Pulmonary Tuberculosis Sequelae Research Articles

Hemoptysis – etiology, evaluation and treatment in a university hospital

ObjectiveEvaluate patients admitted for hemoptysis, its etiology, use of diagnostic tests, treatment and outcome. Material and methodsA retrospective analysis was done, checking clinical files of patients admitted for hemoptysis, between 1st January 2004 and 31st December 2008. ResultsTwo hundred and thirty seven patients were included in this study, with a mean age of 57.9 years. In patients under 18 years, the most frequent diagnoses were bronchiectasis and congenital cardiopathy. In adults, pulmonary tuberculosis sequelae and bronchiectasis were the dominant diagnoses (22.2 % and 15.8 %, respectively), followed by lung cancer. Active infection was responsible for bleeding in 51 patients, especially pulmonary tuberculosis, pneumonia and tracheobronchitis. The etiology of hemoptysis was not established in 6.3 %. All patients performed chest X-Ray. Chest CT was performed in 81.4 % of patients and fiberoptic bronchoscopy in 52.7 %, the latter locating the source of bleeding in 38.4 % and establishing a final diagnosis in 17.6 %. In most patients, effective control of bleeding was achieved by medical treatment (90.7 %). During these 5 years, arterial embolization was performed in 11.8 % of patients. The main reason for embolization was recurrence prevention. There were 14 deaths (5.9 %), being identified as poor prognostic factors, hemodynamic instability and malignancy. ConclusionsHemoptysis is still a frequent symptom, being chronic infection sequelae and lung cancer their main causes. In this study, factors associated with a worse prognosis were hemodynamic instability and malignancy.

Hemoptises-etiologia, avaliação e tratamento num hospital universitário

Objective Evaluate patients admitted for hemoptysis, its etiology, use of diagnostic tests, treatment and outcome. Methods A retrospective analysis was done, checking clinical files of patients admitted for hemoptysis, between 1 st January 2004 and 31 st December 2008. Results Two hundred and thirty seven patients were included in this study, with a mean age of 57.9 years. In patients under 18 years, the most frequent diagnoses were Bronchiectasis and Congenital Cardiopathy. In adults, Pulmonary Tuberculosis Sequelae and Bronchiectasis were the dominant diagnoses (22.2% and 15.8%, respectively), followed by Lung Cancer. Active infection was responsible for bleeding in 51 patients, especially Pulmonary Tuberculosis, Pneumonia and Tracheobronchitis. The etiology of hemoptysis was not established in 6.3%. All patients performed chest X-Ray. Chest CT was performed in 81.4% of patients and Fiberoptic bronchoscopy in 52.7%, the latter locating the source of bleeding in 38.4% and establishing a final diagnosis in 17.6%. In most patients, effective control of bleeding was achieved by medical treatment (90.7%). During these 5 years, arterial embolization was performed in 11.8% of patients. The main reason for embolization was recurrence prevention. There were 14 deaths (5.9%), being identified as poor prognostic factors, hemodynamic instability and malignancy. Conclusion Hemoptysis is still a frequent symptom, being chronic infection sequelae and lung cancer their main causes. In this study, factors associated with a worse prognosis were hemodynamic instability and malignancy.

Outcome of bronchial artery embolisation for life threatening haemoptysis due to tuberculosis and post tuberculosis sequelae.

To determine the long-term outcomes of bronchial artery embolization in patients with massive hemoptysis due to pulmonary tuberculosis and post-tuberculosis sequelae and to study the factors influencing success. In this study, 58 patients underwent 64 bronchial artery embolizations for massive hemoptysis due to tuberculosis or its sequelae between 1998 and 2008. Their images and procedure details were reviewed. Medical records and direct contact were used to obtain information on outcome. The cumulative hemoptysis control rate per follow-up interval was calculated. The data showed that 25 patients presented with acute massive hemoptysis and 33 presented with chronic recurrent hemoptysis. The median quantity of blood was 400 mL (range, 70-2000 mL). The median follow-up period was 432 days (range, 11-1789 days). Twenty-seven patients had recurrence after a median period of 110 days after the procedure (range, 1-959 days). The hemoptysis control rate was 93% at 2 weeks, 86% at one month, 79.5% at 3 months, 63% at 6 months, 51% at one year and 39% at 2 years. Six patients underwent repeat procedures. Chest pain was the most common procedure-related complication (n=20, 34.5%); there was no spinal cord complication or mortality. There were seven deaths, five of which were related to hemoptysis. Nine patients were lost to follow-up. Lung cavities (P = 0.08), nonbronchial systemic artery collaterals (P = 0.081) and systemicto- pulmonary venous shunts (P = 0.053) were more common in those who experienced recurrence. Bronchial artery embolization is a relatively safe procedure that is lifesaving in patients who are not suitable for surgery. However, the associated long-term outcome is less satisfactory.

