Unexplained Pneumonia Research Articles

An Interesting Case of Persistent Pyrexia With Eosinophilia and Pulmonary Infiltrates: “Popcorn Aspiration”

SESSION TITLE: Chest Infections I SESSION TYPE: Case Report Poster PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM INTRODUCTION: Foreign body aspiration (FBA) is uncommon in healthy adults. An unexplainable chronic cough, recurrent pneumonia, or recurrent fevers may be clues that the patient has retained foreign body in the lung. In this case, we discuss a patient who presented with persistent pyrexia and right-sided pneumonia. CASE PRESENTATION: 73-year-old female diabetic presented with complaints of persistent fever, cough, and pleuritic chest pain for 6 weeks. She failed three courses of antibiotics, including one as an inpatient. Physical exam was significant for bilateral coarse breath sounds and right sided rhonchi. Labs showed persistent eosinophilia with a peak of 15.1%, not present on her prior admission. Chest X-Ray (CXR) and CT chest showed right lower lobe infiltrates and evidence of bronchial impactions. Considering her persistent symptoms, new development of eosinophilia, and resistance to broad spectrum antibiotics, a bronchoscopy was performed. Bronchoscopy showed an unexpected finding of what appeared to be a kernel of corn with adjacent granulation tissue in a segment of the RLL. BAL was remarkable for 25% eosinophilia. Remarkably, following removal of the foreign body, the patient’s fevers and eosinophilia immediately resolved. When the patient was informed of the unexpected finding, she recalled an episode of harsh coughing while eating popcorn nearly eight weeks prior. DISCUSSION: FBA in an otherwise healthy patient often presents subtly with chronic cough being present in 80% of cases1. Fever, hemoptysis, chest pain, foul smelling sputum, and eosinophilia may be present2. Partial or complete bronchial obstruction may potentially cause recurrent pneumonia, atelectasis, bronchiectasis, or lung abscess1. CXR and CT may show infiltrative processes, but are not good modalities for detecting aspirated organic materials3. Removal of the foreign body with a flexible or ridged bronchoscope is the mainstay of treatment1. CONCLUSIONS: FBA may subtly present in healthy adults and can mimic other respiratory disorders such as asthma, malignancy, or eosinophilic pneumonia. Clinicians should have a high index of suspicion in patients with symptoms such as unexplained cough, persistent fevers, or recurrent pneumonia. Bronchoscopy can be both diagnostic and therapeutic. Reference #1: Baharloo F, Veyckemans F, Francis C, Biettlot M, Rodenstein DO.“Tracheobronchial foreign bodies*: presentation and management in children and adults.” Chest 1999;115(5):1357-1362. Reference #2: Mukhopadhyay, S, and Katzenstein, A. “Pulmonary Disease Due to Aspiration of Food and Other Particulate Matter: A Clinicopathologic Study of 59 Cases Diagnosed on Biopsy or Resection Specimens.” The American Journal of Surgical Pathology (2007):752-59. Reference #3: Ciftci AO, Bingöl-Koloğlu M, Senocak ME, Tanyel FC, Büyükpamukçu N. “Bronchoscopy for evaluation of foreign body aspiration in children.” J Pediatr Surg. 2003;38 (8):1170. DISCLOSURE: The following authors have nothing to disclose: Omar Taha, Pavan Kumar Gorukanti, Mangalore Amith Shenoy, Karishma Kitchloo, Suchit Khanijao, Shyam Shankar, Animesh Gour, William Pascal, Michael Bergman No Product/Research Disclosure Information

