Presence Of Pleural Effusion Research Articles

Right ventricular involvement in feline hypertrophic cardiomyopathy

ObjectivesTo evaluate right ventricular (RV) wall thickness and chamber dimensions in cats with hypertrophic cardiomyopathy (HCM). AnimalsOne hundred fifty-one healthy control cats and 200 cats with HCM. MethodsRetrospective, observational, clinical cohort study. Two-dimensional echocardiograms from all cats were analyzed. Right atrial diameter, RV free wall thickness, and RV chamber diameter were quantified using multiple imaging views. Conventional (mean ± 2 standard deviations) and allometrically scaled (Y = a × Mb) reference values were determined in normal cats and compared to values found in cats with HCM. Linear and logistic regression, multivariate regression, and mixed model analysis were performed to identify associations between RV wall thickness and severity of left ventricular (LV) hypertrophy, clinical severity of HCM, and presence of pleural effusion. ResultsMean RV wall thickness was increased in HCM (p<0.001). Considering increased RV wall thickness in at least one segment, 94 (47%) and 112 (56%) cats with HCM had RV hypertrophy using upper reference limits based on mean + 2 standard deviations or allometric scaling, respectively. There was an association between severity of LV and RV hypertrophy (p<0.05). Left-sided congestive heart failure (n = 58) was associated with increased RV wall thickness in all segments compared to cats with preclinical HCM (p<0.001). Body weight had negligible effects on RV wall thickness (R2 0.08–0.17, p<0.001), whereas age and breed had no effect (p>0.05) in control cats. ConclusionsIncreased RV wall thickness is common in cats with HCM and relates to severity of LV hypertrophy and clinical status.

Clinical characteristics and outcomes of acute community acquired pneumonia in children at a reference public hospital in Pernambuco State, Brazil (2010-2011)

Abstract Objectives: to describe the clinical characteristics and outcomes of acute community acquired pneumonia in children at a reference public hospital in Pernambuco State, Brazil (2010-2011) Methods: pneumonia case series of 80 children aged 28 days to 14 years old at Hospital da Restauração in Pernambuco, Brazil, from 2010 to 2011. Information was noted from medical files, and two comparison groups were created according to the severity of the disease, considering the presence of pleural effusion. Fisher or Mann-Whitney tests were used for comparative analyses. Results: severe pneumonia with pleural effusion was more frequent in children under five years of age (p=0,025), and was associated with longer period of fever (19 x 15 days) and coughing (17 x 13 days), when compared to non-complicated pneumonia cases. Six children (7,5%, 6/80) died, 50% before the fourth day of hospitalization (p=0,001). All deaths were from the pleural effusion group in children from the countryside (p=0,026). Conclusions: the severity of pneumonia in children attended at this hospital is related to younger children, and those transferred from the health units in the countryside, so, early diagnosis and medical intervention are limited by infrastructure and available resources for the health.

Inverse correlation between serum albumin and serum lactate in adults with dengue

BACKGROUND&lt;br /&gt;Dengue infection is an acute viral infection, in the natural history of which plasma leakage may occur, resulting in shock followed by tissue hypoxia, with death as the final outcome if not treated properly. The purpose of this study was to determine the correlation of the hematocrit, serum albumin concentration, and the presence of pleural effusion or ascites, with hyperlactatemia in adult dengue patients.&lt;br /&gt;&lt;br /&gt;METHODS&lt;br /&gt;A cross-sectional study was conducted on 62 subjects. The inclusion criteria were: diagnosed dengue viral infection, age &amp;gt;14 years, fever during three consecutive days, and hyperlactatemia. Serum albumin was measured on an Advia 1800 analyzer using the bromocresol green method. The lactate oxidase method was used to determine serum lactate levels. Pleural effusion and/or ascites was determined using an ultrasound scanner (Xario SSA-660 A, Toshiba, Japan). The Pearson correlation test was used to analyze the data.&lt;br /&gt; &lt;br /&gt;RESULTS&lt;br /&gt;There was no significant correlation between the hematocrit (r=0.11; p=0.301), serum albumin (r=0.003;p=0.981), and pleural effusion or ascites (r=0.75; p=0.692) with serum lactate levels. However, in patients aged &amp;gt;30 years there was a significant inverse correlation between serum albumin and lactate levels (r =- 0.663;p=0.026). &lt;br /&gt;&lt;br /&gt;CONCLUSION&lt;br /&gt;This study demonstrated a significant inverse correlation between albumin and serum lactate levels in dengue patients aged &amp;gt; 30 years. This can aid in the early recognition and prompt management of at-risk patients to reduce morbidity and mortality.

