Unexplained Respiratory Symptoms Research Articles

Isolated chronic dysphonia revealing a systemic lupus erythematosus: 2 case reports

Background: Laryngeal involvement in systemic lupus erythematosus may be asymptomatic, and diagnosis may only be made through routine screening or investigation for other symptoms. However, laryngeal involvement can also be potentially serious, with the potential for upper airway obstruction and other complications. Treatment typically involves systemic corticosteroids, which are often effective in managing symptoms. In some cases, more invasive procedures such as tracheotomy or mechanical ventilation may be necessary. Aim: Emphasize the involvement of the larynx in systemic lupus erythematosus and the crucial role of clinicians in recognizing its symptoms to consider a potential diagnosis. Case report: We report two cases of isolated dysphonia revealing systemic lupus erythematosus in two young adult females who had no other clinical signs of systemic lupus erythematosus. Conclusion: Due to the potential seriousness of laryngeal involvement in systemic lupus erythematosus, it is important for clinicians to maintain a high degree of suspicion for this condition in patients with systemic lupus erythematosus, particularly in cases where there are unexplained respiratory or throat symptoms. Early diagnosis and treatment can help prevent potentially life-threatening complications.

An analysis of pulmonary function tests in construction workers.

In construction workers, repeated and constant exposure to noxious materials generated at construction sites often increases the risk of respiratory illness. Pulmonary function test (PFT) is an important tool utilized for both diagnosis the cause of unknown or unexplained respiratory symptoms and monitoring prognosis of patients with known respiratory pathology. In the present study, PFT of construction workers was assessed using spirometry. A total of 100 male construction workers (working for >1 year) belonging age group 21 to 60 years were included in the study. Additionally, equal number of age matched healthy individuals without any exposure to construction work was recruited as controls. Indices of pulmonary functions included forced vital capacity (FVC), peak expiratory flow rate (PEFR), forced expiratory volume (FEV1), FEV1/FVC and maximal voluntary ventilation (MVV). Maximum workers belonged to age group 21 to 40 years. A total of 37 had habit of smoking. Construction workers also suffered from respiratory ailments like cough, dyspnea, sorethroat etc. All indices of PFT were significantly decreased in construction workers compared to controls. Construction workers are at high risk of developing respiratory ailments due to continuous long term exposure to noxious material used in construction. Habit of smoking and consumption of alcohol also adds on to risk of developing respiratory disorders. Spirometry can be recommended as an effective tool for screening of construction workers for respiratory ailments. The present study highlights the importance of regular health camps, use of proper protective wears and initiation of awareness program to prevent respiratory ailments in construction workers.

Chronic respiratory disorders due to aberrant innominate artery: a case series and critical review of the literature

BackgroundTracheal compression (TC) due to vascular anomalies is an uncommon, but potentially serious cause of chronic respiratory disease in childhood. Vascular slings are congenital malformations resulting from abnormal development of the great vessels; in this group of disorders the most prevalent entity is the aberrant innominate artery (AIA). Here we provide a report on diagnosis and treatment of AIA in nine children with unexplained chronic respiratory symptoms. We describe the cases, perform a literature review, and provide a discussion on the diagnostic workup and treatment that can help manage AIA.MethodsClinical history, diagnostic procedures and treatment before and after the AIA diagnosis were retrospectively reviewed in nine children (5 boys and 4 girls), who were referred for recurrent-to-chronic respiratory manifestations over 10 years (2012–2022). We performed a comprehensive report on the ongoing clinical course and treatment as well as an electronic literature search on the topic.ResultsDiagnoses at referral, before AIA was identified, were chronic dry barking cough associated with recurrent pneumonia (n = 8, 89%), lobar/segmental atelectasis (n = 3, 33%), atopic/non atopic asthma (n = 3, 33%); pneumomediastinum with subcutaneous emphysema complicated the clinical course in one case. When referred to our Unit, all patients had been previously treated with repeated antibiotic courses (n = 9, 100%), alone (n = 6, 67%) or combined with prolonged antiasthma medications (n = 3, 33%) and/or daily chest physiotherapy (n = 2, 22%), but reported only partial clinical benefit. Median ages at symptom onset and at AIA diagnosis were 1.5 [0.08–13] and 6 [4–14] years, respectively, with a relevant delay in the definitive diagnosis (4.5 years). Tracheal stenosis at computed tomography (CT) was ≥ 51% in 4/9 cases and ≤ 50% in the remaining 5 subjects. Airway endoscopy was performed in 4 cases with CT evidence of tracheal stenosis ≥ 51% and confirmed CT findings. In these 4 cases, the decision of surgery was made based on endoscopy and CT findings combined with persistence of clinical symptoms despite medical treatment. The remaining 5 children were managed conservatively.ConclusionsTC caused by AIA may be responsible for unexplained chronic respiratory disease in childhood. Early diagnosis of AIA can decrease the use of expensive investigations or unsuccessful treatments, reduce disease morbidity, and accelerate the path toward a proper treatment.

