[Hypereosinophilic asthma]

Although moderate airway infiltration by eosinophils is present in the eosinophilic inflammatory phenotype of asthma, hypereosinophilic asthma differs in its frankly elevated levels of eosinophils in the blood, induced sputum, and bronchoalveolar lavage. Some etiologic pitfalls may be tricky especially wheezing in eosinophilic pneumonia induced by drugs or parasitic infections. Idiopathic chronic eosinophilic pneumonia is associated with asthma in most cases. Churg-Strauss syndrome has asthma as a basic feature, but true systemic vasculitis with antineutrophil cytoplasmic autoantibodies is not always present. Systemic corticosteroids are the mainstay of treatment of most hypereosinophilic asthma patients.

Pulmonary vascular manifestations of hereditary hemorrhagic telangiectasia (rendu-osler disease)

Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is a genetic disorder with autosomal dominance and variable penetrance, characterized by epistaxis, telangiectasia and visceral manifestations of the disease. The estimated minimal prevalence is 1/10,000 inhabitants. The diagnosis is established on clinical criteria, and may be further confirmed by the identification of causative mutations in either the ENG or the ACVRL1 gene coding for endoglin and ALK1, respectively. Pulmonary vascular manifestations of HHT include pulmonary arteriovenous malformations (PAVMs; especially in patients with ENG mutations) and less frequently pulmonary hypertension (especially in patients with ACVRL1 mutations). In 15-33% of patients with HHT, PAVMs consist of abnormal communications between pulmonary arteries and pulmonary veins, causing right-to-left shunting, and thus, frequently hypoxemia and dyspnea on exertion, although PAVMs may remain asymptomatic and frequently undiagnosed unless complications occur. PAVMs result in severe and frequent complications often at a young age, which may reveal the diagnosis, e.g. transient ischemic attack and cerebral stroke (10-19% of patients), systemic severe infections and abscesses (including cerebral abscess in 5-19% of patients), and rarely massive hemoptysis or hemothorax. Infections in HHT are related to the right-to-left shunting that bypasses the pulmonary capillaries and facilitates the passage of septic or aseptic emboli into the systemic and especially cerebral circulation, and potentially to minor defects in innate immunity. Treatment of PAVMs based on transcatheter coil vaso-occlusion of the feeding artery significantly decreases right-to-left shunting, hypoxemia and dyspnea on exertion, and reduces the risk of systemic complications. Long-term follow-up is warranted after transcatheter vaso-occlusion of PAVMs due to frequent recanalization of treated PAVMs and development or growth of untreated PAVMs. Patients with HHT should be informed of the risk of PAVM and potentially severe complications occurring in heretofore asymptomatic subjects. All adult patients with HHT should be proposed systematic screening for PAVM, by contrast echocardiography (preceded by anteroposterior chest radiograph) or computed tomography of the chest. Pulmonary hypertension is rare in HHT, and may be due either to systemic arteriovenous shunting in the liver increasing cardiac output or be clinically and histologically indistinguishable from idiopathic pulmonary arterial hypertension. Pulmonary hypertension is detected by systematic examination of right cardiac cavities and tricuspid regurgitation flow at echocardiography, and the diagnosis is established by right heart catheterization.

Challenges in pulmonary fibrosis. 2: Bronchiolocentric fibrosis

Bronchiolocentric fibrosis is essentially represented by the pathological pattern of constrictive fibrotic bronchiolitis obliterans. The corresponding clinical condition (obliterative bronchiolitis) is characterised by dyspnoea, airflow obstruction at lung function testing and air trapping with characteristic mosaic features on expiratory high resolution CT scans. Bronchiolitis obliterans may result from many causes including acute diffuse bronchiolar damage after inhalation of toxic gases or fumes, alloimmune chronic processes after lung or haematopoietic stem cell transplantation, or connective tissue disease (especially rheumatoid arthritis). Airway-centred interstitial fibrosis and bronchiolar metaplasia are other features of bronchiolocentric fibrosis.

Syndrome d'emphysème des sommets et fibrose pulmonaire des bases combinés

A syndrome including upper-lobe emphysema and pulmonary fibrosis of the lower lungs was recently characterized. It is found most often in men who are smokers or ex-smokers of more than 40 pack-years; their mean age is 65 years. Exertional dyspnea is always present. There are basal crackles. The disease has no known cause; the only certain risk factor is smoking. Pulmonary function tests show respiratory volumes and flows that are often normal or subnormal, while carbon monoxide transfer is substantially reduced and exercise hypoxemia is present. Diagnosis is based on findings from millimeter-slices of computed tomography of the chest, which show either centrilobular emphysema or upper-zone bullous emphysema, associated in 90% of cases with very suggestive paraseptal emphysema and diffuse infiltrating fibrosing lung disease at the bases (subpleural reticular opacities, honeycomb images, traction bronchiectasis), with more frequent ground glass opacities than in idiopathic pulmonary fibrosis. Pulmonary hypertension is present in almost half of all patients and represents the principal negative prognostic factor for this condition, which has a median survival of 6 years.