Fungal Colonization of a Pneumonectomy Stump

A 59-year-old woman developed mild recurring hemoptysis once a week for several months after a fall with trauma to the chest. Sixteen years earlier she had undergone a right pneumonectomy at a hospital elsewhere for sequelae of pulmonary tuberculosis. Bronchoscopy, performed because of the recent hemoptysis, showed material in the pneumonectomy stump. The material had a gelatinous appearance, green color with a pale margin, and oblique striations. The material was removed by grasping with forceps and withdrawing the bronchoscope. Grocott methanamine silver stain was positive for septate, nonpigmented fungal organisms. Anatomic pathology microscopy also showed mucous, acute inflammatory cells, and necrotic tissue. Cytopathology of washings from the bronchial stump showed rare degenerated benign bronchial epithelial cells and fungal hyphae. Acid fast bacilli smears and cultures were negative. Bacterial cultures showed 3+ Pseudomonas aeruginosa. The patient had no further hemoptysis.

Survival and pulmonary hemodynamics in patients with sequelae of pulmonary tuberculosis who received home oxygen therapy

We studied the relationship between survival and pulmonary hemodynamics in patients with sequelae of pulmonary tuberculosis. We also studied the effect of home oxygen therapy (HOT) on pulmonary hemodynamics in those patients. The subjects were 59 patients who were treated with HOT after right-heart catheterization. Blood gases and pulmonary hemodynamics were measured twice: while the patients breathed air and after they had inhaled pure oxygen. In 11 patients, right-heart catheterization done before and after HOT was begun. Before HOT was begun, 49 patients were given the diagnosis of pulmonary hypertension, but the difference in survival between those who had and those who did not have pulmonary hypertension was not statistically significant. Mean pulmonary artery pressure fell by more than 5 mmHg after inhalation of pure oxygen in 5 patients (responders), but survival did not differ between responders and non-responders. Blood-gas volumes and pulmonary hemodynamics did not differ between those who died within 2 years after right-heart catheterization and those who lived for more than 5 years. Pulmonary arterial resistance and mean pulmonary artery pressure decreased significantly after HOT was begun. HOT can reduce mean pulmonary artery pressure in patients with sequelae of pulmonary tuberculosis, but survival on HOT is not related to the presence of pulmonary hypertension or to the effect of pure oxygen on mean pulmonary artery pressure.

Angioscopic findings of the peripheral pulmonary arteries in patients with chronic pulmonary diseases

Angioscopic observation of the peripheral pulmonary arteries was performed in 14 patients with chronic lung diseases (male 9/female 5, age 70.8 +/- 8.3 years, pulmonary tuberculosis sequelae 6, chronic bronchitis 4, chronic pulmonary emphysema 3, pneumoconiosis 1). The blood flow was stopped by the inflated balloon of a 7F guiding catheter, and then the peripheral pulmonary arteries (inner diameter 1.0-4.5 mm) were observed with a fiberoptic catheter (outer diameter 0.7 mm). In 10 out of 14 patients abnormal findings were obtained, which included redness, erosion, ulceration of the vascular wall, thrombus, fibrous tissue, and occlusion of the lumen. The incidence of abnormal findings tended to be higher in chronic bronchitis and pulmonary tuberculosis sequelae than in chronic pulmonary emphysema. These results suggest that 1) various changes including "vasculitis" and thrombus exist in the peripheral pulmonary arteries of chronic lung diseases, and 2) that angioscopy may provide the detailed information about both the vascular wall and the lumen which cannot be obtained by pulmonary angiography.