Case report: Eosinophilic pneumonia associated with vedolizumab therapy in a patient with ulcerative colitis

Extraintestinal manifestations are common in patients with inflammatory bowel disease, while respiratory involvement is less common. Vedolizumab is a new class of anti-integrin biological agents approved for treating inflammatory bowel disease. In this report, we present the case of a 38-year-old patient with ulcerative colitis for 7 years who developed cough, fever, and pulmonary infiltrates after taking vedolizumab. There was a spontaneous improvement in clinical symptoms and radiological abnormalities after discontinuing vedolizumab and introducing steroids. Despite the rarity of vedolizumab-induced eosinophilic pneumonia, the case reports indicate that patients with unexplained respiratory symptoms that are taking vedolizumab should be fully contemplated.

Qatagner Syndrome: Case of Adult Southeast Asian Women with Unexplained Respiratory Symptoms

Qatagner Syndrome: Case of Adult Southeast Asian Women with Unexplained Respiratory Symptoms

Inhalation and ingestion of magnetic foreign bodies in a toddler with persistent cough—a case report

: Inhalation and ingestion of foreign bodies are common emergency presentations in paediatric otolaryngology. Here we present a case of an incidental finding of simultaneous ingestion and inhalation of small magnets in a 21-month-old following a history of worsening cough. The initial diagnosis was thought to be a viral upper respiratory tract infection, however, due to the persistence of symptoms, a chest x-ray was obtained, which revealed two foreign bodies in the location of the left main bronchus. The first attempt at endoscopic removal of foreign bodies using laryngoscopy, bronchoscopy and oesophagoscopy (LBO) was unsuccessful due to a complete occlusion of the left main bronchus by a significant mass of friable granulation tissue precluding visualisation of the foreign bodies. An urgent computed tomography (CT) scan was obtained to further delineate the location of the foreign bodies; this, unfortunately, was limited by streak artefacts but raised the possibility of the foreign bodies being in both the airway and the oesophagus. Given the potential of a fistula and the close proximity of the objects to the carina, median sternotomy with cardiopulmonary bypass was planned for retrieval and reconstruction if endoscopic retrieval failed. Repeat endoscopy successfully retrieved two magnetic ball-bearings measuring 6mm in diameter each. One was located in the left main bronchus and the other in the oesophagus. To our knowledge, this is the first case in Australia described of two foreign bodies entering the airway and digestive tract at the same time. We discuss the presentation, diagnosis and management of this case including the diagnostic dilemma encountered and the involvement of multidisciplinary teams. This case highlights the importance of having a high clinical suspicion of foreign body inhalation/ingestion in paediatric patients presenting with prolonged unexplained respiratory symptoms and no resolution with standard treatment.

Mesalazine-induced Hypersensitivity Pneumonitis.

A diagnosis of mesalazine-related hypersensitivity pneumonitis should be considered when unexplained respiratory symptoms develop during treatment with mesalazine.It is important to distinguish pulmonary manifestations in patients with inflammatory bowel disease secondary to drug-related toxicity from the disease process itself.Amelioration of symptoms and improvement in imaging and lung function seem to occur only upon abrupt discontinuation of the drug; severe symptoms such as respiratory failure may justify corticosteroid therapy.