A clinical analysis of twenty-five cases of eosinophilic lung disease

To improve the diagnosis and treatment of eosinophilic lung disease. Patients who were diagnosed with eosinophilic lung disease and hospitalized in the First Affiliated Hospital of Guangxi Medical University Hospital were retrospectively analyzed from January 2004 to August 2012. Data of etiology, clinical manifestation, imaging and pathological features, diagnosis and treatment were recorded. A total of 25 patients were diagnosed with eosinophilic lung disease including 9 chronic eosinophilic pneumonia, 6 churg-strauss syndrome, and 10 cases of parasitic infection of which two patients were the simple pulmonary eosinophilia (Löffler syndrome). Eosinophil counts in peripheral blood and bronchoalveolar lavage fluid (BALF) were increased. Arterial gas analysis showed varying degree of hypoxemia, which pulmonary function tests showed restrictive, obstructive, mixed ventilatory dysfunction. Chest CT showed bilateral flaky, streak or flake diffuse ground-glass infiltrates and reticular opacities. Results of pulmonary biopsy or skin biopsy identified diffuse eosinophil infiltration. Corticoidsteroid therapy alone or combined with immunosuppressive agents were both effective. (1) Liver fluke and other food-borne parasites are the most common causes in eosinophilic lung disease; followed by unexplained chronic acidophilic granulocyte pneumonia; (2) In addition to histopathological evidence, the diagnosis of eosinophilic lung disease was made comprehensively based on clinical features, laboratory test, the BALF analysis, and imaging data.

The clinical features of foreign body aspiration into the lower airway in geriatric patients.

PurposeTo analyze the clinical features of foreign-body aspiration into the lower airway in geriatric patients.Patients and methodsThe clinical data of 17 geriatric patients with foreign-body aspiration were retrospectively analyzed and compared with 26 nongeriatric adult patients. The data were collected from Peking University First Hospital and Anhui Chest Hospital between January 2000 and June 2014.Results(1) In the geriatric group, the most common symptoms were cough and sputum (15 cases, 88%), dyspnea (six cases, 35%), and hemoptysis (four cases, 24%). Five patients (29%) in the geriatric group could supply the history of aspiration on their first visit to doctor, a smaller percentage than in the nongeriatric group (13 cases, 50%). Only three cases in the geriatric group were diagnosed definitely without delay. Another 14 cases were misdiagnosed as pneumonia or lung cancer, and the time of delayed diagnosis ranged from 1 month to 3 years. Complications due to delay in diagnosis included obstructive pneumonitis, atelectasis, lung abscess, and pleural effusion. (2) Chest computed tomography demonstrated the foreign body in three cases (21%) in the geriatric group, which was lower than the positive proportion of detection in the nongeriatric group (nine cases, 35%). The most common type of foreign body in the geriatric group was food, such as bone fragments (seven cases, 41%) and plants (seven cases, 41%), and the foreign body was most often lodged in the right bronchus tree (eleven cases, 65%), especially the right lower bronchus (seven cases, 41%). Flexible bronchoscopy removed the foreign body successfully in all patients.ConclusionThe clinical features of foreign-body aspiration in geriatric patients are usually more obscure than in nongeriatric adults, which may lead to long delay in diagnosis. Flexible bronchoscopy is safe and useful for early diagnosis and effective management in geriatric patients. We suggest flexible bronchoscopy as the first-line approach to similar patients, especially those with aspiration history and unexplained pneumonia.

Non-resolving pneumonia in patient with obsessive–compulsive disorder

A 26-year-old woman presented with a history of chronic progressive dyspnoea and a non-productive cough. Her medical history revealed recurrent, unexplained pneumonias and treatment for anorexia nervosa. The patient was...

Human infection with avian influenza A(H7N9) virus re-emerges in China in winter 2013

Through a national surveillance system for unexplained pneumonia, a severe case of influenza A(H7N9) in a man in his mid-30s was identified in Zhejiang Province, China on 14 October 2013. Epidemiological and clinical findings were consistent with the patterns reported during the outbreak in spring 2013, and laboratory findings showed that the virus had 99.6% identity with earlier H7N9 viruses identified in humans in the spring except for five mutations in the NA gene.

Salivagram After Gland Injection of Botulinum Neurotoxin A in Patients With Cerebral Infarction and Cerebral Palsy