Alveolar hemorrhage in anti-basement membrane antibody disease: a series of 28 cases

Anti-basement membrane antibody disease is a rare disorder characterized by the presence of autoantibodies binding to the alveolar and glomerular basement membranes, and mediating both alveolar hemorrhage and acute glomerulonephritis. We retrospectively analyzed 28 cases of anti-basement membrane antibody disease with alveolar hemorrhage proven by bronchoalveolar lavage. The median age of patients at diagnosis was 23 years; 68% were male, 89% were active smokers, and 36% were exposed to some other inhaled agent. At diagnosis, 46% had predominant pulmonary involvement with normal initial serum creatinine. Lung function tests disclosed a restrictive ventilatory defect in 28% (n = 11) and hypoxemia (moderate in 29% and severe in 29%, n = 21). Carbon monoxide transfer factor was elevated in only 25% (n = 12). Bronchoalveolar lavage was more sensitive than any other criterion for detecting alveolar hemorrhage. After onset of treatment, new hemoptysis or transient worsening of hypoxemia occurred in 29% but did not affect pulmonary outcome. In contrast, worsening of renal function occurred in 33% and adversely affected renal outcome. At last follow-up (median, 2.6 yr; n = 24), all patients were alive and a complete cure was achieved in 50%. Long-term dialysis or renal transplantation was required in 42%, and 8% had mild chronic renal insufficiency. Last chest X-ray was normal in all cases, and no patient had respiratory insufficiency. All patients with predominant pulmonary involvement at presentation maintained independent renal function. In summary, this cohort was characterized by frequent exposure to tobacco smoking and other inhaled agents, and a constantly favorable pulmonary outcome contrasting with frequent chronic renal failure. Renal outcome was excellent in the subgroup of patients with predominant pulmonary involvement.

Hemorrhagic hereditary telangiectasia (Rendu-Osler disease) and infectious diseases: an underestimated association

Among 353 patients with hereditary hemorrhagic telangiectasia retrospectively analyzed during the period 1985-2005, we identified 67 cases of severe infection that affected 48 patients (13.6%). Extracerebral infections accounted for 67% of all infections, and most involved Staphylococcus aureus and were associated with prolonged epistaxis. Cerebral infections accounted for 33% of all infections, were mainly due to multiple and anaerobic bacteria, and were associated with the presence of pulmonary arteriovenous malformations and a short duration of epistaxis.

Churg-Strauss syndrome with poor-prognosis factors: A prospective multicenter trial comparing glucocorticoids and six or twelve cyclophosphamide pulses in forty-eight patients

OBJECTIVE

To compare long and short durations of adjunctive cyclophosphamide for the treatment of severe Churg-Strauss syndrome (CSS).

METHODS

In this prospective multicenter therapeutic trial, 48 patients with CSS with at least 1 poor-prognosis factor at baseline were treated with glucocorticoids and either 12 or 6 intravenous cyclophosphamide pulses.

RESULTS

At 8 years, complete remission rates and severe side effects of therapy were comparable for both groups. The overall difference in relapses was not significant between the 12-pulse and the 6-pulse regimens (P = 0.07), but when considering only the number of mild relapses this difference became statistically significant (P < 0.02). Although the total number of inclusions was not reached, the study was stopped prematurely in response to the superiority of the 12-pulse regimen.

CONCLUSION

We concluded that 12 cyclophosphamide pulses were better able to control severe CSS than a 6-pulse regimen. The optimal duration of therapy remains to be determined.

Pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: a series of 126 patients

Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder characterized by epistaxis, telangiectasia, and visceral vascular manifestations. Infectious and ischemic central nervous system (CNS) manifestations due to embolism through pulmonary arteriovenous malformations (PAVMs) represent the main causes of morbidity. To improve the phenotypic characterization of HHT with PAVM, we conducted a retrospective multicenter study of patients with HHT and at least 1 PAVM detected by chest computed tomography (CT) and/or pulmonary angiography, with particular attention to CNS and infectious manifestations. The study included 126 patients (47 men, 79 women), with a mean age of 43.1 +/- 17.4 years; 45 patients had a mutation of the ENG gene and 16 had a mutation of ACVRL1. PAVMs were diagnosed as a result of systematic screening procedures (29%), incidental imaging findings (15%), dyspnea (22%), or CNS symptoms (13%). The PAVMs were diagnosed at a mean age of 43 +/- 17 years, with a linear distribution of diagnosis between 20 and 75 years. Dyspnea on exertion was present in 56% of patients. Four patients had a hemothorax, including 1 during pregnancy. Fifty-three CNS events directly related to HHT (excluding migraine) were observed in 35% of patients: cerebral abscess (19.0%), ischemic cerebral stroke (9.5%), transient cerebral ischemic attack (6.3%), and cerebral hemorrhage (2.4%). The median age of onset was 33 years for cerebral abscesses (range, 11-66 yr), and 53.5 years for ischemic cerebral events (range, 2-72 yr). Migraine was reported in 16% of patients. The diagnoses of PAVM and HHT were made at the time of the cerebral abscess in 13 cases (54%). Forty-three percent of patients were hypoxemic at rest. Contrast echocardiography showed intrapulmonary right-to-left shunting in 87% of tested patients. PAVMs were seen on chest radiograph in 54% of patients, and on the CT scan in all patients. One hundred five patients (83%) underwent treatment of the PAVM, by percutaneous embolization (71%) and/or by surgical resection (23%). A high frequency of CNS and infectious complications was observed in this large series of patients with HHT-related PAVM. Physicians may not be sufficiently aware of the clinical manifestations of this orphan disorder. Patients diagnosed with HHT should be informed by physicians and patient associations of the risk of PAVM-related complications, and systematic screening for PAVM should be proposed, regardless of a patient's symptoms, familial history, or genetic considerations.

Idiopathic chronic eosinophilic pneumonia

Idiopathic chronic eosinophilic pneumonia is a rare disorder of unknown cause with nonspecific respiratory and systemic symptoms but rather characteristic peripheral alveolar infiltrates on imaging. The disorder is highly responsive to oral corticosteroid therapy. However, relapses are frequent when tapering or after stopping treatment. Moreover, some patients develop severe asthma at some time in the follow-up. The high incidence of relapses and prevalence of severe asthma is responsible for the great proportion of patients with idiopathic chronic eosinophilic pneumonia who require prolonged oral corticosteroid therapy. There are tight links between asthma and idiopathic chronic eosinophilic pneumonia. These links might help in the comprehension of the pathogenesis of both diseases. Interestingly, there might exist a continuum between hypereosinophilic asthma, idiopathic chronic eosinophilic pneumonia, and the Churg-Strauss syndrome.

[Arteriovenous malformations in Rendu-Osler disease: value of systematic screening]

Rendu-Osler disease (hereditary hemorrhagic telangiectasia) is a rare disease of genetic origin characterized by epistaxis, cutaneous and mucous telangiectases, and visceral arteriovenous malformations. Pulmonary arteriovenous malformations are a cause of paradoxical embolism leading to cerebral abscesses and ischemic strokes. Screening for pulmonary vascular manifestations by cardiac contrast echocardiography and imaging permits early vaso-occlusion of arteriovenous malformations.

[Idiopathic chronic eosinophilic pneumonia]

INTRODUCTION

Idiopathic chronic eosinophilic pneumonia (ICEP) is one of the hypereosinophilic lung diseases.

BACKGROUND

ICEP is a rare disease of unknown cause that combines non-specific respiratory and general symptoms with predominantly peripheral radiological infiltrates. The presence of blood and alveolar eosinophilia points strongly to the diagnosis. ICEP is very sensitive to systemic corticosteroids but relapses are common following stopping treatment or reducing the dose. A background of asthma is commonly found and many patients with ICEP develop severe asthma which, together with the relapses, often necessitates prolonged systemic corticosteroid treatment. The long term prognosis, however, remains excellent.

VIEWPOINT

The role of inhaled corticosteroids in non-asthmatic patients remains uncertain and should be evaluated further. The links between asthma and ICEP could lead to a better understanding of the mechanisms underlying hypereosinophilic lung diseases.

CONCLUSION

ICEP is a rare disease that is important to recognise on account of its potentially disabling nature and its good response to corticosteroid treatment though long term maintenance is some times necessary on account of relapses or the development of severe asthma.

Chemotherapy is the cornerstone of the combined surgical treatment of lung cancer with synchronous brain metastases

BACKGROUND

Lung cancer accounts for about 50% of brain metastases, of which nearly 25% are eligible for neurosurgery, providing a neurological control rate of up to 70% when followed by whole brain radiation therapy. How to manage the primary lung carcinoma remains elusive.

METHODS

We undertook a retrospective study of consecutive patients who underwent surgical resection for synchronous brain metastases from non-small cell lung cancer in a single institution, to determine overall survival and prognostic factors, with particular attention to the treatment of the primary lung tumor.

RESULTS

Fifty-one patients underwent surgical resection of synchronous brain metastases from non-small cell lung cancer. Median survival was 13.2 months. Prognosis mainly depended of the treatment of the lung tumor, with a marked survival advantage in the 29 patients receiving a focal treatment (thoracic surgery or radiotherapy), compared to the 22 other patients: median, 1-year, and 2-year survival were 22.5 months, 69%, and 42%, versus 7.1 months, 33%, and 5%, respectively (p<0.001); response to pre-operative chemotherapy before focal treatment was the main favorable prognostic factor (p=0.023), and further identified patients who had benefit from resection of the lung tumor, with a significantly better outcome.