Anti-synthetase syndrome: a rare and challenging diagnosis for bilateral ground-glass opacities\u2014a case report with literature review

BackgroundAnti-synthetase syndrome (ASS) is an uncommon immune-mediated entity characterized by myositis, interstitial lung disease (ILD), non-erosive arthritis, and less common features such as fever, Raynaud’s phenomenon, and skin changes in association with anti-aminoacyl-transfer-RNA antibodies, most commonly anti-Jo-1 antibodies.Case presentationWe present a challenging and rare case of ASS-associated ILD presenting with unexplained respiratory symptoms and bilateral infiltrates on chest imaging during the COVID-19 pandemic. High clinical suspicion for ASS with early appropriate therapy with corticosteroids and immunosuppressive agents led to marked clinical improvement.ConclusionHigh index of suspicion for ASS is mandated in patients with unexplained ILD. A comprehensive autoimmune work-up is important as an early treatment with corticosteroids with or without immunomodulators improves patient outcomes and survival in an otherwise poor prognostic disease.

Infants without apparent risk factors with aspiration as a cause of respiratory symptoms - a retrospective study.

Dysphagia is common in children born prematurely or those with neuromuscular conditions or airway malformations. Few studies have reported on children with isolated dysphagia and there is significant variation in the literature regarding clinical outcomes. The aim of this study was to characterise the clinical presentation of children with isolated dysphagia as well as the diagnostic evaluation, treatment strategies and clinical outcomes. A retrospective chart review was conducted of children with isolated dysphagia presenting to a tertiary paediatric centre over a 10-year period. We describe these patients' presentation, clinical feeding assessment findings, radiological findings, treatment strategies and outcomes. Seventeen children were identified. Recurrent respiratory tract infections were the most common presentation (82%). Oral feeds were continued in 9 (53%) with the remaining being NG fed. Gastrostomy tubes were required for long-term nutrition in 6/8 (75%) of these cases. At follow-up, 11/17 (65%) had resolution of symptoms and are on full oral feeds. The mean age at resolution is 3.45years. Of those who required gastrostomy 50% have had them removed. Isolated dysphagia should be considered in children presenting with recurrent, otherwise unexplained respiratory symptoms. Resolution can take a number of years.

Notes from the Field: Unexplained Dermatologic, Respiratory, and Ophthalmic Symptoms Among Health Care Personnel at a Hospital - West Virginia, November 2017-January 2018.

Notes from the Field: Unexplained Dermatologic, Respiratory, and Ophthalmic Symptoms Among Health Care Personnel at a Hospital - West Virginia, November 2017-January 2018.

Forced oscillation technique in veterans with preserved spirometry and chronic respiratory symptoms

PurposeTo evaluate the utility of the forced oscillation technique (FOT) among military veterans with preserved spirometry and chronic unexplained respiratory symptoms. Methods178 veterans referred for evaluation of unexplained respiratory symptoms completed pulmonary function testing and FOT. Preserved spirometry was defined as FEV1/FVC, FEV1 and FVC ≥ 5th percentile. Frequency dependence of resistance (R4-R20) and reactance area (AX) were assessed via FOT, and R4-R20 ≥ 20% and AX ≥ 95th percentile were considered abnormal. ResultsSpirometry was preserved in 71.3%, of whom 124 had acceptable FOT data. 93 of 124 (75.0%) veterans with preserved spirometry had one or more abnormal findings on FOT. Veterans with abnormal R4-R20 and/or AX had reduced FVC, FEV1, FEF25-75, and diffusing capacity (% predicted) in comparison to those with Normal FOT (p = 0.030 to p < 0.001). ConclusionsIn our referral sample, distal airway dysfunction in the presence of preserved spirometry appears common and may represent an at-risk group requiring closer surveillance.