Outcomes of noninvasive positive-pressure ventilation in patients with acute hypercapnia complicating chronic respiratory failure

We used noninvasive positive-pressure ventilation to treat hypercapnea due to acute exacerbations of chronic respiratory failure (21 episodes in 19 patients; COPD, 4; pulmonary tuberculosis sequelae, 4; silicosis, 3; silicotuberculosis, 3; bronchiectasis, 3; others, 2). All patients had acute onsets of severe hypercapnea (PaCO2 > 45 Torr), acute decreases in pH (< 7.35), and tachypnea, paradoxical breathing or both. During the first 2 to 4 hours of bi-level positive airway pressure, PaCO2 decreased from 72 to 61 Torr (p < 0.0005), pH increased from 7.26 to 7.31 (p < 0.001), and respiratory rate decreased from 30 to 25 breaths/min (p < 0.005). In three cases leakage of air through the mouth prevented improvement in the patients' conditions, but in two of those a face mask was then used successfully. In 17 of the 21 episodes (81%) gas exchange improved and intubation was not necessary. In those 17, the mean duration of noninvasive positive-pressure ventilation was 6.3 days. We conclude that noninvasive positive-pressure ventilation can improve gas exchange in patients with acute hypercapnea complicating chronic respiratory failure.

Long-term study of patients with pulmonary tuberculosis sequelae after bilateral thoracoplasty-airway obstruction and its causes

Chest roentgenograms and results of pulmonary-function tests in patients with pulmonary tuberculosis sequelae 30 years after bilateral thoracoplasty were studied retrospectively to detect airway obstruction in these patients and to determine its causes. For periods of more than 10 years, vital capacity (VC) changed at a rate of 15.5 +/- 5.0 ml/year, and forced expiratory volume in one second as a percent of VC (FEV1%) changed at a rate of 0.546% +/- 0.380% per year (n = 13). Thirty years after thoracoplasty, the VC was 920 +/- 180 ml (%VC = 28.4% +/- 5.3%), and the FEV1% was 66.2% +/- 13.7% (n = 21). Thus, mild airway obstruction was found in about half of the cases. For each patient, the distance from the hilum to the diaphragm was measured along the mid-clavicular line on the side with fewer ribs resected, and this distance was divided by the patient's height. The results of that computation was found to be significantly and negatively related to FEV1% (r = -0.681, which suggests that longer bronchi in the lower and middle lobes on that side were associated with lower values of FEV1%. These findings are similar to those in patients with pulmonary tuberculous sequelae after total pneumonectomy. Over an average of 26 years, scoliosis, the vertebra showing the most bending, the intrapulmonary lesion, and the position of the diaphragm did not change, but the cardio-thoracic ratio increased.

Compliance with long-term home oxygen therapy

Long-term home oxygen therapy has been shown to benefit patients with hypoxemic chronic obstructive pulmonary disease. However, to obtain the expected maximal benefit it is important for the oxygen to be used correctly and for a sufficient length of time. We examined compliance with home oxygen therapy in patients with chronic obstructive pulmonary disease, pulmonary fibrosis, late sequelae of pulmonary tuberculosis, and pulmonary hypertension who used oxygen concentrations. Compliance was defined as the ratio of the amount of oxygen used to the amount prescribed. The average daily length of time the concentrator actually ran was measured from the concentrator meters. These were read every 6 months by an engineer from the company that installed the concentrator. Factors thought to affect compliance were studied. These factors included age, the degree of dyspnea, arterial blood gases, and pulmonary function. Weak positive correlations were found between compliance and age and between compliance and PaCO2. A weak negative correlation was observed between compliance and PaO2. Compliance in patients with chronic obstructive pulmonary disease was higher than in patients with pulmonary fibrosis or pulmonary hypertension. Among those given prescriptions for 24-hr oxygen therapy, compliant patients had more severe dyspnea on excertion than did noncompliant patients. These data suggest that the compliant patients had more severe gas exchange problems.