CONCLUSIONS

Chemotherapy, by its therapeutic and prognostic value, may be considered as the cornerstone of the combined medical and surgical therapeutic sequence whereby brain metastasectomy is followed by chemotherapy and further focal treatment of the primary lung tumor in responders to chemotherapy.

[Idiopathic pulmonary fibrosis]

Idiopathic pulmonary fibrosis is a fibroproliferative disorder characterized histopathologically by heterogenous interstitial fibrosis with fibroblastic foci and honeycomb lung. The diagnosis is based on a pluridisciplinary approach, integrating the clinical evaluation, the chest high-resolution computerized tomography features, and the pathological pattern of usual interstitial pneumonia on video-thoracoscopic lung biopsy when performed. When the tomodensitometric pattern is typical (50% of the cases), the diagnosis may be made without a lung biopsy. No treatment has proven benefit in survival. Treatment with N-acetylcysteine in association with corticosteroids and azathioprine has recently shown a modest functional improvement. Clinical trials are strongly needed in this still uncurable disease with median survival at 3 years of only about 50%.

Idiopathic chronic eosinophilic pneumonia

Idiopathic chronic eosinophilic pneumonia (ICEP) is characterized by subacute or chronic respiratory and general symptoms, alveolar and/or blood eosinophilia, and peripheral pulmonary infiltrates on chest imaging. Eosinophilia is present in most cases, usually in excess of 1000/mm3. In absence of significant blood eosinophilia, a diagnosis of ICEP is supported by the demonstration of bronchoalveolar lavage eosinophilia. ICEP is typically associated with eosinophil counts higher than lymphocyte counts in the bronchoalveolar lavage. ICEP is a rare disorder of unknown cause. Its exact prevalence remains unknown. ICEP may affect every age group but is rare in childhood. It is twice as frequent in women as in men. One third to one half of the ICEP patients have a history of asthma. The mainstay of treatment of ICEP is systemic corticosteroids. Response to oral corticosteroid therapy is dramatic and has led to the consideration of corticosteroid challenge as a diagnostic test for ICEP. Nevertheless, relapses or development of severe asthma are frequent when tapering or withdrawing treatment. Long-term oral corticosteroid therapy is necessary in up to half of the patients.

[Hypereosinophilic asthma]

Hypereosinophilic asthma (defined by blood eosinophils > 1 G/L, especially > 1.5 G/L) may be solitary (and often difficult to treat), or a manifestation of a hypereosinophilic disorder of determined cause (parasitic, iatrogenic, allergic bronchopulmonary aspergillosis) or idiopathic (idiopathic chronic eosinophilic pneumonia, Churg-Strauss syndrome, idiopathic hypereosinophilic syndrome). In addition to etiologic treatment when available long term corticosteroids are necessary in a majority of patients.

Early variations of circulating interleukin-6 and interleukin-10 levels during thoracic radiotherapy are predictive for radiation pneumonitis

PURPOSE

To investigate variations of circulating serum levels of interleukin-6 (IL-6), tumor necrosis factor alpha (TNFalpha), and interleukin-10 (IL-10) during three-dimensional conformal radiation therapy (3D-CRT) in patients with non-small-cell lung cancer and correlate these variations with the occurrence of radiation pneumonitis.

PATIENTS AND METHODS

Ninety-six patients receiving 3D-CRT for stage I to III disease were evaluated prospectively. Circulating cytokine levels were determined before, every 2 weeks during, and at the end of treatment. Radiation pneumonitis was evaluated prospectively between 6 and 8 weeks after 3D-CRT. The predictive value of clinical, dosimetric, and biologic (cytokine levels) factors was evaluated both in univariate and multivariate analyses.

RESULTS

Forty patients (44%) experienced score 1 or more radiation pneumonitis. No association was found between baseline cytokine levels and the risk of radiation pneumonitis. In the whole population, mean levels of TNFalpha, IL-6, and IL-10 remained stable during radiotherapy. IL-6 levels were significantly higher (P = .047) during 3D-CRT in patients with radiation pneumonitis. In the multivariate analysis, covariations of IL-6 and IL-10 levels during the first 2 weeks of 3D-CRT were evidenced as independently predictive of radiation pneumonitis in this series (P = .011).

CONCLUSION

Early variations of circulating IL-6 and IL-10 levels during 3D-CRT are significantly associated with the risk of radiation pneumonitis. Variations of circulating IL-6 and IL-10 levels during 3D-CRT may serve as independent predictive factors for this complication.

Pulmonary arterial hypertension in France: results from a national registry

RATIONALE

Pulmonary arterial hypertension (PAH) is an orphan disease for which the trend is for management in designated centers with multidisciplinary teams working in a shared-care approach.