Reliability of transpulmonary pressure-time curve profile to identify tidal recruitment/hyperinflation in experimental unilateral pleural effusion.

The stress index (SI) is a parameter that characterizes the shape of the airway pressure-time profile (P/t). It indicates the slope progression of the curve, reflecting both lung and chest wall properties. The presence of pleural effusion alters the mechanical properties of the respiratory system decreasing transpulmonary pressure (Ptp). We investigated whether the SI computed using Ptp tracing would provide reliable insight into tidal recruitment/overdistention during the tidal cycle in the presence of unilateral effusion. Unilateral pleural effusion was simulated in anesthetized, mechanically ventilated pigs. Respiratory system mechanics and thoracic computed tomography (CT) were studied to assess P/t curve shape and changes in global lung aeration. SI derived from airway pressure (Paw) was compared with that calculated by Ptp under the same conditions. These results were themselves compared with quantitative CT analysis as a gold standard for tidal recruitment/hyperinflation. Despite marked changes in tidal recruitment, mean values of SI computed either from Paw or Ptp were remarkably insensitive to variations of PEEP or condition. After the instillation of effusion, SI indicates a preponderant over-distension effect, not detected by CT. After the increment in PEEP level, the extent of CT-determined tidal recruitment suggest a huge recruitment effect of PEEP as reflected by lung compliance. Both SI in this case were unaffected. We showed that the ability of SI to predict tidal recruitment and overdistension was significantly reduced in a model of altered chest wall-lung relationship, even if the parameter was computed from the Ptp curve profile.

Trapped Lung Secondary to Cardiomegaly in a 78 year‐old Male with Congestive Heart Failure

Introduction/ObjectiveAlthough the etiologies of both trapped lung and cardiomegaly are well‐established, co‐presentation of the two conditions, and possible interactions between them, are much rarer. The objective of this report is to describe our findings during cadaver dissection, consider possible interactions between the two conditions, and discuss issues related to decision‐making for imaging and clinical interventions.Case ReportDuring routine dissection of a 78 year‐old male cadaver we found a trapped left lung and enlarged heart almost completely occupying the left pleural cavity. The subject's past medical history included heart failure, hypertension, and pleural effusion, and was consistent with a diagnosis of both conditions. A trapped lung is a shrunken lung surrounded by a cortex of fibrotic visceral pleura, typically formed as a consequence of chronic pleural effusion. This subject's left lung was deformed, and markedly diminished compared with the right lung, particularly in the lower lobe. His cardiothoracic ratio was 0.54, consistent with a diagnosis of cardiomegaly. Ventricular wall thickness measurements indicated substantial biventricular hypertrophy. During the final week of his life he underwent multiple chest radiographs showing persistent opacification of the left pleural cavity and the presence of pleural effusion. Both before and after thoracentesis neither the trapped lung, nor the enlarged heart, were identified.Clinical Considerations/ConclusionsWas the presence of both a trapped lung and enlarged heart in the present subject a coincidence, or was there some sort of causation? Although no direct causal connection has been established between the two conditions, analogies can be found in the literature. Compression of the heart on the left lung due to post‐surgical edema after coronary artery bypass grafting has been shown to cause decreased gas volumes in the lower lobe. Conversely, after pneumonectomy, the increased afterload resulting from a decreased pulmonary vascular bed has been shown to cause right ventricular hypertrophy. It is possible that similar mechanisms played a role in the development of either the trapped lung or enlarged heart in the present subject.This subject may have benefitted from earlier identification of his trapped lung in the years prior to his death. This would have offered additional treatment options, such as surgical decortication. Early identification also would have prevented the cost, discomfort and risks of repeat thoracentesis. Thoracentesis is not recommended in the case of trapped lung, as the pleural cavity will immediately refill due to the negative pleural pressure. Greater awareness, and a higher overall index of suspicion among clinicians for the presence of trapped lung and its sequelae, would lead to more routine use of CT scans in similar cases, and likely overall improved, and potentially more efficient, patient care.Support or Funding InformationN/A

Non-tuberculous mycobacterial lung disease: diagnosis based on computed tomography of the chest