Differentiating Lung Involvement in Adult T-Cell Leukemia Lymphoma (ATLL) Versus HTLV Infection: Results from a Large Single-Center Cohort with Implications for Staging and Response Criteria

Introduction: Human T-cell lymphotropic virus (HTLV) is a retrovirus that has been associated with adult-T cell leukemia/lymphoma (ATLL) and other inflammatory conditions. Pulmonary involvement has not been widely associated to HTLV infection; however, high rates of imaging abnormalities in patients with and without ATLL have been reported. Okada reported 30%, 69% and 94% of abnormalities in HTLV1 carriers, ATLL and patients that transformed into ATLL. Whether these abnormalities follow a pattern related to each condition individually has not been defined. Hence, we undertook a retrospective study in ATLL and HTLV infected patients to determine the lung abnormalities which could be due to ATLL involvement rather than HTLV infection.Objectives: To compare the CT pulmonary findings among patients with HTLV infection with and without ATLL diagnosed at Montefiore Medical Center between 2004 and 2017.Methods: Patients diagnosed with HTLV infection by ICD9 were identified using the software Clinical Looking Glass and those with an available chest CT scan were selected. Data regarding demographics, smoking history, prior pulmonary conditions, HTLV and ATLL-associated characteristics was collected by chart review. CT chest was reviewed by an expert radiologist who was unaware of the patient diagnosis (ATLL versus non-ATLL) and findings were compared among groups. The staging CT scan was used to determine baseline pulmonary findings in patients with ATLL and the first CT chest around HTLV diagnosis was used for HTLV patients.Results: A total of 97 patients (72 with ATLL and 25 with HTLV alone) were identified. Mean age at HTLV diagnosis was 58.4 years (range: 33-88), 54.6% were females, 72.2% were Black Non-Hispanics while 27.8% were Hispanic. 88.3% were from Caribbean origin. Smoking history was similar between ATLL and non-ATLL groups (12% vs 8%, p=0.07) with no cases of prior active TB infection. Abnormal CT chest findings were present in 92.8%, 94.4% and 88% for the total cohort, ATLL and non-ATLL patients.Among patients with ATLL, 52.1% had acute and 43.7% had lymphomatous types; while only 1.4% and 2.8% had smoldering and chronic type. The most common CT chest findings were lymphadenopathy (50, 69.4%); followed by 3-10 mm nodules (32, 44.4%), ground-glass opacity, pleural effusion (31, 43.1% each), centrilobular nodules (28, 39.4%), thickening of interlobular septum (23, 31.9%) and bronchiectasis (18, 25%). Compared to the acute subtype, patients with lymphomatous subtype had higher rates of lymphadenopathy (83.9% vs 64.9, p=0.07) and lower rates of bronchiectasis (16.1% vs 35.1%, p=0.07).Among patients with non-ATLL, HTLV infection was diagnosed at an older age (63.8 vs. 56.6 years, p=0.03); HTLV-associated comorbidities were found in 16 cases (64%). Of these, myelopathy was the most frequent (10, 40%), followed by strongyloides (4, 16%). After HTLV diagnosis, CT chest was indicated in 28% patients for otherwise unexplained respiratory symptoms and to evaluate lung nodules or other chest X-ray abnormalities in 24% of cases. Bronchiectasis was the most common finding (12, 48%) followed by pleural thickening (11, 44%), ground-glass opacity and thickening of interlobular septum (10, 40%, each). Persistent abnormalities on follow-up imaging were present in 86.7% of the cases. Among patients with HTLV infection, those with ATLL were more likely to have nodules and lymphadenopathy (41.7% vs 20%, p=0.05 and 69.4% vs 24%, p<0.001, respectively) while bronchiectasis and pleural thickening was more likely in patients without ATLL (48% vs 25%, p=0.03 and 44% vs 23.6%, p=0.05; respectively).Conclusions: Pulmonary findings are highly prevalent in CT chest of patients with HTLV infection with and without ATLL. Bronchiectasis and pleural thickening was more frequently encountered in non-ATLL patients while lymphadenopathy and nodules were common finding in patients with ATLL. Pulmonary involvement in lymphoma is usually characterized by nodules and lymphadenopathy but patients with ATLL had a higher incidence of findings including ground glass opacities, bronchiectasis and interlobular septal thickening possibly due to their underlying HTLV infection. Based on this data, nodules and lymphadenopathy should be classified as ATLL involvement of the lung while other findings described here could be due to HTLV infection. These findings are important in staging and response criteria for ATLL. [Display omitted] DisclosuresJanakiram:Seatle Genetics: Membership on an entity's Board of Directors or advisory committees.