OBJECTIVE

To describe clinical and hemodynamic parameters and to provide estimates for the prevalence of patients diagnosed for PAH according to a standardized definition.

METHODS

The registry was initiated in 17 university hospitals following at least five newly diagnosed patients per year. All consecutive adult (> or = 18 yr) patients seen between October 2002 and October 2003 were to be included.

MAIN RESULTS

A total of 674 patients (mean +/- SD age, 50 +/- 15 yr; range, 18-85 yr) were entered in the registry. Idiopathic, familial, anorexigen, connective tissue diseases, congenital heart diseases, portal hypertension, and HIV-associated PAH accounted for 39.2, 3.9, 9.5, 15.3, 11.3, 10.4, and 6.2% of the population, respectively. At diagnosis, 75% of patients were in New York Heart Association functional class III or IV. Six-minute walk test was 329 +/- 109 m. Mean pulmonary artery pressure, cardiac index, and pulmonary vascular resistance index were 55 +/- 15 mm Hg, 2.5 +/- 0.8 L/min/m(2), and 20.5 +/- 10.2 mm Hg/L/min/m(2), respectively. The low estimates of prevalence and incidence of PAH in France were 15.0 cases/million of adult inhabitants and 2.4 cases/million of adult inhabitants/yr. One-year survival was 88% in the incident cohort.

CONCLUSIONS

This contemporary registry highlights current practice and shows that PAH is detected late in the course of the disease, with a majority of patients displaying severe functional and hemodynamic compromise.

Antineutrophil cytoplasmic antibodies and the Churg-Strauss syndrome

BACKGROUND

Since testing for antineutrophil cytoplasmic antibodies (ANCA) became available for routine evaluation, no large homogeneous cohort of patients with the Churg-Strauss syndrome has been studied.

OBJECTIVE

To define the clinical and biological characteristics of newly diagnosed Churg-Strauss syndrome, according to the presence or absence of ANCA.

DESIGN

Cross-sectional analysis of manifestations of participants who were enrolled in treatment trials between December 1995 and December 2002.

SETTING

Multicenter study in 63 clinical centers in France, Belgium, Latvia, and the United Kingdom, coordinated by the French Vasculitis Study Group.

PARTICIPANTS

112 patients with Churg-Strauss syndrome that was recently diagnosed on the basis of current classifications.

MEASUREMENTS

The authors compared principal demographic, clinical, and laboratory features according to ANCA status at diagnosis.

RESULTS

The authors detected ANCA in 43 (38%) patients. Positive ANCA status at diagnosis was associated with renal involvement, peripheral neuropathy, and biopsy-proven vasculitis, whereas negative ANCA status was associated with heart disease and fever.

LIMITATIONS

The authors assessed ANCA by immunofluorescence, but they did not assess ANCA centrally or systematically retest if ANCA was undetected at diagnosis.

CONCLUSIONS

Phenotypically, ANCA-positive and ANCA-negative Churg-Strauss syndrome might differ. The association of ANCA positivity with clinical symptoms that indicate inflammation and necrosis of small vessels might characterize a predominantly vasculitic pattern of the Churg-Strauss syndrome.

Bronchiolitis obliterans organizing pneumonia

Bronchiolitis obliterans with organizing pneumonia (BOOP) is a pathological syndrome common to a variety of pulmonary inflammatory disorders. It is defined by the presence of buds of granulation tissue consisting of fibroblasts and collagen within the lumen of the distal airspaces. BOOP may be secondary to lung injury resulting especially from infection or drug toxicity or may develop in the context of connective tissue diseases or after lung or bone marrow transplantation. BOOP may also be idiopathic (and then preferentially called cryptogenic organizing pneumonia) and then is the hallmark of a distinct clinicoradiological syndrome of subacute pneumonia, with typical alveolar patchy and often migratory pulmonary opacities on imaging. Other imaging presentations consist of diffuse infiltrative opacities or focal pneumonia. Improvement with corticosteroids is usually spectacular, but relapses are common after stopping or while reducing treatment.

Organizing pneumonia: cryptogenic and disease associated

Organizing pneumonia is defined by the presence of buds of granulation tissue (fibroblastic cells and connective matrix) within the alveolar lumen, usually associated with proliferative bronchiolitis obliterans. It may result from several causes, but cryptogenic organizing pneumonia is a distinct clinicopathologic entity with characteristic clinical and imaging features. Typical COP is thus easily recognized by the clinician, and the diagnosis is made by the finding of organizing pneumonia on lung biopsy specimen. The response to corticosteroids is rapid and complete usually without sequelae, but relapses occur frequently and prolonged corticosteroid treatment is often necessary.