To elucidate the accuracy and inter-observer agreement of non-tuberculous mycobacterial lung disease (NTM-LD) diagnosis based on chest CT findings. Two chest radiologists and two pulmonologists interpreted chest CTs of 66 patients with NTM-LD, 33 with pulmonary tuberculosis and 33 with non-cystic fibrosis bronchiectasis. These observers selected one of these diagnoses for each case without knowing any clinical information except age and sex. Sensitivity and specificity were calculated according to degree of observer confidence. Inter-observer agreement was assessed using Fleiss' κ values. Multiple logistic regression was performed to elucidate which radiological features led to the correct diagnosis. The sensitivity of NTM-LD diagnosis was 56.4% (95% CI 47.9-64.7) and specificity 80.3% (73.1-86.0). The specificity of NTM-LD diagnosis increased with confidence: 44.4% (20.5-71.3) for possible, 77.4% (67.4-85.0) for probable, 95.2% (87.2-98.2) for definite (P < 0.001) diagnoses. Inter-observer agreement for NTM-LD diagnosis was moderate (κ = 0.453). Tree-in-bud pattern (adjusted odds ratio [aOR] 6.24, P < 0.001), consolidation (aOR 1.92, P = 0.036) and atelectasis (aOR 3.73, P < 0.001) were associated with correct NTM-LD diagnoses, whereas presence of pleural effusion (aOR 0.05, P < 0.001) led to false diagnoses. NTM-LD diagnosis based on chest CT findings is specific but not sensitive. • Diagnosis of NTM-LD based on radiological findings showed high specificity. • Sensitivity of NTM-LD diagnosis was around 50%. • Inter- observer agreement was moderate. • Identification of tree-in-bud pattern, consolidation and atelectasis led to correct diagnoses.

Concurrence of pleural effusion and inferior vena cava thrombus in antiphospholipid syndrome complicated by intra-cardiac thrombus

Introduction: Antiphospholipid syndrome (APS) associated with intra-cardiac thrombus and pulmonary embolism is infrequent. However, the presence of pleural effusion is extremely rare. Case Presentation: A 42-year-old woman, admitted with palpitation, dyspnea and history of stroke and thrombocytopenia is described. Doppler sonography revealed deep vein thrombosis. Moreover, subsequent investigation confirmed the presence of right atrial thrombus, pulmonary arteries embolism and bilateral pleural effusion. Inferior vena cava thrombosis was confirmed during cardiac surgery and all thrombi were removed subsequently. Laboratory studies revealed the diagnosis of APS. The patient experienced deep vein thrombosis one year later and no evidence of recurrent disease was documented after three years follow up. Conclusions: APS complicated by inferior vena cava thrombosis coexistence of pulmonary embolism and intra-cardiac thrombus is not previously reported. Moreover, presence of pleural effusion with these conditions describes a unique case of APS.

Clinical Features and Radiological Findings of Adenovirus Pneumonia Associated with Progression to Acute Respiratory Distress Syndrome: A Single Center Study in 19 Adult Patients.

ObjectiveTo describe radiologic findings of adenovirus pneumonia and to understand clinico-radiological features associated with progression to acute respiratory distress syndrome (ARDS) in patients with adenovirus pneumonia.Materials and MethodsThis study included 19 patients diagnosed with adenovirus pneumonia at a tertiary referral center, in the period between March 2003 and April 2015. Clinical findings were reviewed, and two radiologists assessed imaging findings by consensus. Chi-square, Fisher's exact, and Student's t tests were used for comparing patients with and without subsequent development of ARDS.ResultsOf 19 patients, nine were immunocompromised, and 10 were immunocompetent. Twelve patients (63%) progressed to ARDS, six of whom (32%) eventually died from the disease. The average time for progression to ARDS from symptom onset was 9.6 days. Initial chest radiographic findings were normal (n = 2), focal opacity (n = 9), or multifocal or diffuse opacity (n = 8). Computed tomography (CT) findings included bilateral (n = 17) or unilateral (n = 2) ground-glass opacity with consolidation (n = 14) or pleural effusion (n = 11). Patients having subsequent ARDS had a higher probability of pleural effusion and a higher total CT extent compared with the non-ARDS group (p = 0.010 and 0.007, respectively). However, there were no significant differences in clinical variables such as patient age and premorbid condition.ConclusionAdenovirus pneumonia demonstrates high rates of ARDS and mortality, regardless of patient age and premorbid conditions, in the tertiary care setting. Large disease extent and presence of pleural effusion on CT are factors suggestive of progression to ARDS.

