Improvement In Pulmonary Symptoms Research Articles

METASTATIC COLORECTAL CANCER PRESENTING AS AN OBSTRUCTING ENDOBRONCHIAL LESION

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Colorectal cancer is one of the most common malignancies worldwide with the pulmonary parenchyma a common site for distant metastasis. Colorectal endobronchial metastases, however, are exceedingly rare. We present a patient with previously resected colon cancer who was found to have an obstructing endobronchial colorectal metastasis. CASE PRESENTATION: A 66-year-old male with a 12 pack-year smoking history presented with dyspnea. On routine colonoscopy 4 years prior, he was diagnosed with moderately differentiated colorectal adenocarcinoma with negative tumor margins and without any lympho-vascular involvement. Imaging was without evidence of regional or distant metastases so he underwent hemicolectomy. Medical oncology recommended no adjuvant chemotherapy and 1 year follow-up. The patient did not follow-up. Four years later, he presented with fever, dyspnea, cough, and pleuritic chest pain. CT pulmonary angiography demonstrated a RUL mass with RML lobe collapse, a moderate right-sided pleural effusion, and no pulmonary embolism. He was started on empiric antibiotics. Thoracentesis revealed an exudative effusion with negative cultures and cytology. Bronchoscopy demonstrated a fungating endobronchial lesion completely occluding the right middle lobe for which cryobiopsy and cryo-excision were performed. Pathology was consistent with metastatic moderately differentiated colorectal adenocarcinoma, with morphology and histology identical to his prior colorectal cancer. Transbronchial needle aspiration using endobronchial ultrasound of the station 7 mediastinal lymph node was negative for malignant cells. Patient left against medical advice before further work-up was completed. DISCUSSION: About 20% of patients with colorectal cancer have distant metastases at presentation, with the lungs being a common site, usually involving the pulmonary parenchyma and very rarely as an endobronchial lesion. In fact, endobronchial metastases from extra-thoracic malignancies account for 1% of all endobronchial tumors, with the most common being colorectal, breast and renal. These patients may present with a variety of non-specific respiratory symptoms. It is also not uncommon for endobronchial metastasis to occur after resection of the primary tumor and without other signs of metastases. One should consider the possibility of endobronchial involvement of a tumor in a patient with a history of an extra-thoracic malignancy who presents with vague respiratory symptoms, as timely bronchoscopic intervention can improve quality of life and help mitigate the risk of post obstructive complications. CONCLUSIONS: Endobronchial metastasis from extra-thoracic malignancies are very rare, accounting for 1% of all endobronchial tumors. Diagnosis can be difficult due to vague respiratory complaints. Bronchoscopic intervention can assist in diagnosis, management, and it can lead to substantial improvement in pulmonary symptoms. REFERENCE #1: Akoglu S, Uçan ES, Celik G, et al. Endobronchial metastases from extrathoracic malignancies. Clin Exp Metastasis. 2005;22:587–591. REFERENCE #2: Coriat R, Diaz O, de la Fouchardiere C, et al. Endobronchial metastases from colorectal adenocarcinomas: clinical and endoscopic characteristics and patient prognosis. Oncology. 2007;73:395-400. REFERENCE #3: Lin CY, Chung FT. Central airway tumors: interventional bronchoscopy in diagnosis and management. J Thoracic Dis. 2016;8(10):E1168-E1176. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: 2014-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: 2019-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Advisory Committee Member relationship with Vapotherm, Inc Please note: 2020 Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Ken Dekitani, source=Web Response No relevant relationships by Michael Lewis, source=Web Response No relevant relationships by Roberto Mempin, source=Web Response No relevant relationships by Scott Oh, source=Web Response

Co-infection with nocardia and mycobacterium tuberculosis in a patient with systemic lupus erythematosus: A case report