Pulmonary aspiration in patients with brain lesions may result from dysfunction of theswallowing process or gastroesophageal reflux. Inadequate protection of the airway fromoral secretions such as saliva may also induce aspiration. Chronic pulmonary aspiration ofsaliva can lead to substantial respiratory morbidity, including unexplained lung disease orrecurrent pneumonia, and is an important issue in the rehabilitation unit. In particular,patientswithneurologicdiseasewhoareinalong-termbedriddenstatecanbeatgreaterriskfor development of chronic salivary aspiration and pulmonary complications [1,2].Incontrast to aspiration during the swallowing process, continuous secretion of saliva and itsaspiration are difficult to control, even through modification of food consistency orcessation of oral feeding.Useofaradionuclidesalivagramtodetectpassiveaspirationofsalivawasintroducedby Heyman [3] in 1989. After sublingual instillation of a small amount of radiolabeledcolloid, serial images are evaluated for the presence of radiotracer uptake in thetracheobronchial tree, which is suggestive of aspiration. This test may be useful fordetection of aspiration of saliva and for patients with limitations of oral feeding or poorcooperation. For these reasons, a radionuclide salivagram has been used in infants orchildren with neurologic diseases, for example, cerebral palsy, who have recurrentpulmonary infection [4-6]. A radionuclide salivagram can be performed under morephysiological conditions without the challenge of an oral bolus for swallowing and isless invasive than a videofluoroscopic swallow study or a fiberoptic-endoscopic evalu-ation of swallowing[4].TherehasbeenanincreaseintheuseofbotulinumneurotoxinA(BoNT-A)injectionintosalivary glands for the treatment of drooling in patients with neurologic disease, includingcerebral palsy [7], Parkinson disease [8], and amyotrophic lateral sclerosis [9,10]. Variousobjective or subjective methods have been used to evaluate treatment response to BoNT-Ainjection.However,mostofthemethodsfocusonreductionofsialorrheaordroolingitself.FewstudiesassesspulmonaryaspirationofsalivaaftersalivaryglandinjectionwithBoNT-A[11]. We hypothesized that a positive radionuclide salivagram could be strong evidence ofaspirationofsalivaandhelpfultoassesstheindicationformoreintensivetreatment,suchasglandinjectionwithbotulinumtoxinorsurgicalexcision.Inourexperiencewith2patients,saliva aspiration resolved after administration of BoNT-A into salivary glands, as demon-strated on a follow-up radionuclide salivagram.

Clinical Significance of Quantifying Pneumocystis jirovecii DNA by Using Real-Time PCR in Bronchoalveolar Lavage Fluid from Immunocompromised Patients

Quantitative PCR (qPCR) is more sensitive than microscopy for detecting Pneumocystis jirovecii in bronchoalveolar lavage (BAL) fluid. We therefore developed a qPCR assay and compared the results with those of a routine immunofluorescence assay (IFA) and clinical data. The assay included automated DNA extraction, amplification of the mitochondrial large-subunit rRNA gene and an internal control, and quantification of copy numbers with the help of a plasmid clone. We studied 353 consecutive BAL fluids obtained for investigation of unexplained fever and/or pneumonia in 287 immunocompromised patients. No qPCR inhibition was observed. Seventeen (5%) samples were both IFA and qPCR positive, 63 (18%) were IFA negative and qPCR positive, and 273 (77%) were both IFA and qPCR negative. The copy number was significantly higher for IFA-positive/qPCR-positive samples than for IFA-negative/qPCR-positive samples (4.2 ± 1.2 versus 1.1 ± 1.1 log(10) copies/μl; P < 10(-4)). With IFA as the standard, the qPCR assay sensitivity was 100% for ≥2.6 log(10) copies/μl and the specificity was 100% for ≥4 log(10) copies/μl. Since qPCR results were not available at the time of decision-making, these findings did not trigger cotrimoxazole therapy. Patients with systemic inflammatory diseases and IFA-negative/qPCR-positive BAL fluid had a worse 1-year survival rate than those with IFA-negative/qPCR-negative results (P < 10(-3)), in contrast with solid-organ transplant recipients (P = 0.88) and patients with hematological malignancy (P = 0.26). Quantifying P. jirovecii DNA in BAL fluids independently of IFA positivity should be incorporated into the investigation of pneumonia in immunocompromised patients. The relevant threshold remains to be determined and may vary according to the underlying disease.