Prognostic Value of Pleural Effusion in Hodgkin's Lymphoma Patients

Background: There has been little investigation into the incidence or prognostic significance of a pleural effusion when present with the diagnosis of Hodgkin's Lymphoma. In our small clinical practice we had two patients with Hodgkin's lymphoma who presented with pleural effusion and subsequent poor outcomes, including relapse and eventual death. These events stemmed this retrospective study investigating the incidence of pleural effusion with the diagnosis of Hodgkin's disease and whether the presence of pleural effusion at the time of diagnosis would reveal any association with outcomes in a larger cohort of patients.Procedure: A single centered retrospective chart review of 134 patients' age 0-50 with confirmed Hodgkin's lymphoma was performed. Charts were evaluated for the presence of any radiographic evidence of pleural effusion at the time of diagnosis, along with the patient's eventual outcome.Result: 8/133 (6%) patients with Hodgkin's lymphoma had a pleural effusion at the time of diagnosis. Death is dependent on pleural effusion (p= 0.019) with 3 of 8 (37.5%) of patients that had pleural effusion who died.There is an 8.77 (CI 1.8 - 43.5) times greater odds of death for patients with pleural effusion versus those without pleural effusion.Recurrence is dependent on pleural effusion (p= 0.0061) with 5/8 (62.5%) of patients that had pleural effusion who experienced recurrence.There is an 8.75 (CI 1.9 - 39.6) times greater odds of recurrence for patients with pleural effusion versus those without pleural effusion.Of the 5 patients who had recurrence, as stated above 3 patients died, 1 patient was salvaged by stem cell transplant and another patient was recently diagnosed with relapse thus, clear outcome is yet to be determinedConclusion: The presence of a pleural effusion at the time of diagnosis of Hodgkin's lymphoma is a rare finding, yet when present, was associated with death and recurrence. This finding may suggest a more aggressive initial treatment be required given the association with poor outcomes. An evaluation of a larger cohort of patients, along with a determination of the diagnostic stage, will be required to confirm prognostic potential. DisclosuresNo relevant conflicts of interest to declare.

Disseminated Abdomino-Pelvic Intraperitoneal Hydatid Disease Presenting as Advanced Ovarian Cancer: A Case Report and Review of the Literature

Abstract Background: Abdomino-pelvic masses with ascites, peritoneal disease, pleural effusion, and elevated serum CA-125 levels in a patient raises the clinical suspicion of advanced ovarian cancer. However, disseminated tuberculosis and echinococcosis are benign conditions that can mimic an ovarian malignancy. This article presents an unusual case of double benign pathology of an ovarian fibroma and disseminated pelvic hydatid disease that appeared to be advanced ovarian cancer. Case: A 57-year-old postmenopausal woman of Peruvian origin presented with a history of abdominal pain, distension, and chronic cough. On examination, she was noted to be cachectic and had ascites. A chest X-ray showed the presence of pleural effusion. Her serum CA-125 level was elevated. Computed tomography (CT) scans of her thorax, abdomen, and pelvis confirmed the right-sided pleural effusion and revealed the presence of adnexal masses, a calcified parenchymal liver mass, and an omental cake. Initial decision was to start on ...

Perioperative outcomes of upper lobectomy according to preservation or division of the inferior pulmonary ligament.