Outcome of long-term nasal intermittent positive pressure ventilation in 41 patients with hypercapnic respiratory failure

Nasal intermittent positive pressure ventilation (NIPPV) is widely used in domiciliary treatment of chronic ventilatory disorders. The outcomes of long-term NIPPV were analyzed in 41 patients with hypercapnic respiratory failure due to pulmonary tuberculosis sequelae (PTS; n = 17), neuromuscular disease (NMD; n = 8), kyphoscoliosis (KS; n = 7), chronic obstructive pulmonary disease (COPD; n = 6), and miscellaneous diseases (n = 3). Twenty-seven patients with chronic conditions but without acute exacerbations began receiving NIPPV, and fourteen patients began receiving NIPPV after an acute exacerbation. Outcome measures included the probability of continuing NIPPV, survival after starting NIPPV, survival after starting home oxygen therapy (HOT), arterial blood gases, nocturnal oxygen saturation, pulmonary function, and the number of hospital days. Two patients with PTS died, 7 and 40 months after starting NIPPV. Two patients (one with PTS and one with COPD) switched from NIPPV to intermittent positive pressure ventilation via a tracheostomy. The condition of one patient with NMD improved and NIPPV was discontinued. The three-year and five-year probabilities of continuing NIPPV in all patients were 82%, and 71%, respectively. The survival rates three and five years after starting NIPPV were 97% and 85%, respectively. The survival rates one to nine years, and ten to eleven years after starting HOT were 98% and 65%, respectively. The arterial PO2 and PCO2, nocturnal oxygen saturation, vital capacity, and forced expiratory volume, in one second all improved after NIPPV was begun. NIPPV also reduced the number of hospital days, particularly in patients with KS. In conclusion, the long-term outcome of NIPPV in patients with hypercapnic respiratory failure is encouraging.

Exertional dyspnea-related acidotic and sympathetic responses in patients with sequelae of pulmonary tuberculosis

The objective of this study was to investigate whether exertional dyspnea correlates with exercise responses, especially arterial blood pH and plasma norepinephrine (NE) changes, in patients with sequelae of tuberculosis (TBsq). Cardiopulmonary exercise testings were performed in 49 TBsq patients and 9 controls. Each group had a break point in the dyspnea, plasma lactate, and plasma NE changes during exercise, all of which occurred at a similar exercise point. In TBsq patients in both exercise phases before and after the dyspnea break point, the dyspnea-slope (DeltaBorg scale/Deltaminute ventilation) correlated with the pH-slope (DeltapH/Deltaoxygen uptake) (r = -0.616, p < 0.0001; r = -0.629, p < 0.0001, respectively, before and after the break point) and with the NE-slope (DeltaNE/Deltaoxygen uptake) (r = 0.443, p = 0.0012; r = 0.643, p < 0.0001, respectively, before and after the break point). In TBsq patients during exercise, increases in circulating NE levels and exertional acidosis were correlated with exertional dyspnea.

Noninvasive Ventilation in Patients with Acute Exacerbation of Pulmonary Tuberculosis Sequelae

The efficacy of noninvasive ventilation (NIV) in acute exacerbation of pulmonary tuberculosis sequelae has not been fully studied. We retrospectively reviewed 58 patients with acute exacerbation of pulmonary tuberculosis sequelae who were admitted to Tosei General Hospital and treated with NIV over a 9-year period. The 58 patients (mean age: 76.2±8.0) consisted of 39 males and 19 females. Arterial blood gas analysis on admission showed a mean pH of 7.28±0.07 and a mean PaCO(2) of 72.6±14.2 mmHg. After the start of NIV, significant improvement occurred in pH, to 7.32±0.06 after 2 h and 7.36±0.06 after 24 h, and in PaCO(2), to 66.4±11.2 mmHg after 2 h and 61.6±11.3 mmHg after 24 h. The success rate in weaning from NIV was 86.2%. There were statistically significant differences in pH, body mass index (BMI), blood leukocyte count and serum potassium between patients successfully and unsuccessfully weaned from NIV. We conclude that patients with acute exacerbation of pulmonary tuberculosis sequelae can be treated successfully with NIV. Lower pH, BMI, and serum potassium, and higher blood leukocyte count are related to NIV failure.