Protocolo diagnóstico y tratamiento de la enfermedad pulmonar por fármacos

Drug-induced pulmonary disease is a common clinical problem observed in patients under medication who present unexplained respiratory symptoms and changes on chest radiography, pulmonary function impairment and histological changes. More than 150 medications are related with pleuropulmonary pathology pharmacologically induced. A proper management requires the identification of the causative drug and an appropriate differential diagnosis. Treatment is the prompt withdrawal of the drug suspected to cause the disease.

The role of high resolution oesophageal manometry in occult respiratory symptoms

Cough Hypersensitivity Syndrome is the urge to cough following minimal stimulation, but its mechanism and method of provocation remain unexplained. 121 patients (44 males, 77 females; age range 18-81 years) were evaluated. High resolution manometry was performed on consecutive patients presenting with unexplained respiratory symptoms (Respiratory Group 61). Data were compared with matched controls, i.e. dyspepsia without respiratory symptoms (Dyspepsia Group 60). Results showed increased inspiratory gastro-oesophageal pressure gradient due to significantly lower intra-oesophageal pressure on inspiration (p = 0.001), and reduced oesophageal motility in the Respiratory Group. Further research in respiratory conditions characterised by decreased intrathoracic pressure during inspiration is needed.

Pneumocystis jiroveci pneumonia (PJP) in non-HIV immunocompromised individuals

Objectives: PJP is a major cause of morbidity and mortality in immunocompromised individuals. Diagnosing PJP is often difficult because respiratory signs might be minimal or absent and the sensitivity of a chest X-ray (CXR) is low. We studied the clinical risk factors in order to increase awareness and facilitate the diagnosis.Methods: We studied a prospective case series over a one year period (from 1 January 2015 to 1 January 2016) and did a retrospective analysis (from 2013 to 2016) of all PJP positive bronchoalveolar lavage (BAL) analysis.Results: Seven patients with metastatic solid tumors were diagnosed with symptomatic PJP (based on positive polymerase chain reaction) over a one year period. The median age was 61 years. Three patients had brain metastasis. Four of them were on steroids, the median dose was 16 mg methylprednisolone with three of them at a tapered dose. Respiratory failure developed in four cases and prompted intensive care monitoring. Two patients needed non-invasive ventilation and the third patient was intubated and mechanically ventilated. No patient died of PJP. A retrospective analysis on microbiological results obtained from BAL in our hospital from 2013 to 2016 shows a striking high percentage PJP positivity in cancer patients (including hematologic cancers) of nearly 22% (15/69) as opposed to the overall number of PJP-positives 7.3% (59/803).Discussion: The incidence of clinical PJP in patients treated for metastatic cancer is substantial. A high index of suspicion, especially in cases with unexplained respiratory symptoms, concurrent or recent use of steroids, a normal CXR and otherwise unexplained increased lactate dehydrogenase levels, is critical. The threshold for performing a CT-scan must be low and the diagnosis needs to be confirmed microbiologically.

D-dimer test for excluding the diagnosis of pulmonary embolism.