The aim of this study was to investigate the relationship between inferior pulmonary ligament division and postoperative complications. Medical records of 72 non-small cell lung cancer (NSCLC) patients who underwent video-assisted thoracic surgery (VATS) upper lobectomy between March 2012 and November 2013 performed by a single thoracic surgeon at our center were reviewed retrospectively. Patients were categorized into two groups: the division group, who underwent division of the inferior pulmonary ligament, and the preservation group, who did not. The division group included 43 patients (27 right, 16 left), while the preservation group included 29 (11 right, 18 left). Postoperative outcomes such as the presence of pleural effusion, chest tube duration, and changes in the angle and diameter of remnant bronchus were compared; bronchial diameter and angle were measured on three-dimensional (3D) reconstruction chest CT images. Chest tube duration, duration of chest tube drainage >200 mL, and the presence of pleural effusion on chest X-rays taken 1 month after surgery were not significantly different between the two groups (P=0.07, 0.33, and 1.00, respectively). There were also no significant differences between groups in the presence of apical dead space or in change in bronchial angle (P=0.22 and 0.74, respectively). In 3D reconstruction images, changes in the diameter of the right middle, right lower, and left lower lobar (LLL) bronchi were similar between groups (P=0.72, 0.12 and 0.29, respectively). Change in the angle between the right bronchus intermedius (RBI) and the right middle lobar (RML) bronchus and between the RBI and the right lower lobar (RLL) bronchus were significantly different between the division and preservation groups (P=0.02 and 0.05, respectively). Inferior pulmonary ligament division had no clear benefits. Complications related to excessive dislocation of remnant bronchi might be associated with inferior pulmonary ligament division, but further research is needed to elucidate this relationship.

Abstract 19078: Early Predictors of Survival to Heart Transplantation in Patients With Amyloid Light-chain Cardiomyopathy

Background: Amyloid cardiomyopathy progresses more rapidly and has different manifestations than more common cardiomyopathies. Nevertheless, survival of selected cardiac amyloid patients after orthotopic heart transplantation (OHT) followed by autologous stem cell transplant is similar to other restrictive cardiomyopathies. The importance of clinical presentation and pre-transplantation characteristics on outcome in patients with AL amyloid cardiomyopathy evaluated for heart transplantation is still not well defined. Methods: The impact of echocardiographic, hemodynamic, and clinical parameters on outcome in 46 patients evaluated for OHT and enrolled in the International Consortium for Cardiac Amyloid Transplant (iCCAT) database was studied. Cox proportional hazards models of time to death were used. End point was death after transplant evaluation censored at transplant. Results: The median age at the time of transplant evaluated was 57.6 (+/- 9.6) years, and the mean time from presentation to listing was 27 (+/- 26) days. 19 (41%) patients underwent OHT after an average wait time of 72 days. Univariate risk factors associated with death after initial evaluation were cardiac output (p=0.012), right ventricular stroke work index (p=0.033), left ventricular end diastolic dimension (p=0.024), left ventricular outflow tract velocity time integral (p=0.019), mean arterial pressures (p=0.005), NT pro-BNP (p=0.007), presence of pleural effusion (p=0.005), as well as elevated kappa and lambda serum free light chain concentrations (p=0.004). Whereas left ventricular ejection fraction did not correlate with death after evaluation, increased right ventricular wall thickness remained a strong mortality predictor in a multivariate model with light chain difference and cardiac output (HR 1.6 for every 1 mm increase in thickness, p=0.017). Conclusions: Pleural involvement, high light chain burden, and right ventricular infiltration predicted death while awaiting a donor organ and may be markers of more systemic disease. Ultimately, this could affect transplant candidate selection and allocation strategies.

Risk Factors for Multidrug-Resistant Tuberculosis among Patients with Pulmonary Tuberculosis at the Central Chest Institute of Thailand.

There are limited data available on the risk factors for multidrug-resistant tuberculosis (MDR-TB). Therefore, we here conducted a retrospective matched case−control study among adults with pulmonary TB who received treatment at the Central Chest Institute of Thailand (CCIT) between January 2007 and December 2013, in order to determine the risk factors associated with MDR-TB among patients with pulmonary TB. We identified 145 patients with pulmonary MDR-TB (cases) and 145 patients with drug-sensitive pulmonary TB (controls). Multivariate analysis identified the independent risk factors for MDR-TB as follows: (1) ≥ 2 episodes of prior pulmonary TB (odds ratio [OR] 39.72, 95% confidence interval (95% CI) 7.86−200.66), (2) duration of illness > 60 days (OR 3.08, 95% CI 1.52−6.22), (3) sputum acid fast bacilli smear 3+ (OR 13.09, 95% CI 4.64−36.91), (4) presence of lung cavities (OR 3.82, 95% CI 1.89−7.73), and (5) presence of pleural effusion (OR 2.75, 95% CI 1.06−7.16). Prior pulmonary TB management with a non-category I regimen (P = 0.012) and having treatment failure or default as treatment outcomes (P = 0.036) were observed in a higher proportion among patients with MDR-TB. Particular characteristics of lung cavities, including the maximum diameter ≥ 30 mm (P < 0.001), the number of cavities ≥ 3 (P = 0.001), bilateral involvement (P < 0.001), and ≥ 2 lung zones involved (P = 0.001) were more commonly observed in patients with MDR-TB. In conclusion, these clinical factors and chest radiographic findings associated with MDR-TB among patients with pulmonary TB may help physicians to provide proper management of cases for prevention of the development and spread of MDR-TB in future.