Reactivation of Pulmonary Tuberculosis in a Patient with Polygonum multiflorum Thunb-Induced Hepatitis

Several cases of Polygonum multiflorum Thunb-induced hepatitis have been reported worldwide. Anthraquinone is an active ingredient of P. multiflorum Thunb. that has been thought to play a role in its hepatotoxicity. Here we report the case of a 34-year-old Korean man who had P. multiflorum Thunb-induced hepatitis and reactivation of pulmonary tuberculosis caused by bone marrow suppression, which developed simultaneously. He was admitted to our hospital with recently developed fatigue and aggravated jaundice. He was a previously healthy man except for the sequelae of pulmonary tuberculosis seen on chest X-ray. He had a 30-day history of ingesting the root of P. multiflorum as a form of liquor and tea. The patient was diagnosed with P. multiflorum Thunb-induced hepatitis after excluding all other potential causes of acute hepatitis. Liver function gradually improved following the total cessation of the consumption of the material. However, he suffered from spiking fever with progressive pancytopenia during the hospital stay. A bone marrow biopsy showed markedly hypocellular marrow, suggesting transient bone marrow suppression, which was probably caused by extrinsic factors such as drugs, toxins, and viral infection. Although he began to complain of a dry cough, repeated sputum investigations revealed positive acid-fast bacillus staining. The fever subsided and pancytopenia improved after treatment for pulmonary tuberculosis. These observations suggest that P. multiflorum Thunb induces both bone marrow suppression and hepatotoxicity.

Exercise Limitation Factors of Patients with Chronic Respiratory Failure: a Comparison of Chronic Obstructive Pulmonary Disease and Sequelae of Pulmonary Tuberculosis

[Purpose] The purpose of this study was to explain the difference in characteristics of exercise limitation factors of patients with chronic obstructive pulmonary disease (COPD) and sequelea of pulmonary tuberculosis (PTB-s) . [Subjects] The subjects were 29 patients with COPD (28 males, 1 female; 70.6 8.0 years) and 8 patients with PTB-s (5 males, 3 females; 69.5 ± 9.5 years). [Method] We conducted the cardiopulmonary exercise test. This test was conducted using a respiratory metabolism measuring device with a electronically braked cycle ergometer and simultaneous breath-by-breath analysis of expired gas. Main outcome measures were oxygen uptake (peak VO2), minute ventilation (peak VE), oxygen equivalent (peak VE/VO2), carbon dioxide equivalent, (peak VE/VCO2), and oxygen pulse (peak O2 pulse) at peak exercise. [Results] There were no significant differences between peak VO2 and peak VE/VO2 and peak VE/VCO2. The Peak O2 pulse, an index of circulatory ability, was 6.6 ± 1.8 ml/beats/min in COPD and 4.5 ± 1.4 ml/beats/min in PTB-s (p<0.01), showing that the reaction of the circulatory system to exercise was poor in both groups. [Conclusions] We suggest that the difference in characteristics of exercise limitation factors of patients with COPD and PTB-S are circulatory ability. Studies of the synergistic effects of pharmacotherapy and kinesitherapy on the circulatory system may enable the establishment of a rehabilitation program based on disease-specific characteristics of PTB-s.

NPPV for sequelae of pulmonary tuberculosis and restrictive lung diseases

NPPV for sequelae of pulmonary tuberculosis and restrictive lung diseases

Perfil funcional de pacientes portadores de seqüela de tuberculose de um hospital universitário