Objective: Pulmonary infection is an important cause of morbidity and death in immunosuppressed patients. Recent studies showed that infections caused by Nocardia are quite rare, especially mixed infections with Nocardia and Mycobacterium Tuberculosis (MTB). This case emphasizes the importance of being alert to the possibility of co-infection in immunosuppressed patients. Case description: A 31-year-old female patient presented to the outpatient clinic with recurrent fever and cough. She had also suffered from Systemic Lupus Erythematosus (SLE) and type V lupus nephritis for 8 years. Additionally, she tested positive for the Nocardia nova complex and MTB following culture of the sputum/bronchoalveolar lavage fluid (BALF) and lung tissue. Initial Computed Tomography (CT) showed a bi-pulmonary massive high-density shadow with multiple cavities, Ground-Glass Opacity (GGO) and multiple miliary nodules. After admission, the patient was given Cefoperazone-Sulbactam (CSL) for empiric treatment and also received low-flow oxygen therapy. Four days later, microscopic examination suggested infection with Nocardia and CSL was replaced with Trimethoprim/Sulfamethoxazole (SXT), Moxifloxacin (MFX) and Imipenem (IPM). On the 9th day, the Nocardia nova complex was confirmed although there was a significant improvement in pulmonary symptoms and imaging results. However the images showed that there was no significant change in GGO and miliary nodules. Moreover, 18 days later she was confirmed with MTB infection and was subsequently transferred to the infectious diseases hospital for further treatment. Conclusion: Immunosuppressed patients have higher morbidity and mortality after opportunistic infection with pulmonary pathogens such as Nocardia and MTB. Therefore, early detection of pathogens and selection of appropriate antimicrobial therapy can significantly improve the prognosis.

Disseminated coccidioidomycosis in an immunocompetent patient

A 35-year-old healthy Hispanic male was grinding metal to remove encrusted dirt without a protective mask at a construction site in inland southern California 3 months prior to hospitalization. He reported significant dust exposure. After several days on the project, he developed fever, myalgia, and cough and was sent by his employer to see a community physician. He was prescribed azithromycin for presumed community-acquired pneumonia, with mild improvement in pulmonary symptoms. Approximately 1 week later he developed ulcerating skin nodules on the face and chest (Figure 1).

S2262 A Rare Manifestation of Cryptogenic Organizing Pneumonia in a Patient With Ulcerative Colitis Being Treated With an Anti-TNF Biosimilar

INTRODUCTION: Ulcerative colitis (UC) is an inflammatory bowel disorder (IBD) resulting in continuous mucosal inflammation from the rectum with variable extension to the proximal colon. Symptoms can include abdominal pain, hematochezia, or tenesmus. Anti-tumor necrosis factor (anti-TNF) therapy has been recognized as a treatment modality for moderate to severe UC. Extraintestinal manifestations of IBD have been well documented, with pulmonary manifestations being an uncommon presentation. One such manifestation is cryptogenic organizing pneumonia (COP). The most common finding is diffuse ground glass opacities and bilateral infiltrates on CT. In addition, COP has been described as a noninfectious complication associated with anti-TNF therapy. Here we present a case of COP in a patient being treated with an anti-TNF biosimilar for moderate to severe UC. CASE DESCRIPTION/METHODS: A 38 year-old female with left-sided UC presented to the hospital complaining of 2 weeks of progressively worsening shortness of breath. She had been on Inflectra and mesalamine for 2 years without complications. A chest CT revealed bilateral infiltrates concerning for organizing pneumonia. Bronchoscopy with bronchoalveolar lavage (BAL) was negative for fungal, pneumocystis jirovecii, bacterial, or viral etiologies. The patient was eventually discharged, however, she still required supplemental oxygen. She was started on prednisone and Bactrim for pneumocystis pneumonia prophylaxis. She was referred to gastroenterology for a concern of a possible association between Inflectra and COP. Mesalamine and Inflectra were stopped and the patient developed fecal urgency and rectal bleeding. The patient was started on vedolizumab and prednisone with an eventual prednisone taper, in addition to levalbuterol for her ongoing dyspnea. After two months of vedolizumab therapy, the patient noted significant improvement in her gastrointestinal symptoms as well as her pulmonary symptoms. DISCUSSION: There have been case reports detailing COP in patients undergoing therapy with Infliximab, however, this is the first known case of COP with a biosimilar. The improvement in pulmonary symptoms with discontinuing Inflectra, which was controlling her UC, and starting vedolizumab to continue control of the UC with subsequent improvement in her COP suggests the biosimilar, Inflectra, as opposed to an extra intestinal manifestation of UC, was the cause of COP.