Intrapleural Cisplatin for Management of Malignant Pleural Effusion in a Patient With Plasma Cell Leukemia

SESSION TITLE: Miscellaneous Cases - Student/Resident SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Tuesday, October 27, 2015 at 04:30 PM - 05:30 PM INTRODUCTION: Plasma cell leukemia (PCL) is defined by the presence of >20 % plasma cells in the peripheral blood and an absolute plasma cell count of > 2×109/L.1 Management of PCL requires early induction therapy with intensive chemotherapy regimens to control the disease activity followed by autologous stem-cell transplantation to decrease the risk of early death.1 MMPEs (Myelomatous Malignant Pleural Effusion) when present portend a poorer prognosis which may be due to the lack of standard treatment for MMPEs.2 CASE PRESENTATION: A 64 yr old with history of plasma cell leukemia receiving chemotherapy was admitted for treatment of osteomyelitis. He was transferred to ICU for hypercarbic respiratory failure; likely from a large recurrent left sided pleural effusion. The pleural fluid on sampling had 85% plasma cells while the plasma cells comprised 5% of the peripheral blood; consistent with aggressive loco-regional disease. Approximately, 1.5 Liters were drained twice a week prior to the pulmonary consultation. We placed an indwelling tunneled pleural catheter (TPC) and instilled Cisplatin (20mg/m2) via the catheter to treat the local disease and to assure easy drainage. The pleural plasma cell count and output decreased to zero within a week. During the same period his plasma cells in peripheral blood increased from 5 to 34 % and his general debilitation precluded systemic chemotherapy or autologous stem cell transplantation. With this knowledge even though there was significant improvement in his symptoms he elected comfort as his primary goal. DISCUSSION: Plasma cell leukemia can also rarely involve pleura causing MMPE. Although pleural effusions occur in 6% of MM patients, effusions due to pleural myelomatous involvement, are very rare occurring in less than 1% of the patients.2 Presence of pleural effusion is associated with worse prognosis.1-2 Treatment of MPE's depend on the size of pleural effusion, the rate of accumulation, patients' symptoms and overall prognosis. In some cases, systemic chemotherapy for the primary cancer can completely resolve the MPE.2 Symptomatic patients are usually managed by therapeutic thoracentesis or pleurodesis. Numerous sclerosing agents have been studied including talc, doxycycline, antineoplastics such as bleomycin.1-2 Success rates for these treatments range between 40 to 100%. CONCLUSIONS: To the best of the authors' knowledge, this is the first case of pleural involvement of PCL managed by intrapleural cisplatin instilled via a TPC. Reference #1: Fernández de Larrea C, Kyle RA, Durie BG, Ludwig H, Usmani S, Vesole DH, et al. Plasma cell leukemia: Consensus statement on diagnostic requirements, response criteria and treatment recommendations by the International Myeloma Working Group. Leukemia. 2013; 27:780-91 Reference #2: Ramsingh G, Mehan P, Luo J, Vij R, Morgensztern D. Primary plasma cell leukemia: a Surveillance, Epidemiology, and End Results database analysis between 1973 and 2004. Cancer. 2009; 115:5734-5739 DISCLOSURE: The following authors have nothing to disclose: Abhishek Agarwal, Jagpal Klair, Karim Nathan, Abhinav Agrawal, Kevin Kuriakose, Setu Patolia, Nikhil Meena No Product/Research Disclosure Information

Utility of serum procalcitonin and C-reactive protein in severity assessment of community-acquired pneumonia in children

