Drug-induced pulmonary disease

Expert Consensus on the Diagnosis and Treatment of Anticancer Drug-Induced Interstitial Lung Disease

Drug-induced interstitial lung disease (DILD) is the most common pulmonary adverse event of anticancer drugs. In recent years, the incidence of anticancer DILD has gradually increased with the rapid development of novel anticancer agents. Due to the diverse clinical manifestations and the lack of specific diagnostic criteria, DILD is difficult to diagnose and may even become fatal if not treated properly. Herein, a multidisciplinary group of experts from oncology, respiratory, imaging, pharmacology, pathology, and radiology departments in China has reached the "expert consensus on the diagnosis and treatment of anticancer DILD" after several rounds of a comprehensive investigation. This consensus aims to improve the awareness of clinicians and provide recommendations for the early screening, diagnosis, and treatment of anticancer DILD. This consensus also emphasizes the importance of multidisciplinary collaboration while managing DILD.

Lungenbeteiligung bei Tumorkrankheiten

Die Lunge ist bei Tumorerkrankungen sehr oft und auf sehr vielfältige Weise betroffen. Das Lungenkarzinom ist eine der häufigsten Tumorerkrankungen und erfährt gerade in den letzten Jahren eine erhebliche Erweiterung der Therapiemöglichkeiten. Die Lunge ist zudem ein häufiges Metastasierungsorgan verschiedenster Tumorentitäten. Aber auch Therapieansätze wie Tyrosinkinase- und Checkpointinhibitoren, chimäre Antigenrezeptorzelltherapien oder strahlentherapeutische Verfahren können pulmonale Nebenwirkungen verursachen. Schließlich gibt es viele Patienten, deren pulmonale Grunderkrankung auf den klinischen Verlauf und die Prognose der Tumorerkrankung Einfluss nimmt und ihrerseits beeinflusst werden kann. Beispielhaft werden verschiedene Aspekte wie pulmonale venookklusive Erkrankung, chronisch-obstruktive Atemwegserkrankung und idiopathische pulmonale Fibrose diskutiert.

SARS-CoV-2 receptor is co-expressed with elements of the kinin-kallikrein, renin-angiotensin and coagulation systems in alveolar cells

SARS-CoV-2, the pathogenic agent of COVID-19, employs angiotensin converting enzyme-2 (ACE2) as its cell entry receptor. Clinical data reveal that in severe COVID-19, SARS-CoV-2 infects the lung, leading to a frequently lethal triad of respiratory insufficiency, acute cardiovascular failure, and coagulopathy. Physiologically, ACE2 plays a role in the regulation of three systems that could potentially be involved in the pathogenesis of severe COVID-19: the kinin-kallikrein system, resulting in acute lung inflammatory edema; the renin-angiotensin system, promoting cardiovascular instability; and the coagulation system, leading to thromboembolism. Here we assembled a healthy human lung cell atlas meta-analysis with ~ 130,000 public single-cell transcriptomes and show that key elements of the bradykinin, angiotensin and coagulation systems are co-expressed with ACE2 in alveolar cells and associated with their differentiation dynamics, which could explain how changes in ACE2 promoted by SARS-CoV-2 cell entry result in the development of the three most severe clinical components of COVID-19.

[Pulmonary involvement in cancers]

Die Lunge ist bei Tumorerkrankungen sehr oft und auf sehr vielfältige Weise betroffen. Das Lungenkarzinom ist eine der häufigsten Tumorerkrankungen und erfährt gerade in den letzten Jahren eine erhebliche Erweiterung der Therapiemöglichkeiten. Die Lunge ist zudem ein häufiges Metastasierungsorgan verschiedenster Tumorentitäten. Aber auch Therapieansätze wie Tyrosinkinase- und Checkpointinhibitoren, chimäre Antigenrezeptorzelltherapien oder strahlentherapeutische Verfahren können pulmonale Nebenwirkungen verursachen. Schließlich gibt es viele Patienten, deren pulmonale Grunderkrankung auf den klinischen Verlauf und die Prognose der Tumorerkrankung Einfluss nimmt und ihrerseits beeinflusst werden kann. Beispielhaft werden verschiedene Aspekte wie pulmonale venookklusive Erkrankung, chronisch-obstruktive Atemwegserkrankung und idiopathische pulmonale Fibrose diskutiert.

Pulmonary Toxicities from Conventional Chemotherapy

Despite significant recent progress in precision medicine and immunotherapy, conventional chemotherapy remains the cornerstone of the treatment of most cancers. Chemotherapy-induced lung toxicity represents a serious diagnostic challenge for health care providers and requires careful consideration because it is a diagnosis of exclusion with significant impact on therapeutic decisions. This review aims to provide clinicians with a valuable guide in assessing their patients with possible chemotherapy-induced lung toxicity.

Japanese herbal medicine-induced pneumonitis: A review of 73 patients

BACKGROUND

The number of reports concerning Japanese herbal medicine (JHM)-induced pneumonitis has increased. However, comprehensive data are lacking in this regard, and the clinical characteristics of the disease remain unclear.