P78 CRITICAL APPRAISAL OF THE IMPACT OF SURGICAL REPAIR OF TYPE II - IV PARAOESOPHAGEAL HERNIA ON PULMONARY IMPROVEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Aim This systematic review and meta-analysis aimed at characterising impact of PEH repair on patient reported improvement in pulmonary symptoms Background Paraoesophageal hernia (PEH) comprising Type II - IV hiatal hernia often present with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear Methods This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II - IV PEH. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes. Results This systematic review identified 27 studies, of which 21 studies were included in final meta-analysis. There was significant improvement in patient reported pulmonary symptoms following PEH repair (OR: 8.40, CI95%: 4.91 - 14.35, p<0.001), with improvement in all types of PEH. This was noticed in both patients who had noticed pulmonary symptoms prior to surgery and those that did not complain of these symptoms. Conclusion PEH repair is a major upper gastrointestinal procedure, which may be associated with high morbidity. However, pulmonary impairment from PEH warrant surgical repair with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.

Magnetic Resonance Lymphangiography and Lymphatic Embolization in the Treatment of Pulmonary Complication of Lymphatic Malformation.

Lymphatic malformations (LMs; especially those involving the central conducting lymphatic channels) are characterized by dysplastic and incompetent lymphatic channels in multiple tissues and organs. The major cause of mortality and morbidity in patients with thoracic LM is deterioration of pulmonary function due to chronic chylous effusions and progressive interstitial lung disease. The etiology of these pulmonary processes is unknown, although lymphatic involvement is certain. Understanding of the changes in the lymphatic anatomy in patients with LM has been hindered by difficulty of imaging of the lymphatic system. Recently developed dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows dynamic MR imaging of the lymphatic system by injecting gadolinium contrast agent in the groin lymph nodes. Using this technique, pathological lymphatic flow from the central lymphatic system and/or retroperitoneal and mediastinal masses into lung parenchyma ("pulmonary lymphatic perfusion syndrome") has been demonstrated in patients with LM. This abnormal lymphatic perfusion overflows pulmonary parenchyma and results in deterioration of pulmonary function due to interstitial process and/or compression effect of chylous effusions. Percutaneous thoracic duct embolization or lymphatic interstitial embolization of the lymphatic masses results in cessation of the pulmonary lymphatic overflow and significant improvement in pulmonary symptoms in these patients.

A case of hepatopulmonary syndrome solved by mycophenolate mofetil (an inhibitor of angiogenesis and nitric oxide production)