Pulmonary Amyloidosis in Hematological Disorders

Amyloidosis is defined by tissue deposits of amyloid, a proteic substance with a characteristic spatial structure of beta-sheet fibrils assembled into bundles. This structure results in specific staining with Congo red dye, with green birefringence under polarized light microscope. AL amyloid forms from amyloidogenic immunoglobulins produced by clonal plasma cells. Pulmonary amyloidosis may be either part of systemic amyloidosis (primary amyloidosis or associated with myeloma) or organ-limited. Pulmonary interstitial amyloidosis in systemic amyloidosis is rarely symptomatic unless amyloid deposits severely affect gas exchange alveolar structures, thus resulting in serious respiratory impairment. Localized parenchymal involvement may present as nodular amyloidosis or as amyloid deposits in the vicinity of pulmonary lymphomas. Tracheobronchial amyloidosis, which is not associated with evident clonal proliferation, results in airway stenoses necessitating iterative laser treatment. Treatment of systemic amyloidosis aims at reducing the clonal cell populations producing amyloidogenic immunoglobulins, using high-dose chemotherapy followed by autologous stem cell transplantation in carefully selected patients. Its efficiency in treating diffuse pulmonary amyloidosis has not been established.

Pulmonary Varix Mimicking Pulmonary Arteriovenous Malformation in a Patient with Turner Syndrome

A 36-year-old asymptomatic female with Turner syndrome was referred for a 3-cm opacity of the left lung detected by routine chest X-ray. A computed tomography scan of the chest suggested a vascular lesion such as pulmonary arteriovenous malformation, and transcatheter embolotherapy was considered. The lack of a right-to-left shunt on contrast echocardiography led to suspect an alternate diagnosis. Magnetic resonance imaging and pulmonary angiography eventually demonstrated a pulmonary varix associated with a partial anomalous pulmonary venous return. Contrast echocardiography may help to distinguish between pulmonary varix and arteriovenous malformation.

[Opportunistic infections and sarcoidosis]

INTRODUCTION

In spite of CD4+ T-lymphocytopenia and corticosteroids-induced immune suppression, the risk of opportunistic infection is not usually considered to be increased in sarcoidosis.

METHODS

We describe 5 cases of opportunistic infection in patients with sarcoidosis and CD4+ T- lymphocytopenia. A systematic review of the literature was done.

RESULTS

We describe 2 cases of chronic necroziting aspergillosis, one case of Mycobacterium avium complex pneumonia, one case of pneumocystis pneumonia, and one case of cryptoccocal meningitidis in five patients with sarcoidosis. Four patients were receiving corticosteroids at time of diagnosis. Four patients had CD4+ T-lymphocytopenia. In the literature, we documented 65 cases reports of sarcoidosis complicated by opportunistic infection. At the time of infection diagnosis, 36 patients were receiving corticosteroids. CD4+ T-lymphocytopenia was present in 5 of 11 reported cases. Cryptococcosis was the most common reported infection.

CONCLUSION

Opportunistic infectious complications are rare in patients with sarcoidosis. Opportunistic infections mainly occur in patients receiving corticosteroids, and with CD4+ T-lymphocytopenia. Except for cryptococcosis, sarcoidosis by itself does not appear to be a risk factor of opportunistic infection.

Improvement of refractory rheumatoid arthritis-associated constrictive bronchiolitis with etanercept

Rheumatoid arthritis (RA)-associated constrictive bronchiolitis is a severe condition with no established efficient treatment. A 55-year-old woman with seropositive RA developed rapidly progressive constrictive bronchiolitis confirmed by lung biopsy. Her clinical condition worsened despite steroids and azathioprine. Treatment with etanercept-a tumor necrosis factor (TNF)-alpha inhibitor-combined with methotrexate, resulted in a marked improvement of both her clinical condition and pulmonary function tests. Treatment with TNF-alpha inhibitors and methotrexate may be proposed in RA-associated constrictive bronchiolitis, a severe condition hitherto not amenable to improvement.

Cryptogenic organizing pneumonia

Cryptogenic organizing pneumonia is a rare, distinct disorder that is sufficiently different from the other diseases in the group of idiopathic interstitial pneumonias to be designated as a separate entity. In its most typical presentation, it is characterized by dyspnea and cough, with multiple patchy alveolar opacities on pulmonary imaging. Definite diagnosis is obtained by the finding of buds of granulation tissue in the distal airspaces at lung biopsy. No cause (as infection, drug reaction, or associated disease as connective tissue disease) is found. Corticosteroid treatment is rapidly effective, but relapses are common on reducing or stopping treatment.