ObjectivesAlthough the importance of serum Procalcitonin (PCT) levels at diagnosis is well established in adult Community-Acquired Pneumonia (CAP), its use remains controversial in pediatric CAP. The aim of our study is to investigate the role of PCT and C-Reactive Protein (CRP) in the assessment of pediatric CAP severity defined by the extent of consolidation on chest X-rays and the presence of pleural effusion. In this particular setting, no clinical severity score is available at present and chest X-ray, although important for diagnosis confirmation, is not recommended as routine test. Design and methodsThe study involved 119 children admitted to the Department of Pediatric Infectious Disease for radiographically documented CAP aged 1year to 14years, without chronic diseases. Baseline PCT, CRP and routine laboratory tests were performed on admission. ResultsThe median PCT (μg/L) and CRP (mg/L) were 0.11 (0.05–0.58) and 21.3 (4.2–48.1), respectively. PCT showed a good correlation with CRP, neutrophils and WBC (r=0.538, P<0.001; r=0.377, P<0.001; r=0.285, P0.002, respectively). CRP, but not PCT, was associated with lobar consolidation (P=0.007) and pleural effusion (P=0.002). Logistic regression analysis revealed that only CRP was a predictor of lobar consolidation (OR: 1.078; 95% CI: 1.017–1.143; P=0.011) and pleural effusion (OR: 1.076; 95% CI: 1.005–1.153; P=0.036). ConclusionOur findings revealed that PCT is correlated to the main inflammatory markers in children with CAP. CRP, unlike PCT, is able to predict the extent of chest X-ray infiltration and ultimately the severity of the disease confirming its usefulness in the management of pneumonia.

Diagnostic significance of pleural fluid pH and pCO2

The diagnosis of pleural effusion is still difficult. The presence of pleural effusion can be confirmed by radiological studies including simple chest radiography, ultrasonography, or computed tomography. Identifying the causes of pleural effusions by pleural fluid analysis is essential. Aim of this workThe aim of this work is to assess the role of pleural fluid pH and pCO2 in differentiating the etiologies of pleural effusion and to study the correlation between pleural fluid pH and pCO2 and cellular content of the effusion. ResultsWe conducted this study on 50 patients with pleural effusions of different causes. The patients were classified into 5 groups according to the cause. For all the patients, measurement of pleural pH, pCO2, pO2, HCO3, protein, LDH, glucose and WBC was done. We observed lowest pH in complicated parapneumonic effusion (empyema) 6.80±0.15 and highest pH was observed in transudative effusion 7.47±0.07. Tuberculous effusion has pH lower than pH of malignant effusion 7.17±0.017 and 7.39±0.08, respectively. Post pleurodesis malignant effusion has pH lower than pH of malignant effusion 7.28±0.17 and 7.39±0.08, respectively. There is a strong inverse correlation between pH and pCO2, WBC, LDH and protein (r=−0.813 and p<0.001), (r=−0.796 and p, 0.001), (r=−0.829 and p, 0.001) and (r=−.837 and p, 0.001), respectively. While there is a weak correlation between pH and glucose of pleural fluid (r=0.249 and p=0.066). The highest increase of PNL numbers was in empyema (20169±8094.8cells/cc).The highest increase of lymphocytes was in malignant effusions (4285.00±2948.20cells/cc) and tuberculous effusion (3977.7±3169cells/cc).

Individualizing risk of multidrug-resistant pathogens in community-onset pneumonia.

IntroductionThe diffusion of multidrug-resistant (MDR) bacteria has created the need to identify risk factors for acquiring resistant pathogens in patients living in the community.ObjectiveTo analyze clinical features of patients with community-onset pneumonia due to MDR pathogens, to evaluate performance of existing scoring tools and to develop a bedside risk score for an early identification of these patients in the Emergency Department.Patients and MethodsThis was an open, observational, prospective study of consecutive patients with pneumonia, coming from the community, from January 2011 to January 2013. The new score was validated on an external cohort of 929 patients with pneumonia admitted in internal medicine departments participating at a multicenter prospective study in Spain.ResultsA total of 900 patients were included in the study. The final logistic regression model consisted of four variables: 1) one risk factor for HCAP, 2) bilateral pulmonary infiltration, 3) the presence of pleural effusion, and 4) the severity of respiratory impairment calculated by use of PaO2/FiO2 ratio. A new risk score, the ARUC score, was developed; compared to Aliberti, Shorr, and Shindo scores, this point score system has a good discrimination performance (AUC 0.76, 95% CI 0.71-0.82) and calibration (Hosmer-Lemeshow, χ2 = 7.64; p = 0.469). The new score outperformed HCAP definition in predicting etiology due to MDR organism. The performance of this bedside score was confirmed in the validation cohort (AUC 0.68, 95% CI 0.60-0.77).ConclusionPhysicians working in ED should adopt simple risk scores, like ARUC score, to select the most appropriate antibiotic regimens. This individualized approach may help clinicians to identify those patients who need an empirical broad-spectrum antibiotic therapy.