The autoimmune lymphoproliferative syndrome (ALPS) is a rare, multisystemic disease, caused by an inherited defect in the Fas apoptotic pathway, characterized by a chronic non-malignant lymphoid accumulation and autoimmune manifestations. Lung, kidney, liver, and gut infiltration is described in severe, multisystemic cases; so far there has been no description of hepatopulmonary syndrome (HPS), for which orthotopic liver transplantation (OLT) is currently the only known effective treatment. A teenage boy, diagnosed with ALPS at 4years of age (lymph nodes enlargement, splenomegaly, immune cytopenias), was stable until 13years of age, when he developed insidious hypoxemia (PaO 2 =46.7mmHg). He was diagnosed with HPS on the basis of hypoxemia, non-cirrhotic liver disease with portal hypertension, and pulmonary vascular dilatation (intrapulmonary shunt=45%). He was treated with oxygen (maximum 6L/min), prednisolone and sirolimus. There was significant regression of all manifestations of ALPS, except for the pulmonary symptoms, therefore, after evaluation in referral centers in England, OLT was proposed. Since he was to undergo major surgery, sirolimus, which has wound-healing problems, was switched to mycophenolate mofetil (MMF). Following this change, we observed a huge improvement in pulmonary symptoms and reduction of oxygen needs. The intrapulmonary shunt decreased from 45% to 0% in less than a year, and it has not changed since (18months after complete normalization), on continued treatment with MMF. Indication for OLT was suspended. In the last year, lymphoid proliferation increased again, with huge splenomegaly, but no recurrence of HPS. The addition of sirolimus to MMF produced again a rapid resolution of lymphoid proliferation. The dramatic and unexpected regression of HPS may have been due to inhibition of angiogenesis and nitric oxide (NO) production by MMF (both important pathways/mediators in HPS pathogenesis). Therefore, we propose to perform clinical trials with MMF, and/or other angiogenesis and NO inhibitors, on a long-term treatment basis, to confirm their potential as a valid alternative to medical treatment of HPS.

Treatment of allergic bronchopulmonary aspergillosis (ABPA) in CF with anti‐IgE antibody (omalizumab)

Allergic bronchopulmonary aspergillosis (ABPA) results from IgE induced pulmonary response to aspergillus species. Recognition and management of ABPA is challenging in cystic fibrosis (CF) patients because changes in symptoms, lung function and chest radiograph are similar to that seen in CF related pulmonary infection. Standard therapy for ABPA includes systemic steroids and adjunctive use of antifungal agents. Little has been published regarding the use of monoclonal anti-IgE antibody in those with ABPA. We report a CF patient with her third exacerbation of ABPA who was treated with monoclonal anti-IgE (omalizumab) antibody; she had unfavorable side effects with prednisone therapy. This therapy resulted in improvement of pulmonary symptoms and lung function not achieved with antibiotics or prednisone alone.

Exacerbation of pre-existing interstitial lung disease after oxaliplatin therapy: A report of three cases

To describe the possible role of oxaliplatin in worsening pre-existing interstitial lung disease. After we encountered a patient with an interstitial lung disease who experienced a fatal progression of his pulmonary disease associated with oxaliplatin therapy, a computer-aided search was conducted to identify other similar patients. Twenty-six patients with various lung diseases who had received oxaliplatin therapy at Mayo Clinic in Rochester, MN from January 2000 to December 2006 were identified. Three of these patients had radiologic evidence of interstitial lung disease before undergoing oxaliplatin therapy. We examined the medical records and imaging studies of these three patients to further define their clinical presentation, radiological and functional characteristics, and clinical outcome. All three patients experienced symptomatic and radiologic worsening of their interstitial lung disease following oxaliplatin administration. One of these patients died from refractory respiratory failure; the remaining two patients stabilized after the discontinuation of oxaliplatin therapy and have since shown modest improvement in pulmonary symptoms and lung function. There were no other potential causes identified for the unexpected progression of their lung disease other than the temporal relationship to oxaliplatin therapy. Treatment with oxaliplatin, in the setting of a pre-existing interstitial lung disease, may be associated with respiratory deterioration. It is unknown whether this is mediated by acceleration of the underlying parenchymal disease or by a superimposed acute lung injury caused by oxaliplatin.

Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease.