A prospective study on radiation pneumonitis following conformal radiation therapy in non-small-cell lung cancer: clinical and dosimetric factors analysis

BACKGROUND AND PURPOSE

Clinical and dosimetric prognostic factors for radiation pneumonitis (RP) have been reported after three-dimensional conformal radiotherapy (3D-CRT) in patients with non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Ninety-six patients who received 3D-CRT for stage IA to IIIB NSCLC were evaluated prospectively. Surgery was performed before radiation in 51% of the patients (n = 49). RP was diagnosed six-eight weeks after 3D-CRT using the Lent-Soma classification. Factors evaluated included treatment factors such as total mean lung dose (MLD), and dose-volume histogram (DVH) thresholds for several radiation dose steps. These thresholds were originally determined from the median of the irradiated lung volume at each step.

RESULTS

Six patients could not be evaluated for RP six weeks after 3D-CRT. Of the 90 remaining patients, 40 (44%) had RP (i.e. grade > or =1) at 6 weeks, including 7 patients (7.8%) with severe RP (grade > or =2). Regarding the whole toxicity (grade > or =1), age (> or =60 years), MLD, V20 and V30 were significantly related to RP. DVH thresholds determined for radiation doses from 20 to 40 Gy were also predictive of RP. Considering only severe RP (grade > or =2), only MLD, V20 and V30 remained associated with increased acute pulmonary toxicity.

CONCLUSIONS

In this study, dosimetric factors (MLD, V20, V30) and age (> or =60 years) were predictive of RP regarding the whole pulmonary toxicity (grade > or =1). In addition, thresholds from 20 to 40 Gy, based on a stratification according to the median of the percentage of irradiated lung volume, were also predictive factors. They may, therefore, help discriminate patients at high and low risk for RP. However, only MLD, V20 and V30 remained associated with severe RP (grade > or =2), probably due to the small number of severe events in our series.

Low initial KCO predicts rapid FEV1 decline in pulmonary lymphangioleiomyomatosis

Pulmonary lymphangioleiomyomatosis (LAM) is a rare interstitial disorder affecting exclusively women, and leading to progressive deterioration of lung function. The disease course is highly variable from one patient to another, but no clinical predictor of rapid disease progression is currently available. To identify clinical variables, which could detect patients at risk for rapid lung function decline, we searched for correlations between the rate of forced expiratory volume in 1 s (FEV1) decline and clinical features at diagnosis in a retrospective series of 31 cases of LAM followed for > or = 1 yr. The mean FEV1 decline was 106+/-143 ml/yr or 3.4+/-4.6% predicted FEV1/yr. Among clinical features at diagnosis, only initial values of carbon monoxide transfer factor (TLCO, P = 0.006) and carbon monoxide transfer coefficient (KCO, P = 0.0001) were significantly correlated with the rate of FEV1 decline. Lung volumes and FEV1/forced vital capacity ratio at diagnosis were not predictive of rapid decline. No effect of previous smoking, contraceptive use or pregnancy on FEV1 decline could be detected. We conclude that low TLCO and KCO at the time of diagnosis are the best clinical predictors of rapid FEV1 decline in patients with LAM.

Molecular screening of ALK1/ACVRL1 and ENG genes in hereditary hemorrhagic telangiectasia in France

Hereditary hemmorrhagic telangiectasia (HHT, or Osler-Rendu-Weber syndrome) is an autosomal dominant disease characterized by arteriovenous malformations, affecting 1 out of 10,000 individuals in France. The disease is caused by mutations of two genes: ENG and ALK1 (ACVRL1). We screened the coding sequence of ENG and ALK1 in 160 unrelated French index cases. A germline mutation was identified in 100 individuals (62.5%). A total of 36 mutations were found in ENG, including three nonsense mutations, 19 small insertions/deletions leading to a frameshift, two inframe deletions, seven missense mutations, and five intronic or splice-site mutations. Of the 36 mutations, 33 were novel mutations. A total of 64 mutations were found in ALK1, including six nonsense mutations, 28 small insertions/deletions leading to a frameshift, one inframe deletion, 27 missense mutations, and two intronic or splice-site mutations. Of the 64 mutations, 27 were novel mutations. Mutations were found in most parts of the coding sequence for both genes, except ALK1 exon 5 and ENG exons 12 to 14. Missense mutations in ALK1 were more frequent in exons 7, 8, and 10. ENG cDNA was sequenced for three intronic mutations: c.689+2T>C produced an abnormal transcript excluding exon 5, c.1103+3_1103+8del activated a cryptic splice site 22 bp upstream, and c.1428G>A produced two abnormal transcripts, one including intron 11 and the other excluding exon 10. Although most of the mutations were private, some recurrent mutations in ALK1 were of particular interest. Mutation c.1112_1113dupG (p.Gly371fsX391) was found in 17 unrelated individuals sharing a common haplotype, strongly suggesting a founder effect related to the concentration of patients previously reported in a specific French region (Rhône-Alpes). Three missense mutations involved the same codon: c.1231C>T (p.Arg411Trp), c.1232G>C (p.Arg411Pro), and c.1232G>A (p.Arg411Gln) were found in seven, two, and one patients, respectively. Haplotype analysis was in favor of both a founder effect and a mutation hot-spot.