Secondary Haemophagocytic Lymphohistiocytosis – The Differential Diagnosis Dilemma In Paediatrics

ABSTRACT Secondary haemophagocytic lymphohistiocytosis (SHFLH) is a rare, potentially fatal disorder, most commonly caused by the Epstein–Barr virus. It is characterized by neoplastic proliferation of cells that belong to the monocyte–macrophage system and by varied clinical expression. A girl aged 3 years and 7 months was hospitalized due to continuing high febricity, yellow skin colouring, hepatosplenomegaly and cytopenia in a complete blood count (CBC). Four weeks before hospitalization, she had a lacunar angina and lymphadenopathy. A low number of erythrocytes, leukocytes and thrombocytes were noted in CBC, with anaemia and the presence of virocytes in a peripheral blood smear. Biochemical blood analyses indicated hyperbilirubinaemia, increased values of transaminases, lactic dehydrogenase, ferritin, triglycerides, D-dimer, acceleration of the activated partial thromboplastin time and decreased values of fibrinogen, with increased values of C-reactive protein and procalcitonin. Using an ultrasound examination of the abdomen, hepatosplenomegaly was perceived; using echocardiographic examination, pericardium layering was noticed; and using a roentgen graphic picture of the lungs, the presence of pleural effusion was detected. In a bone marrow biopsy, the percentage of blasts did not exceed 25%, and rare chemophagocytes were noticed. Using serologic tests, positivity to Epstein-Barr virus in IgM class was demonstrated. According to the criteria by Histiocyte Society, there were sufficient criteria to establish a diagnosis of SHFLH. With the exception of symptomatic therapies, according to the protocol for SHFLH treatment, a double antibiotic therapy and IV immunoglobulins were given, to which the patient responded with a clinical and laboratory recovery. Therefore, there was no demand for a treatment protocol with cytostatics or bone marrow transplantation. To resolve a differential diagnosis dilemma in solving cases of uncertain febrile neutropenia.

CT-Guided Core Needle Biopsy of Pleural Lesions: Evaluating Diagnostic Yield and Associated Complications

ObjectiveThe purpose of this study was to retrospectively evaluate the diagnostic accuracy and complications of CT-guided core needle biopsy (CT-guided CNB) of pleural lesion and the possible effects of influencing factors.Materials and MethodsFrom September 2007 to June 2013, 88 consecutive patients (60 men and 28 women; mean [± standard deviation] age, 51.1 ± 14.4 years; range, 19-78 years) underwent CT-guided CNB, which was performed by two experienced chest radiologists in our medical center. Out of 88 cases, 56 (63%) were diagnosed as malignant, 28 (31%) as benign and 4 (5%) as indeterminate for CNB of pleural lesions. The final diagnosis was confirmed by either histopathological diagnosis or clinical follow-up. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and complication rates were statistically evaluated. Influencing factors (patient age, sex, lesion size, pleural-puncture angle, patient position, pleural effusion, and number of pleural punctures) were assessed for their effect on accuracy of CT-guided CNB using univariate and subsequent multivariate analysis.ResultsDiagnostic accuracy, sensitivity, specificity, PPV, and NPV were 89.2%, 86.1%, 100%, 100%, and 67.8%, respectively. The influencing factors had no significant effect in altering diagnostic accuracy. As far as complications were concerned, occurrence of pneumothorax was observed in 14 (16%) out of 88 patients. Multivariate analysis revealed lesion size/pleural thickening as a significant risk factor (odds ratio [OR]: 8.744, p = 0.005) for occurrence of pneumothorax. Moreover, presence of pleural effusion was noted as a significant protective factor (OR: 0.171, p = 0.037) for pneumothorax.ConclusionCT-guided CNB of pleural lesion is a safe procedure with high diagnostic yield and low risk of significant complications.

CT features of pulmonary arterial hypertension and its major subtypes: a systematic CT evaluation of 292 patients from the ASPIRE Registry

We evaluated the prevalence and prognostic value of CT-pulmonary angiographic (CTPA) measures in 292 treatment naive patients with pulmonary arterial hypertension (PAH). Pulmonary artery calcification (13%) and thrombus (10%) were...