To describe data related to the pulmonary function of patients with sequelae of pulmonary tuberculosis, pleural tuberculosis or both. In the outpatient clinic of a university hospital, 218 patients were evaluated. Of those 218, 56 had sequelae of tuberculosis (pulmonary, pleural or both), and 162 had other types of tuberculosis. All patients were evaluated in the pulmonary function laboratory between February 2000 and July 2004, and 43 were found to be eligible for inclusion in the study. Patients with a history of asthma, chronic pulmonary obstructive disease, cardiac insufficiency, collagen diseases, silicosis or thoracic surgery, as well as those for whom spirometry yielded unacceptable results or was not performed, were excluded. The lung fields were divided into six zones, and radiographic results were classified by degree: I (involvement of only one zone with no cavitation); II (involvement of two or three zones or of one zone with cavitation); or III (extensive involvement of three or more zones with or without cavitation). The final study sample comprised 50 patients, 44 (88%) of whom had pulmonary tuberculosis. The most prevalent form (17/50; 34%) was mixed ventilatory disturbance. Severe disturbances were more significant in degree III radiographs (p = 0.0002) and normal pulmonary function was predominant among patients presenting degree I and II radiographs (p = 0.002). The early discovery and treatment of tuberculosis contribute to reduce the number of cases, as well as the incidence of tuberculosis sequelae, thereby improving the quality of life of tuberculosis patients. Further studies, involving longitudinal, sequential analysis and larger samples of patients with tuberculosis sequelae, should be conducted in referral centers in Brazil.

Exercise Training for the Improvement of Exercise Performance of Patients with Pulmonary Tuberculosis Sequelae

To examine whether exercise training using nontreadmill walking is effective for the improvement of exercise performance of patients with pulmonary tuberculosis sequelae (PTS) characterized by restrictive ventilatory defect. Fourteen patients with stable PTS hospitalized for assessment of exertional dyspnea in Fukujuji Hospital from April 1997 to March 1999 were enrolled in this observational study. All patients underwent baseline pulmonary function tests, arterial blood-gases analysis and exercise tests for initial assessment. Four patients were excluded because of hypoxemia during the initial treadmill test. The remaining 10 patients who stopped exercising because of symptom limitations became candidates for the exercise training. The patients were instructed to perform daily walking exercise training in a hallway in the hospital for 2 weeks. The training was started at their maximum walking speeds during the treadmill test, and walking speed was gradually increased as the patients gained confidence. After finishing the exercise training, the patients performed pulmonary function tests, arterial blood-gases analysis was done, and exercise tests were conducted in identical fashion to the baseline protocol. There were no significant changes in pulmonary function tests and arterial blood-gases analysis after the exercise training. Exercise tolerance improved with a significant increase in peak oxygen uptake (from 13.6+/-2.8 to 14.8+/-2.8 ml/kg/min, p<0.01) and distance covered in a 6-minute walk (from 399+/-62 to 467+/-65 m, p<0.01) after the exercise training. The exercise training we conducted is shown to be a safe and effective modality for the improvement of exercise performance of patients with PTS.

Successful treatment of secondary pulmonary hypertension by long-term non-invasive positive pressure ventilation

The case of 57-year-old man with chronic ventilatory insufficiency due to asbestos pleurisy and sequelae of pulmonary tuberculosis is described. Non-invasive positive pressure ventilation therapy appeared to improve the pulmonary hypertension. Ultrasonic cardiography was valuable in the serial assessment of pulmonary artery pressure.

Derrame pleural por micobactéria não tuberculosa

O Mycobacterium kansasii, micobactéria não tuberculosa, pode causar doença pulmonar com manifestação clínico-radiológica semelhante à tuberculose. Estão associados fatores de risco: bronquiectasias, doença pulmonar obstrutiva crônica, seqüela de tuberculose, pneumoconiose e imunossupressão. Relata-se um caso de derrame pleural, em paciente de 67 anos, com doença pulmonar obstrutiva crônica e antecedente de tuberculose. O diagnóstico de tuberculose pleuropulmonar foi sugerido pelo exame anatomopatológico de pleura, que demonstrou processo crônico granulomatoso e presença de bacilo álcool-ácido resistente. Nas culturas de líquido e tecido pleurais foi detectado Mycobacterium kansasii. Discute-se o diagnóstico diferencial com outros agentes infecciosos na doença granulomatosa pleural e tratamento.

Noninvasive positive pressure ventilation in patients with kyphoscoliosis and pulmonary tuberculosis sequelae

Noninvasive positive pressure ventilation in patients with kyphoscoliosis and pulmonary tuberculosis sequelae