Infants older than 6 months are more likely to present with wheeze and infants less than 4 months old are likely to present without chest signs on auscultation.

Respiratory viruses in exacerbations of non-cystic fibrosis bronchiectasis in children

BackgroundRespiratory viral infections precipitate exacerbations of chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease though similar data in non-cystic fibrosis (CF) bronchiectasis are missing. Our study aimed...

Traumatic Asphyxia

Traumatic asphyxia is a rare condition in children that usually occurs after severe compression to the chest or abdomen. We report 3 cases in patients 18, 20, and 36 months of age who presented signs and symptoms of traumatic asphyxia after car accidents. Two clinical features were consistent in all 3 patients: multiple petechiae on the face and bulbar conjunctival hemorrhage; 2 patients had facial cyanosis, and 1 had facial edema.In children, the number of clinical manifestations that should be evident to diagnose traumatic asphyxia has not been ascertained. However, in any history of trauma with compression of the chest or abdomen and signs of increased intravenous craniocervical pressure, traumatic asphyxia should be suspected.

A case report of the rapid dissemination of Kaposi’s sarcoma in a patient with HIV

Introduction: Kaposi’s sarcoma is the most common HIV-associated neoplastic disease. In most cases it starts on the skin and later spreads to other visceral organs. We reported a case of HIV-associated cutaneous Kaposi’s sarcoma which rapidly progressed to involve the visceral organs within a few weeks and resulted in fatality. Case presentation: A 21-year old man who recently started antiretroviral therapy developed disseminated Kaposi’s sarcoma with a right-sided pleural effusion. Chest x-ray confirmed the effusion which was tapped for diagnostic purposes. Biopsy confirmed Kaposi’s sarcoma. He insisted on being discharged so that he could visit a traditional healer. Management and outcome: Despite antiretroviral therapy and supportive management his condition deteriorated rapidly and he died within a month of the diagnosis of disseminated Kaposi’s sarcoma. He died before chemotherapy could be commenced. Discussion: The lessons that could be learned from this case include the following: Kaposi’s sarcoma is asymptomatic and, since one out of three are HHV-8 positive, patients should have a thorough examination before starting on highly-active antiretroviral therapy. Patients with Kaposi’s sarcoma or even those on treatment should be warned of deterioration in the first 12 weeks of treatment. Pulmonary Kaposi’s sarcoma is fatal and requires timeous management and chemotherapy. Patients with HIV-related Kaposi’s sarcoma and chest signs require sputa to exclude pulmonary tuberculosis. Finally, traditional healers may be used to assist, especially if they are taught to identify HIV-related skin conditions and can refer patients appropriately.

Spontaneous hemothorax following thrombolytic and anticoagulant therapy for massive pulmonary embolism

Massive spontaneous hemothorax following combined thrombolytic and anticoagulant therapy for pulmonary embolism(PE) is a rare event that is little documented in the literature. Here, we describe a rare case of spontaneous hemothorax in a 23-year-old woman with underlying systemic lupus erythematosus following combined administration of tissue plasminogen activator and low-molecular-weight heparin for massive PE. This report of our successful treatment of this case by video-assisted thoracoscopic thoracotomy demonstrates that although the occurrence is rare, massive hemothorax following anticoagulant and/or thrombolytic therapy for PE should be suspected if patients experience chest pain, dyspnea, or signs of anemia, and follow-up physical examination and hemogram should be performed to facilitate diagnosis of this life-threatening complication.