Childhood lymphoma: diagnostic accuracy of chest radiography for severe pulmonary complications

INTRODUCTION

We sought to determine whether chest radiography can be reliably used to distinguish persistent or relapsing pulmonary lymphoma from a variety of infectious and noninfectious pulmonary conditions that can occur in children receiving treatment for lymphoma.

METHODS

We studied chest radiographs of 37 patients (30 with non-Hodgkin's lymphoma, and seven with Hodgkin's disease) who died of paediatric lymphoma or of treatment complications. Pulmonary findings at autopsy comprised lung tumour (n = 14), pleural tumour (n = 12), pneumonia (n = 22), adult respiratory distress syndrome (ARDS; n = 16), haemorrhage (n = 27), and infarction (n = 13). Using a 4-point scale and without knowledge of autopsy findings, three radiologists independently rated antemortem radiographs for the presence of pulmonary tumour, pleural tumour, pneumonia in general, pneumonia caused by viral, bacterial, fungal, and protozoan pathogens, ARDS, pulmonary haemorrhage, and pulmonary infarction. Diagnostic accuracy was defined by the area under the receiver-operating-characteristic curve (AZ).

RESULTS

Diagnostic accuracy was good for pulmonary tumour (AZ, 0.71 +/- 0.6), protozoan pneumonia (AZ, 0.77 +/- 0.06), and ARDS (AZ, 0.86 +/- 0.07) but poor for all other conditions. The absence of both pleural effusions and mediastinal/right hilar lymphadenopathy was significantly associated (P < or = 0.04) with the absence of lung tumour.

DISCUSSION

The pulmonary processes in these patients can all demonstrate diffuse airspace opacification, and many patients had multiple lung abnormalities at autopsy. The radiologist-readers were unable to identify which pulmonary conditions were responsible for radiographic findings in most patients. The readers were able to identify patients who did not have pulmonary lymphoma. If pulmonary involvement with lymphoma is unlikely, bronchoscopy with bronchoalveolar lavage may be sufficient to establish a diagnosis. When pulmonary lymphoma is a clinical consideration, open lung biopsy is usually required for diagnosis.

Pulmonary manifestations in the initial phase of schistosomiasis mansoni

The clinical and radiological pulmonary manifestations in the initial phase of schistosomiasis mansoni were studied in thirty previously healthy individuals who were simultaneously infected. The findings were compared with those concerning a control group and related to possible pathogenetic factors. The respiratory manifestations were of light or of moderate intensity, the dry cough being the most common symptom. The significant radiological alterations were: thickening of bronchial walls and beaded micronodulation, predominantly localized in the lower pulmonary fields. It was observed significant association between wheezing and IgE levels, estimated by the area of immediate intradermal reaction, as well as between the number of blood eosinophils and the occurrence of radiological changes. Moreover, there was correlation between the worm burden and the presence of wheezing, thoracic pain and beaded micronodulation. Thus, the clinical and radiological pulmonary manifestations described are significant part of the initial phase of schistosomiasis mansoni and present the worm burden, eosinophilia and levels of IgE as probable pathogenetic factors.

Pulmonary dirofilariasis in man: a new Italian case. Review of the European literature

In June 1991 a 62-year-old retired man, from Udine (northern Italy), was suddenly affected by dyspnoea. X-ray and CT control detected a coin lesion in the lung, in May 1992 this lesion was removed surgically. Histological examination revealed the presence of a nematode inside an arteriole which had provoked a small infarct in the pulmonary tissue. The parasite presented marked regressive phenomena that made an accurate morphological analysis impossible. However, in the light of certain details of the cuticle, and by analogy with four similar cases occurring in northern Italy, as well as 10 others (nine subcutaneous and one submucosa) reported in man from the same region (Venetia) over the last 15 years, the aetiologic agent was thought to be Dirofilaria (N.) repens. Over all 10 cases of human pulmonary dirofilariasis were reported in Europe: five in Italy, probably by D (N.) repens, two in Germany, in patients coming from Corsica and two in Spain (only by serology), attributed to D. immitis. In addition one case was reported in U.S.A. in a man who previously visited Italy.

[Lung findings in filariasis]

A solitary intrapulmonary mass, found accidentally, demands further investigations to assure the diagnosis. Even if we are unable to give an exact diagnosis, we should try to determine the character of the lesion; often the clinical findings can be helpful. If this is not the case, further possibilities to arrive at the correct diagnosis should be indicated.

Pulmonary strongyloidiasis: clinical and imaging features

Strongyloides stercoralis is an important cause of severe pulmonary infection and death in many areas of the world [1, 2]. The nematode is endemic in the tropical and subtropical regions of the world, including the southeastern United States and Puerto Rico, where infection rates may exceed 6% of the population [1, 3-7]. Although pulmonary symptoms from strongyloidiasis can be mild, consisting only of cough and bronchospasm, the potential for severe pulmonary disease and adult respiratory distress syndrome is great in certain persons at high risk for strongyloidiasis [1, 2]. Unfortunately, pulmonary strongyloidiasis is seldom diagnosed until late in the course of the disease, which contributes to a high death rate [1, 2, 5, 8]. We review the clinical and imaging features of pulmonary strongyloidiasis and emphasize clues that can lead to earlier diagnosis, recognition of complications, and prompt treatment.