Silent gastroesophageal disease: Clinical implications of an unknown disease

Silent gastroesophageal disease: Clinical implications of an unknown disease

Year in review 2010: Interstitial lung diseases, acute lung injury, sleep, physiology, imaging, bronchoscopic intervention and lung cancer

Year in review 2010: Interstitial lung diseases, acute lung injury, sleep, physiology, imaging, bronchoscopic intervention and lung cancer

The clinical and public health value of non-culture methods in the investigation of a cluster of unexplained pneumonia cases

During 2003, a cluster of initially unexplained pneumonia cases (two fatal) occurred in patients aged <50 years in a British city. Routine culture tests were inconclusive, however, pneumococcal infection was suspected and the putative outbreak was investigated using non-culture methods. Clinical samples from ten patients were tested by pneumococcal polymerase chain reaction (PCR) and multi-locus sequence typing (MLST), or Binax NOW pneumococcal urine antigen test and serotype-specific enzyme-linked immunosorbent assay (ELISA). Lung samples from the deceased patients were PCR positive and yielded different MLST types. Two patients in one family group were serotype 1 pneumococcal antigen positive. Two further patients were serotype 1 antigen positive, and one serotype 4 positive. Two antigen-positive cases were also serum PCR positive. Non-culture methods confirmed the disease aetiology in six cases. Serotype and MLST results showed no single outbreak, but a family cluster of cases in a high background of pneumococcal pneumonia, providing important epidemiological data that would not otherwise have been available.

Pulmonary involvement by Niemann–Pick disease. A report of six cases

Although pulmonary involvement is a known cause of morbidity in Niemann-Pick disease, histological features in the lung are not well characterized. The purpose of this study is to document the histological features seen in pulmonary involvement by types B and C Niemann-Pick disease and to correlate them with clinical and imaging data. Surgical lung biopsies from six patients (four with type B and two with type C disease) were reviewed and all showed diffuse endogenous lipid pneumonia, with lesser involvement of the interstitium by fibrosis and foamy macrophage accumulation. In type B disease only, there was also fine cytoplasmic vacuolation within the cytoplasm of ciliated epithelial cells. Neither disease showed foamy changes within pneumocytes. One patient had a bronchial cast removed on whole lung lavage. Electron microscopy showed abnormal lamellar inclusions within lysosomes of affected cells in type B disease. In patients with type C disease, biopsies were undertaken as part of investigations into acute respiratory failure in the context of multiorgan systemic presentation. Three patients with type B disease had clinical disease limited to the lung, all adults (mean age of 40 years) with unexplained diffuse parenchymal lung disease and mainly ground-glass shadowing on high-resolution computed tomography. Niemann-Pick disease should be considered for any patient with unexplained diffuse endogenous lipid pneumonia, even when disease is limited to the lungs and presentation is during adulthood.

Retrospective study of morbidity and mortality of captive jaguars (Panthera onca) in North America: 1982–2002

One hundred seventy-two medical records of captive jaguars (Panthera onca) were examined from 30 American Zoo and Aquarium Association (AZA) institutions housing jaguars between 1982–2002. The study determined common causes of morbidity and mortality, and the influence of age, gender, and melengestrol-acetate (MGA) exposure on these rates. The most common causes of morbidity in captive jaguars were found to be dental, gastrointestinal, integumentary, and musculoskeletal diseases. Prevalence of types of disease varied with age, with older animals experiencing a higher prevalence of multiple types of disease. Females developed reproductive disease more frequently than males, and the data suggest that MGA exposure increased the risk of developing female reproductive disease. The most common causes of mortality were reproductive diseases in females and musculoskeletal diseases in males. There was a high rate of neonate and pediatric mortality, primarily due to stillbirths or unexplained neonatal death, trauma, and pneumonia. Other diseases or clinical signs that seemed remarkable were a high prevalence of episodes of epistaxis among young, as well as old, jaguars. Based on these findings, management suggestions for the captive jaguar population are presented. Zoo Biol 0:1–12, 2006. © 2006 Wiley-Liss, Inc.

Severe acute respiratory syndrome: public health response and clinical practice update for an emerging disease.

Severe acute respiratory syndrome is an emerging infectious disease with high morbidity and mortality and potential for global spread. This review highlights the salient points of the 2002-2003 outbreak to help clinicians with early recognition, treatment, disease control, and prevention. Severe acute respiratory syndrome is a respiratory illness caused by a novel coronavirus, severe acute respiratory syndrome-coronavirus. The disease was first recognized in Asia in February 2003 and, over the next several months, spread to more than two dozen countries in North and South America, Europe, and Asia. The disease is characterized by fever with symptomatic and radiographic evidence of pneumonia. Because diagnosis cannot be established by clinical findings alone, epidemiologic findings (including history of travel to affected areas, close contact with other case patients, or linkage to clusters of unexplained pneumonia) play a critical role in the diagnostic evaluation. Infection control procedures (including droplet and airborne precautions) are critical for preventing transmission.