Pulmonary embolism (PE) can occur when a thrombus (blood clot) travels through the veins and lodges in the arteries of the lungs, producing an obstruction. People who are thought to be at risk include those with cancer, people who have had a recent surgical procedure or have experienced long periods of immobilisation and women who are pregnant. The clinical presentation can vary, but unexplained respiratory symptoms such as difficulty breathing, chest pain and an increased respiratory rate are common.D-dimers are fragments of protein released into the circulation when a blood clot breaks down as a result of normal body processes or with use of prescribed fibrinolytic medication. The D-dimer test is a laboratory assay currently used to rule out the presence of high D-dimer plasma levels and, by association, venous thromboembolism (VTE). D-dimer tests are rapid, simple and inexpensive and can prevent the high costs associated with expensive diagnostic tests. To investigate the ability of the D-dimer test to rule out a diagnosis of acute PE in patients treated in hospital outpatient and accident and emergency (A&E) settings who have had a pre-test probability (PTP) of PE determined according to a clinical prediction rule (CPR), by estimating the accuracy of the test according to estimates of sensitivity and specificity. The review focuses on those patients who are not already established on anticoagulation at the time of study recruitment. We searched 13 databases from conception until December 2013. We cross-checked the reference lists of relevant studies. Two review authors independently applied exclusion criteria to full papers and resolved disagreements by discussion.We included cross-sectional studies of D-dimer in which ventilation/perfusion (V/Q) scintigraphy, computerised tomography pulmonary angiography (CTPA), selective pulmonary angiography and magnetic resonance pulmonary angiography (MRPA) were used as the reference standard.• Adults who were managed in hospital outpatient and A&E settings and were suspected of acute PE were eligible for inclusion in the review if they had received a pre-test probability score based on a CPR.• quantitative, semi quantitative and qualitative D-dimer tests.• Target condition: acute symptomatic PE.• Reference standards: We included studies that used pulmonary angiography, V/Q scintigraphy, CTPA and MRPA as reference standard tests. Two review authors independently extracted data and assessed quality using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). We resolved disagreements by discussion. Review authors extracted patient-level data when available to populate 2 × 2 contingency tables (true-positives (TPs), true-negatives (TNs), false-positives (FPs) and false-negatives (FNs)). We included four studies in the review (n = 1585 patients). None of the studies were at high risk of bias in any of the QUADAS-2 domains, but some uncertainty surrounded the validity of studies in some domains for which the risk of bias was uncertain. D-dimer assays demonstrated high sensitivity in all four studies, but with high levels of false-positive results, especially among those over the age of 65 years. Estimates of sensitivity ranged from 80% to 100%, and estimates of specificity from 23% to 63%. A negative D-dimer test is valuable in ruling out PE in patients who present to the A&E setting with a low PTP. Evidence from one study suggests that this test may have less utility in older populations, but no empirical evidence was available to support an increase in the diagnostic threshold of interpretation of D-dimer results for those over the age of 65 years.

Lung function abnormalities among service members returning from Iraq or Afghanistan with respiratory complaints

BackgroundService members deploying to Afghanistan (OEF) and Iraq (OIF) often return with respiratory symptoms. We sought to determine prevalence of lung function abnormalities following OEF/OIF. MethodsWe identified OEF/OIF patients who had unexplained respiratory symptoms evaluated using lung function testing. Lung function data were summarized and analyzed for associations with demographic and deployment characteristics. ResultsWe found 267 patients with unexplained cough or dyspnea, lung function testing and a history of OEF/OIF deployment. All patients had basic spirometry performed and 82 had diffusion capacity for carbon dioxide (DLCO) measured. The median (IQR) number of deployments and total days deployed were 1 (1–2) and 352.0 (209–583), respectively. There were 83 (36.6%) patients with abnormal spirometry, 53 (63.9%) of whom had an abnormal FEV1/FVC. Only one (1.2%) patient had an abnormal DLCO adjusted for alveolar volume. Of 104 patients who had post bronchodilator (BD) testing performed, six (5.8%) had a positive response by ATS criteria. We found no relationships between lung function and time in theater, deployment location, deployment frequency, or land based-deployment. Dyspnea and enlisted rank were associated with tobacco use and lower FEV1, and cough was associated with total number of deployments. ConclusionsService members with respiratory complaints following OEF/OIF have a high prevalence of abnormalities on spirometry. Tobacco use, enlisted rank and total number of deployments were associated with symptoms or spirometric abnormalities.