[Human pulmonary dirofilariasis acquired in Brazil: report of a case]

We report the second published case of human dirofilariasis acquired in Brazil. The patient had two pulmonary coin lesions seen in conventional chest roentgenogram and confirmed as solid round nodules by computerized X-ray chest scan. Diagnosis was done by surgical removal of one of the lesions and anatomopathological study of tissue removed.

[Pulmonary dirofilariasis]

Dirofilariosis usually concerns dogs among which it is transmitted by mosquito bites. Human infection is rare and we describe here a case observed in a 75 years old woman in New Caledonia. A systematic pulmonary radiograph showed suspicious pulmonary nodules. At microscopic examination one can see pulmonary infarctus with thrombosis and Dirofilaria immitis inside a vessel. Diagnosis is usually made by histologic examination because biological investigations are of a little interest. Surgical treatment is enough. Chemioprophylaxia for dogs can reduce the risks of man infection.

[CT findings of pulmonary paragonimiasis westermani]

The CT findings of six patients (three symptomatic and three asymptomatic) with pulmonary paragonimiasis westermani were reviewed in correlation with the findings of radiography. Pleural changes were recognized in all cases on CT. In addition to pleural fluid collection and hydropneumothorax, which were demonstrated on plain radiograph, CT showed minimal pleural thickening and adhesion adjacent to the parenchymal lesions. CT showed round nodules of lower attenuation within a subpleural consolidation of triangular shape in two patients. Small air-filled cavities in a parenchymal lesion with central dense spots were demonstrated in two patients, and multiple cavities with irregular wall were seen in one patient. CT also demonstrated the parenchymal lesion with a tunnel-like cavity in one patient. These may represent the worm nodules, the worm within worm cysts, and the worm migration tract, respectively. These pulmonary lesions were located adjacent to the localized pleural thickening or adhesion in all six cases. CT was more useful than radiography in the diagnosis of pulmonary paragonimiasis westermani.

Pulmonary paragonimiasis: clinical and experimental studies

Pulmonary paragonimiasis is a disease caused by a lung fluke. It is endemic to East Asia, but there have been several case reports in North America. Human infestation occurs by ingestion of raw or incompletely cooked freshwater crab or crayfish infected with metacercaria. A retrospective study was performed with 78 patients who lived in South Korea and had chest radiographic findings of pleuropulmonary disease; it was subsequently shown that they had paragonimiasis. The diagnosis was based on positive results of serologic tests for Paragonimus-specific antibody or on the detection of eggs in sputum samples. Radiologic findings from these 78 patients were correlated with the pathologic and radiologic findings from a study of experimentally induced pulmonary paragonimiasis in 21 cats. Findings from the correlative study document that the typical radiologic manifestations of pulmonary paragonimiasis vary with the stage of the disease. Early findings include pneumothorax or hydropneumothorax, focal airspace consolidation, and linear opacities and are caused by the migration of juvenile worms. Later findings include thin-walled cysts, dense masslike consolidation, nodules, or bronchiectasis and are due to worm cysts.

Pulmonary paragonimiasis simulating lung abscess in a 9-year-old: CT findings

We present the CT findings of pulmonary paragonimiasis in a 9-year-old girl. It appeared as a large cystic mass with an air-fluid level and simulated a lung abscess. Communication with a segmental bronchus was demonstrated well on a CT scan obtained after aspiration.

[CT of pulmonary dirofilariasis--differential diagnosis from lung cancer]

We present here four cases of pulmonary dirofilariasis in which histological examination of the surgical specimen showed occlusion of the peripheral pulmonary artery by filariae and formation of a necrotic mass surrounded by reactive inflammation and hemorrhage. Radiological examination showed a solitary pulmonary nodule in three cases and a wedge-shaped consolidation in one case. Although pulmonary nodules in dirofilariasis closely mimic bronchogenic carcinoma on radiographs , it is possible to distinguish them from bronchogenic carcinoma on the basis of the following findings: (1) coexistence of subtle satellite lesions, (2) absence of pleural involvement, (3) fine marginal speculations, and (4) lack of concentric marginal speculations (eccentric speculation). In each case of dirofilariasis, CT showed the peripheral pulmonary artery entering the mass. This finding differentiates this disease from metastatic lung tumor, because in tumor metastasis via the pulmonary arteries, visible vessels are not usually involved.