Molecular screening of ALK1/ACVRL1 and ENG genes in hereditary hemorrhagic telangiectasia in France

Hereditary hemmorrhagic telangiectasia (HHT, or Osler-Rendu-Weber syndrome) is an autosomal dominant disease characterized by arteriovenous malformations, affecting 1 out of 10,000 individuals in France. The disease is caused by mutations of two genes: ENG and ALK1 (ACVRL1). We screened the coding sequence of ENG and ALK1 in 160 unrelated French index cases. A germline mutation was identified in 100 individuals (62.5%). A total of 36 mutations were found in ENG, including three nonsense mutations, 19 small insertions/deletions leading to a frameshift, two inframe deletions, seven missense mutations, and five intronic or splice-site mutations. Of the 36 mutations, 33 were novel mutations. A total of 64 mutations were found in ALK1, including six nonsense mutations, 28 small insertions/deletions leading to a frameshift, one inframe deletion, 27 missense mutations, and two intronic or splice-site mutations. Of the 64 mutations, 27 were novel mutations. Mutations were found in most parts of the coding sequence for both genes, except ALK1 exon 5 and ENG exons 12 to 14. Missense mutations in ALK1 were more frequent in exons 7, 8, and 10. ENG cDNA was sequenced for three intronic mutations: c.689+2T>C produced an abnormal transcript excluding exon 5, c.1103+3_1103+8del activated a cryptic splice site 22 bp upstream, and c.1428G>A produced two abnormal transcripts, one including intron 11 and the other excluding exon 10. Although most of the mutations were private, some recurrent mutations in ALK1 were of particular interest. Mutation c.1112_1113dupG (p.Gly371fsX391) was found in 17 unrelated individuals sharing a common haplotype, strongly suggesting a founder effect related to the concentration of patients previously reported in a specific French region (Rhône-Alpes). Three missense mutations involved the same codon: c.1231C>T (p.Arg411Trp), c.1232G>C (p.Arg411Pro), and c.1232G>A (p.Arg411Gln) were found in seven, two, and one patients, respectively. Haplotype analysis was in favor of both a founder effect and a mutation hot-spot.

Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia

Pulmonary arteriovenous malformations (PAVMs) associated with hereditary hemorrhagic telangiectasia may cause severe cerebral complications that may be prevented by embolization therapy. We retrospectively compared the diagnostic value of noninvasive tests for the screening of treatable (amenable to embolization) PAVMs in a series of 105 patients, using chest computerized tomography (CT) and/or pulmonary angiography as a "gold standard." Patients had assessment of dyspnea, chest radiograph, alveolar-arterial PO2 gradient under 100% oxygen (AaPO2), contrast echocardiography, and radionuclide perfusion lung scanning. Contrast echocardiography in the supine position was the most sensitive test (93%). The sensitivity of self-reported dyspnea (59%), chest radiograph alone (70%), measurement of AaPO2 by the 100% oxygen method (62%), or radionuclide lung scanning (71%), was not suitable for efficient screening. A 100% sensitivity and negative predictive value could be obtained when combining anteroposterior chest radiograph and contrast echocardiography. Our data support a screening algorithm based on the combined use of contrast echocardiography and anteroposterior chest radiograph, followed by chest CT if either test is positive. An alternative is to screen directly by chest CT. However, this algorithm may obviate the need for chest CT in patients without PAVM, who represent a majority of patients with hereditary hemorrhagic telangiectasia.

Chronic eosinophilic pneumonia after radiation therapy for breast cancer

The priming of bronchiolitis obliterans organising pneumonia by radiation therapy (RT) to the breast is now a well recognised syndrome. This study describes the occurrence of chronic eosinophilic pneumonia following RT after surgery for breast cancer in five female patients, with a mean age of 68 yrs (range 49-77). All patients had a history of asthma and/or allergy. At the onset of eosinophilic pneumonia, all patients were symptomatic. Chest radiograph showed pulmonary infiltrates, unilateral and limited to the irradiated lung in three patients, and bilateral in two. Pulmonary opacities were migratory in one patient. All patients had blood eosinophilia >1.0 10(9) x L(-1) and/or eosinophilia >40% at bronchoalveolar lavage differential cell count. The median time interval between the end of radiation therapy and the onset of eosinophilic pneumonia was 3.5 months (range 1-10). All patients rapidly improved with oral corticosteroids without sequelae. Relapse occurred in two patients after treatment withdrawal. Priming of alveolitis by radiation therapy to the breast might promote either bronchiolitis obliterans organising pneumonia or chronic eosinophilic pneumonia, with the latter depending on genetic or acquired characteristics of patients and/or further stimulation that may trigger a T-helper cell type 2 form of lymphocyte response, especially in patients with asthma or other atopic manifestations.