From the Centers for Disease Control and Prevention. Update: outbreak of severe acute respiratory syndrome--worldwide, 2003.

CDC and the World Health Qrganization (WHO) are continuing to investigate the multicountry outbreak of unexplained atypical pneumonia referred to as severe acute respiratory syndrome (SARS). Pending development of confirmatory laboratory testing capacity, CDC's interim suspected SARS case definition is based on clinical criteria and epidemiologic linkage to other SARS cases or areas with community transmission of SARS. This case definition will be updated periodically as new information becomes available. Epidemiologic and laboratory investigations of SARS are ongoing. As of April 2, 2003, a total of 2,223 suspected and/or probable SARS cases have been reported to WHO from 16 countries, including the United States. The reported SARS cases include 78 deaths (case-fatality proportion: 3.5%). This report summarizes SARS cases among U.S. residents and surveillance and prevention activities in the United States.

Pulmonary alveolar proteinosis mimicking idiopathic pulmonary fibrosis

Pulmonary alveolar proteinosis (PAP) is a rare disorder of unknown etiology. While most biopsies from patients with PAP disclose a prominent positive periodic acid-Schiff, diastase-resistant intra-alveolar exudate, and minimal interstitial thickening, interstitial fibrosis and honeycombing can be the predominant histologic findings. We recently identified two patients with PAP who initially were thought to have idiopathic pulmonary fibrosis, but whose biopsies ultimately disclosed PAP with considerable interstitial fibrosis. Because the clinical and radiographic presentation of PAP can overlap with other interstitial lung disorders, it should be considered in the differential diagnosis of unexplained idiopathic interstitial pneumonias in young patients. Ann Diagn Pathol 7: 82-86, 2003.

Psittacose sévère multiviscérale chez un garçon de dix ans

Psittacosis is rare among children and severe cases appear exceptional. We describe a child with psittacosis and multiorgan involvement. Case report. – T., a ten-year-old boy, was admitted for a prolonged fever associated with meningism. Laboratory tests showed an important inflammatory response, mild renal failure and coagulation disorders. On admission, the chest X-Ray and the cerebrospinal fluid were normal. He rapidly developed shock, acute abdomen, oxygenodependency, pneumonia and bilateral pleural effusion. No improvement was observed after 48 hours of cefotaxime therapy. History revealed the presence of two parrots at home. Treatment by intravenous clarithromycin was therefore initiated. Serology for Chlamydia psittaci was strongly positive. All symptoms disappeared a few days later. Conclusion. – The case reported was particular for two reasons: severe disease with multi-organ involvement and young age of the patient. We emphasize the need to search for a history of contact with birds in any case of unexplained pneumonia.

Pediatric foreign body aspiration.

1. Joshua D. Rovin, MD* 2. Bradley M. Rodgers, MD† 1. 2. *Division of Pediatric Surgery, Children’s Medical Center, University of Virginia Health Sciences Center, Charlottesville, VA. 3. 4. †Editorial Board. After completing this article, readers should be able to: 1. Delineate the signs and symptoms of foreign body aspiration. 2. Explain the process of evaluating for suspected foreign body aspiration. 3. Describe the possible radiographic manifestations of foreign body aspiration. 4. Explain the management of foreign body aspiration in children. 5. Delineate the potential late complications of foreign body aspiration. Aspiration of foreign bodies by children can lead to serious illness and sometimes even death. According to National Safety Council statistics, in 1995, mechanical suffocation accounted for 5% (167) of all unintentional deaths among children in the United States younger than 4 years of age. Most of these deaths occurred in children younger than 1 year of age (81 deaths, accounting for 10% of all unintentional deaths in children younger than 1 year of age). Fortunately, the number of deaths has decreased over the past decade, which has been attributed to better education of the public and stricter guidelines for toy manufacturers. Nevertheless, foreign body aspiration continues to account for a significant number of preventable childhood deaths. Younger children are at the highest risk for accidental foreign body aspiration. This increased incidence has been attributed to several factors among younger children, including that they: 1) have the tendency to put small objects into their mouths; 2) often cry, shout, run, and play with objects in their mouths; and 3) do not have molars to chew certain foods adequately. Most studies show that fewer than 15% of foreign body aspirations occur among children older than 5 years of age. Boys comprise more than 50% of all cases of foreign body aspiration. By far, the objects aspirated most frequently are organic or food matter. In North America, peanuts are most common (Table 1⇓ ). View this table: Table 1. Commonly Aspirated Foreign Bodies Unlike aspiration in adults, there is only a …