Supra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD) are common and often under-appreciated, in part due to the absence of classic symptoms of heartburn and regurgitation. Patients with supra-oesophageal manifestations of GERD may report symptoms involving the pulmonary, otolaryngologic or pharyngeal systems. Endoscopy is often negative and therefore of limited diagnostic value in these patients, and while laryngoscopy and 24 h dual-channel intra-oesophageal pH-metry may have greater yields they are costly, invasive and time-consuming. Therefore, a trial of proton pump inhibitor therapy is now widely considered a first-line diagnostic test in those with suspected GERD-induced supra-oesophageal symptoms. The dose as well as duration of the proton pump inhibitor trial is dependent upon a patient's presenting symptoms. For example, GERD-related non-cardiac chest pain may be relieved with a short-term (e.g. 1 week) treatment with standard doses of a proton pump inhibitor. The use of high-dose twice daily proton pump inhibitor therapy for an extended period (e.g. 2-3 months) may be required before any discernible improvement in pulmonary symptoms or pharyngo-laryngitis is noted. Patients who do not experience symptom improvement following a proton pump inhibitor trial may require further diagnostic evaluations including 24 h oesophageal pH studies, while on acid anti-secretory therapy, to establish the absence of persistent acid reflux. The role of anti-reflux surgical or endoscopic interventions in those with supra-oesophageal manifestations of GERD remains to be established.

Gastroesophageal Reflux and Asthma

The medical literature has been deluged with articles on the relation between gastro-esophageal reflux (GER) and asthma. In an effort to piece together the complex puzzle, investigators from all disciplines have gathered their patients with wheezing and heartburn and studied the epidemiology, the possible cause or effect mechanisms and the therapeutic response to GER treatment. Indeed, since humans first began to hunker down and work together to discuss interesting observations, the world has begun to breathe easier. Epidemiological evidence for a GER/asthma association suggests that about three-fourths of asthmatics, independent of the use of bronchodilators, have acid GER, increased frequency of reflux episodes, or heartburn; and 40% have reflux esophagitis. Physiological studies suggest that 2 separate mechanisms are involved in the GER/asthma relationship: (1) a vagally mediated pathway and (2) microaspiration. In any given patient, however, there is no acceptable diagnostic method available to confirm the presence or absence of GER-induced asthma. Clinical trials, using antireflux medical therapy and antireflux surgery have begun to provide some clues about GER-related pulmonary symptoms. The trials of medical therapy using acid suppressing drugs (e.g. histamine-2 receptor antagonists) have ranged from no benefit to modest improvement of only nocturnal asthma symptoms. Studies with proton-pump inhibitors are underway. In uncontrolled surgical studies, antireflux surgery has resulted in partial or complete remission of asthma symptoms in a large proportion of patients. Despite the uncontrolled nature of these studies, many patients have had dramatic subjective improvement in pulmonary symptoms. It appears for now that clinical trials are the only available means to assess whether medical or surgical treatment of GER in patients with both GER and asthma improves the symptoms of asthma and decreases the need for pulmonary medications. One conclusion is certain: We no longer can ignore the important co-existent nature of these 2 afflictions.

GASTROESOPHAGEAL REFLUX AND ASTHMA IN THE ELDERLY PATIENT: Pathogenesis, Diagnosis, and Treatment

The prevalence of gastroesophageal reflux (GER) in the elderly population may be as high as 20%. There is little information, however, about elderly patients with GER-associated asthma. The exact relationship between GER and asthma is unclear, although the association is well recognized. This article reviews the data that link GER to clinical presentations, diagnostic tools, and treatment options.

Two-month comparative study of tulobuterol aerosol versus fenoterol aerosol in patients with chronic obstructive lung disease