Pleuropulmonary paragonimiasis: radiologic findings in 71 patients

Pleuropulmonary paragonimiasis is a disease caused by lung flukes characterized by migration of a juvenile worm in the early stage and by formation of cysts around the worm later on. The purpose of this study was to describe the radiologic manifestations of pleuropulmonary paragonimiasis, with special emphasis on the worm cyst and worm migration track. We retrospectively studied 71 patients who had evidence of pleuropulmonary paragonimiasis on chest radiographs (n = 71) and CT scans (n = 17). The diagnosis was based on the detection of eggs or on positive antibody tests. On chest radiographs, 59 patients (83%) had pulmonary lesions and 43 patients (61%) had pleural lesions. Pulmonary findings included patchy air-space consolidation (n = 37) with or without cystic changes; ring shadows (n = 16); and peripheral linear opacities (n = 29), which were more prominent in patients with pleural effusion. Twelve patients (17%) had bilateral pleural effusions or pneumothoraces. On CT scans, round low-attenuation cystic lesions (5-15 mm), filled either with fluid (n = 5) or gas (n = 5), were characteristically seen within the consolidation. Peripheral linear opacities seen on radiographs were suggestive of worm migration tracks on CT scans. CT may reveal an intracystic worm. Although the findings vary depending on the stage of the disease, findings on chest radiographs are usually typical of paragonimiasis. CT provides more specific information about the worm cyst and the worm migration track.

Prevalence of HTLV-I antibody in pulmonary cryptococcosis

A retrospective study was done to determine the prevalence of anti-HTLV-I antibodies in patients with pulmonary cryptococcosis. None of the 19 patients with pulmonary cryptococcosis had underlying immunodeficiency. Anti-HTLV-I antibody was present in 6 (32%) of 19 patients with pulmonary cryptococcosis, a significantly higher prevalence than found in patients with bronchial asthma (4 (7%) of 58) (p less than 0.01, chi-square test). No statistical difference was noted when anti-HTLV-I antibody seropositivity was compared to that of patients with pulmonary tuberculosis (16% (17/105)), lung cancer (17% (22/129)) and pneumonia (9% (6/64)). A reduced cellular immunity as shown by lymphopenia, the CD4/CD8 ratio, and purified protein derivative skin test was found in only 1 (5%) of 19, 2 (12%) of 17, and 6 (33%) of 18 patients, respectively. These results do not explain the susceptibility to pulmonary cryptococcosis in HTLV-I carriers. This is the first report of high prevalence of pulmonary cryptococcosis in HTLV-I carriers and it raises the question whether HTLV-I carriers are more susceptible to opportunistic infections and other malignancies probably due to subtle immunological abnormalities.

Pleuropulmonary paragonimiasis in a Laotian immigrant to Australia

A case of pleuropulmonary paragonimiasis that mimicked reactivation of pulmonary tuberculosis, pneumonia, and neoplasm occurred in a Laotian immigrant to Australia. The key to the diagnosis of this condition is awareness of the disease in persons from this region. The diagnosis was supported by enzyme-linked immunosorbent assay testing. The patient was successfully treated with praziquantel.

[Human pulmonary dirofilariasis: parasitological aspects of the 2d case reported in Italy]

The parasitological aspects of a case of pulmonary human dirofilariasis, recently reported by Fabbretti and collaborators (1990) in a 58 year-old man from Ferrara province, are described. This is the second case of pulmonary human dirofilariasis recorded in Italy. The nematode was rolled up inside a small pulmonary artery and was associated with a nodular infarcted lesion, discovered during an X-ray check as a "coin lesion". A pulmonary lobectomy was performed on the patient with a presumptive diagnosis of a malignant neoplastic nodule. The exact diagnosis was only made with the histological examination. In spite of the bad preservation of the nematode, it was possible to diagnose it as an immature female of Dirofilaria probably belonging to the species repens.

[The surgical therapy of pulmonary aspergilloma. Our experience]

Between 1971 and 1986 11 patients suffering from pulmonary aspergilloma were seen in the thoracic surgery service at Genova-Sampierdarena Hospital. Nine patients underwent thoracotomy. Lobectomy was the most frequent operation. Complications occurred in 3 patients (33%). There were no recurrent symptoms in any of them over a mean follow-up of 4 years. The remaining two patients were treated by instillation of antifungal agents into the aspergilloma cavity. There was no systemic toxicity and in one patient the mycetoma resolved. The authors conclude that pulmonary resection can provide effective long-term treatment, while intracavity infusion of antifungal agent can be a successful nonoperative method in critically ill patients.

[Clinico-roentgenologic manifestations of larval paragonimiasis in children]

Investigation of 60 children with acute types and 45 children with latent types of larval paragonimiasis (LP) has revealed various clinical and x-ray manifestations of this disease, spread in the southern Primorski Territory. Three syndromes of this disease were singled out: toxico-allergic, abdominal and pulmonary. X-ray investigation showed characteristic LP symptoms: exudate in the pleural cavity, thickening of the wall, diaphragmatic and interlobular pleura, sometimes--pneumothorax. Pathology of the bronchopulmonary system manifested itself in focal and infiltrative shadows, enhanced and deformed lung markings, and bullous inflation. Diagnosis and differential diagnosis must be based on analysis of clinical and x-ray data and the results of serological reactions.