Arterial chemoembolization before liver transplantation in patients with hepatocellular carcinoma: marked tumor necrosis, but no survival benefit?

Background/Aims: Hepatic artery chemoembolization was introduced in the treatment of patients with unresectable hepatocellular carcinoma waiting for liver transplantation. The rationale for this preoperative treatment was to control tumor growth during the waiting period and to improve long-term survival. This study aimed to investigate whether preoperative chemoembolization not only induces marked tumor necrosis but also has a survival benefit. Methods: In this study 21 patients with hepatocellular carcinoma who underwent pretransplant chemoembolization (group I) were compared with 21 historical control patients (group II) without preoperative chemoembolization in a case-control study. The number of pretransplant chemoembolizations in each patient in group I varied between 1 and 5 with a mean of 2.44±1.15. In addition, six patients of this group received preoperative systemic chemotherapy. Results: Overall, there were no differences in survival between the groups with and without pretransplant chemoembolization at 1 year (60.8% vs 61.5%) and at 3 years (48.4% vs 53.9%). In group I, three patients developed unexplained severe pneumonia, leading to death very early after liver transplantation. Marked tumor necrosis (>50 %) was found in 14 cases in group I. In 6 out of these 14 patients, total tumor necrosis was observed. Conclusion: Although preoperative chemoembolization or chemotherapy induced marked tumor necrosis, these patients showed no benefit in survival compared to historical controls, and appeared to be at higher risk of developing immediate postoperative infective complications.

Insuffisance respiratoire aiguë révélatrice d'une myasthénie juvénile : à propose de trois cas

Myasthenia gravis is usually revealed by a ptosis or a diplopia. A respiratory muscle weakness often occurs during the course but an acute respiratory failure as initial feature is unusual. Three girls, aged 8, 10 and 14 years, were hospitalised in an intensive care unit, along a 15 year-period, for an acute respiratory distress. The first two children suffered from skeletal and bulbar muscle weakness. The third, admitted with the diagnosis of unexplained pneumonia, was complaining of skeletal and bulbar muscle weakness for the last 18 months. Myasthenia gravis was confirmed with electromyography, and detection of the acetylcholine-receptors antibodies in all three cases. Any unexplained acute respiratory distress must lead to search for skeletal and bulbar muscle weakness, specially after muscular exercise or at the end of day, manifestations which characterize myasthenia gravis.

The radionuclide salivagram in children with pulmonary disease and a high risk of aspiration

Purpose. We wanted to demonstrate the utility of the radionuclide salivagram in assessing children whose underlying medical problems suggest that aspiration of oral contents is a factor contributing to otherwise unexplained lung disease or recurrent pneumonias. Materials and methods. Following sublingual administration of 300 &mu;Ci (11.1 MBq) of technetium-99m sulfur colloid in a drop of saline, serial images were obtained for 60 min and evaluated for entrance of tracer into the major airways and lung parenchyma. Thirty-four studies were performed on 31 patients (age: 3 weeks - 16.7 years, mean 5.5 years) with recurrent pneumonias or unexplained lung disease. All had medical conditions, most frequently neurological, predisposing to aspiration. Results. Pulmonary aspiration was detected in eight patients. All positive studies demonstrated aspirated tracer distal to the tracheal bifurcation, either in bronchi or in bronchi and lung parenchyma. Aspiration was bilateral in six cases. Clearance of aspirated tracer was noted in one patient. Conclusion. The salivagram is an effective tool for demonstrating aspiration of oral contents and the level to which aspirated fluid penetrates the tracheobronchial tree. Additionally, by allowing for the evaluation of clearance of aspirated tracer, the salivagram may provide information on the status of airway-protective mechanisms.