In this two month, double-blind, crossover study, the efficacy and safety of tulobuterol aerosol (400 micrograms qid) was compared to fenoterol aerosol (400 micrograms qid) in patients with chronic obstructive lung disease. Thirty-six (36) adults with reversible bronchospasm were enrolled. All patients were evaluable. On set of response was within 5 minutes for both drugs. Mean increases in FEV1 were greater after tulobuterol than fenoterol at every time interval. Increases peaked at 30-60 minutes postdose. Duration of response was longer after tulobuterol with mean FEV1 remaining greater than 15% over baseline for at least 6 hours postdose. Mean predose FEV1 values were significantly greater after 2 and 4 weeks of tulobuterol treatment compared with fenoterol. Despite these large increases, changes in mean FEV1 from predose to 1 hour postdose at these visits were not significantly different between treatment groups. Results of plethysmography testing also indicated greater improvement after tulobuterol. In addition, improvement in pulmonary symptoms was more pronounced during tulobuterol therapy. Small changes in mean blood pressure occurred, with greater changes after fenoterol than after tulobuterol. Changes in mean pulse rate were significantly greater following fenoterol administration. No adverse reactions were reported during tulobuterol treatment; however, one patient experienced severe tremor, tachycardia, and sweating during fenoterol treatment and withdrew from the study prematurely. The results in this study indicate that tulobuterol aerosol is more effective than fenoterol aerosol in the treatment of patients with chronic obstructive lung disease, with fewer cardiovascular effects and no adverse reactions.

Antireflux treatment for asthma. Improvement in patients with associated gastroesophageal reflux.

Fifteen patients with both nonallergic asthma and symptomatic gastroesophageal reflux were studied before and after an eight-week period of vigorous antireflux therapy, which included ranitidine hydrochloride, 150 mg twice a day. Pulmonary and esophageal symptoms were recorded on daily diary cards. Therapy was associated with prompt amelioration of reflux symptoms and with a less dramatic and more delayed improvement in pulmonary symptoms. Objectively, esophageal erosions healed completely in eight of the ten patients who had them at the beginning of the trial, and pulmonary function measurements improved significantly. Intraesophageal infusions of physiologic saline and 0.1N hydrochloric acid in patients and healthy controls did not significantly alter pulmonary function, as measured by standard spirometry. There is a subset of patients in whom bronchoconstriction is triggered by gastroesophageal reflux. Treatment of reflux in such patients may improve their asthma.

Antireflux Treatment for Asthma

• Fifteen patients with both nonallergic asthma and symptomatic gastroesophageal reflux were studied before and after an eight-week period of vigorous antireflux therapy, which included ranitidine hydrochloride, 150 mg twice a day. Pulmonary and esophageal symptoms were recorded on daily diary cards. Therapy was associated with prompt amelioration of reflux symptoms and with a less dramatic and more delayed improvement in pulmonary symptoms. Objectively, esophageal erosions healed completely in eight of the ten patients who had them at the beginning of the trial, and pulmonary function measurements improved significantly. Intraesophageal infusions of physiologic saline and 0.1N hydrochloric acid in patients and healthy controls did not significantly alter pulmonary function, as measured by standard spirometry. There is a subset of patients in whom bronchoconstriction is triggered by gastroesophageal reflux. Treatment of reflux in such patients may improve their asthma. (<i>Arch Intern Med</i>1987;147:56-60)

Corticosteroids in COPD: A Clinical Trial and Reassessment of the Literature

A placebo-controlled, double-blind cross-over trial was conducted to assess whether 16 men with chronic obstructive pulmonary disease (COPD) would benefit from orally taken corticosteroids. Two weeks of treatment with 40 mg of prednisone daily did not result in improvement of pulmonary symptoms or function in the group as a whole, although one patient had small improvement in airflow. The baseline spirometric data and beta-agonist responsiveness of the patients in the study were then compared to a reference population consisting of 264 men who fulfilled a criteria for chronic obstruction out of 730 men who comprised a systematic sample drawn from all patients referred for spirometry at three hospitals. Our study subjects and those of five similar trials of corticosteroids in COPD had more severe obstruction than this reference group. Furthermore, the proportion of steroid responders found in each study was inversely related to the baseline FEV1 of the patients examined. It appears that previous studies of corticosteroids in COPD may have overestimated the number of COPD patients who might benefit from corticosteroids, due to a bias resulting from the selection of severely obstructed subjects.