Esophageal Inlet Patch: An Under-Recognized Cause of Symptoms in Children

To determine the incidence of inlet patch (IP) and to assess the clinical and pathological features, role of the diagnostic workup in treatment decision making, efficacy of medical and endoscopic therapy, and natural history in a pediatric population. Consecutive patients aged <18years (n=1000) undergoing esophagogastroduodenoscopy were enrolled prospectively. Biopsy specimens were obtained from IPs and the proximal and distal esophagus, stomach, and duodenum. Multichannel intraluminal impedance and pH monitoring (MII-pH) was performed in all symptomatic patients. Symptomatic patients were treated with proton pump inhibitors for 8weeks, and IP ablation by argon plasma coagulation (APC) was performed in unresponsive patients. The endoscopic incidence of IP was 6.3%, with a cumulative missing rate of 5.8%. Thirty-five of the 63 patients (56%) were asymptomatic, 11 (17%) had symptoms clearly related to the underlying digestive disorder, and 17 (27%) had chronic IP-related symptoms. MII-pH was positive in 10 of the 28 symptomatic patients. All 17 patients with IP-related symptoms were unresponsive to proton pump inhibitors and were treated with APC, and all had achieved complete remission by the 3-year follow-up. Patients with underlying disorders were successfully treated with medical therapy, and asymptomatic patients remained symptom-free, with no endoscopic or histological changes seen at the 3-year follow-up. IP is an under-recognized cause of symptoms in children with unexplained esophageal and respiratory symptoms. MII-pH and bioptic sampling are needed to exclude entities mimicking IP symptoms and to direct therapy. APC is safe and effective for treating IP-related symptoms.

PTU-126 High Incidence of Oesophageal Dysmotility and Increased Inspiratory Gastro-Oesophageal Pressure Gradients in Patients with Unexplained Respiratory Symptoms

Introduction It has been suggested that reflux and aspiration are common precipitants in respiratory diseases such as cough, asthma and Chronic Obstructive Pulmonary Disease. An excess of acid in these patients has been demonstrated by conventional pH monitoring, but correlation with symptoms are relatively poor. We have previously hypothesised that oesophageal dysmotility leading to both acid and non-acid aspiration may be an important etiological mechanism. Studies have also highlighted the importance of the gastro-oesophageal pressure gradient (GOPG) in the prevalence of reflux. 1 Methods High Resolution Oesophageal Manometry (HRM) was performed in 121 patients, 61 of whom presented primarily with unexplained respiratory symptom and complained predominantly of chronic cough (50), or breathlessness (11). An age and sex matched control group was chosen from patients presenting with suspected gastro-oesophageal reflux disease (GORD). The HRM findings of 61 patients (38 female), mean age 56 (range 18–81) with respiratory symptoms were compared with those of 60 suspected GORD patients (39 female), mean age 57, (range 19–81). Results Mean lower oesophageal sphincter (LOS) and upper oesophageal sphincter (UOS) resting pressures were similar between the two groups. There were fewer intact swallows in the respiratory group compared to those of the GORD group (42% vs 57%, P = 0.03). Intraoesophageal pressure was significantly lower during inspiration in the respiratory group compared to those of the GORD group (-11.5mmHg vs -8.7, p = 0.001). Consequently, there was a significantly higher GOPG was found in respiratory patients compared to those of the GORD group (46 mmHg vs 33 mmHg, p Conclusion Using High Resolution Oesophageal Manometry, we have demonstrated a higher prevalence of oesophageal dysmotility in patients with unexplained respiratory symptoms than those presenting with typical GORD. Moreover, we have shown that those with unexplained respiratory symptoms exhibit higher inspiratory GOPGs and greater LOS peak contractions possibly stimulating an afferent vagal cough response. Reference 1 Ayazi S, DeMeester SR, et al . Thoracic-abdominal pressure gradients during the phases of respiration contribute to gastroesophageal reflux disease. Digestive Disease and Sciences 2011; 56 :1718–22. Disclosure of Interest None Declared

The effect of disease modifying drugs on the lung in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disease mainly affecting the joints. It has extra-articular manifestations, including lung disease, a major contributor to morbidity and mortality. Careful assessment of systemic signs and symptoms of patients presenting to a pulmonologist with unexplained respiratory symptoms is very important, since RA itself can present with initial pulmonary symptoms without articular manifestations. Several disease modifying agents and biologics have been introduced to treat RA and have been shown to improve the quality of life and slow down the disease progression itself. The possibility of pulmonary toxicity with these drugs has been raised but establishing a causal relationship is difficult. In some case reports stopping the drug in question has reversed radiological changes and decreased inflammatory markers and symptoms, suggesting drug-related toxicity. However, some experts suggest that evolving or increasing pulmonary toxicity usually represents failure of treatment and an indication to switch to a different biologic or disease modifying agent. In this review we evaluate the association between methotrexate, leflunomide, and newer biologic agents and lung disease in patients with rheumatoid arthritis.