Benefit of intravenous IgG replacement in hypogammaglobulinemic patients with chronic sinopulmonary disease

Seven patients with hypogammaglobulinemia and chronic sinopulmonary infections were treated with a preparation of intravenous gammaglobulin. In order to maintain levels of serum IgG at greater than 500 to 750 mg/dl four weeks after infusion, 0.6 g/kg was administered every month. Stable serum levels were achieved after three to eight months. After six to 12 months of this regimen, there was significant reduction in acute infections requiring hospitalization, amelioration of clinical and radiographic evidence of chronic maxillary sinusitis, and improvement in pulmonary symptoms and pulmonary function test results. The administration of increased amounts of IgG intravenously is of benefit in patients with chronic sinopulmonary infections.

Bilateral Pulmonary Resection for Bronchiectasis: A 40-Year Experience

Ninety-nine patients underwent bilateral pulmonary resection for severe multisegmental bilateral bronchiectasis at the Overholt Thoracic Clinic during the period 1937 to 1977. A total of 216 operations were performed, and 20 patients underwent three or more procedures. The operative mortality was 1.4% and the incidence of severe complications, 7%. Follow-up ranged from 1 to 30 years (average 10.2 years). Only 1 patient was lost to follow-up. Improvement in pulmonary symptoms was achieved in 83 patients; there was no improvement in 9 patients; and 4 patients were worse following resection. The results suggest that bilateral bronchiectasis need not be a contraindication to operation. In properly selected patients, lasting symptomatic improvement can be provided by resection.

Genital ulceration and infectious mononucleosis: Report of a case

ble of’ parasitic growth at a site distant from the primary focus and the intravenous tumors are capable of spread only by direct extension within a blood vessel. One plausible theory is that the metastasizing leiomyoma is a form of. generalized leiomyomatosis in which multiple primary foci of smooth-muscle tumors occur. However, eight case reports of this condition disclosed a histologic appearance in the tumors of the uterus unlike that of the tumors in distant sites.’ In addition, there was a peculiar interstitial pattern of growth not characteristic of vascular metastasis. Finally, the clinical effect of this condition was more devastating than that of’ metastatic leiomyomas. In leiomyomarosis, peritoneal and pleural effusions and death have been the result in a majority of reported cases. Whether or not estrogen stimulated the development of this condition has not been determined. Experimentally, tibromyoma has been induced in laboratory animals by exogenous estrogens.” Other reports ha\‘e shown accelerated tumor growth under high estrogen stimulation and regression following removal of estrogen.6 Our patient showed clinical improvement of pulmonary symptoms when exogenous estrogen was stopped and the ovaries were removed. The hyperplastic stroma of‘ the ovaries H’as undoubtedly a source of high levels of endogenous estrogen. The removal of the primary tumor focus probably had a favorable effect as well. Numerous reports link estrogen to proliferation of uterine and extrauterine mvomas. but its role in the disease process will be known on+ when estrogen binding and metabolism are clarified. The diagnosis of benign metastasizing leiomyoma to the lung can be made only by lung biops),. The treatment consists of castration and little, if any. estrogen replacement. Irradiation and chemotherapy have not proved to be of value. The prognosis is generally good; however. frquent examinations of the patient are advisable becatlse o’f the possible insidious progression and lojr-grade malignant potential of these tumors.

Waldenström's macroglobulinemia: Report of a case with pulmonary involvement and improvement in pulmonary symptoms only following chlorambucil therapy

A case of Waldenström's macroglobulinemia is presented in which the sole demonstrable presenting clinical manifestation was related to pulmonary infiltration. Bone marrow aspirates revealed no increase in lymphocytic cells. Protein studies demonstrated the characteristic monoclonal increase in immunoglobulin M (IgM) which, by analytical ultracentrifugation, proved to be a 19S macroglobulin. A bronchial biopsy specimen, obtained at bronchoscopy, revealed a dense lymphocytic infiltration. There was an excellent clinical response to small (4 to 6 mg/day) doses of chlorambucil as evidenced by disappearance of symptoms, resolution of pulmonary lesions as seen on roentgenogram and decrease in abnormal serum protein.