METHODS

A literature review was performed using PubMed and Ichushi-Web-the database of the Japan Medical Abstracts Society-to identify articles published between 1996 and 2015 describing patients with JHM-induced pneumonitis. The final cohort included 73 patients in 59 articles (7 in English; 52 in Japanese).

RESULTS

Among the various JHMs reported, sho-saiko-to was the most frequently used drug (26%), followed by sairei-to (16%), seishin-renshi-in (8%), and bofu-tsusyo-san (8%). These drugs commonly contain ougon (skullcap) and kanzo (liquorice). The mean age at pneumonitis diagnosis was 63.2 ± 15.5 years (range: 7-89 years). The male/female ratio was 44/29. Sixty-five patients (89%) developed pneumonitis within 3 months of beginning JHM treatment. Bilateral ground-glass attenuations on chest computed tomography, as well as lymphocytosis with a low CD4/CD8 T-cell ratio in bronchoalveolar lavage fluid, were common findings. Twenty-six patients (36%) recovered from the pneumonitis after simply discontinuing the causative JHM. However, the remainder required immunosuppressive therapy, and 13 patients (18%) received mechanical ventilation. Importantly, three patients (4%) did not survive, with two showing pathological diffuse alveolar damage upon autopsy.

CONCLUSIONS

Clinicians should be cautious regarding JHM-induced pneumonitis, particularly when using drugs/ingredients known to cause this complication, and during the early treatment period. Although most events are non-severe, critical cases should be recognized.

Suspected drug-induced infiltrative lung disease culminating in acute respiratory failure in a dog treated with cytarabine and prednisone

OBJECTIVE

To describe a case of suspected drug-induced infiltrative lung disease (ILD) and acute respiratory failure associated with the administration of cytarabine and prednisone in a dog requiring mechanical ventilation.

CASE SUMMARY

A 4.5-year-old, female spayed Yorkshire Terrier presented to the ICU with acute onset of respiratory distress following a 24-hour cytarabine infusion. The patient was previously diagnosed with meningoencephalitis of unknown etiology (MUO), caudal occipital malformation, and syringohydromyelia, and was being treated with oral prednisone and levetiracetam, and cytarabine infusions. The patient developed tachypnea and dyspnea, and had diffuse crackles on auscultation of all lung fields, and hypoxemia 6 hours following completion of the fourth cytarabine infusion (300 mg/m² ). Thoracic radiographs revealed diffuse, bilateral infiltrates consistent with noncardiogenic pulmonary edema or acute respiratory distress syndrome. Respiratory distress and hypoxemia persisted despite oxygen supplementation and furosemide therapy and led to initiation of mechanical ventilation. Approximately 12 hours later, the dog became progressively hypoxemic with worsening pulmonary edema. The owners elected euthanasia. Postmortem examination revealed pulmonary edema and diffuse interstitial pneumonia. Histopathologic evaluation revealed pulmonary edema, severe acute neutrophilic and histiocytic pneumonia, and multifocal interstitial fibrosis. Bacterial culture yielded no growth.

NEW OR UNIQUE INFORMATION PROVIDED

Drug-induced ILD is rarely reported in the veterinary literature, and has not previously been reported in dogs receiving cytarabine. As with administration of any medication, adverse events may occur. While ILD is unlikely to be commonly recognized, it may be considered in veterinary patients receiving chemotherapy that acutely become dyspneic.

Disposition and safety of inhaled biodegradable nanomedicines: Opportunities and challenges

The inhaled delivery of nanomedicines can provide a novel, non-invasive therapeutic strategy for the more localised treatment of lung-resident diseases and potentially also enable the systemic delivery of therapeutics that are otherwise administered via injection alone. However, the clinical translation of inhalable nanomedicine is being hampered by our lack of understanding about their disposition and clearance from the lungs. This review provides a comprehensive overview of the biodegradable nanomaterials that are currently being explored as inhalable drug delivery systems and our current understanding of their disposition within, and clearance from the lungs. The safety of biodegradable nanomaterials in the lungs is discussed and latest updates are provided on the impact of inflammation on the pulmonary pharmacokinetics of inhaled nanomaterials. Overall, the review provides an in-depth and critical assessment of the lung clearance mechanisms for inhaled biodegradable nanomedicines and highlights the opportunities and challenges for their translation into the clinic.

Drug induced pulmonary parenchymal disease

Drug-induced pulmonary parenchymal disease (DIPPD) can be caused by a variety of agents, including antibiotics, chemotherapeutic drugs, antiarrhythmic agents and non-steroidal anti-inflammatory drugs (NSAIDs). DIPPD includes acute bronchospasm, organizing pneumonia, alveolar hypoventilation and hypersensitivity reactions. History, physical examination and investigations are required mainly to exclude other causes of lung diseases. Investigations may include chest radiography, pulmonary function testing and bronchoscopy with bronchoalveolar lavage (BAL). Recognition of DIPPD is difficult because the clinical, radiologic, and histologic findings are nonspecific. Management includes drug withdrawal and in some cases corticosteroid therapy. In this article we reviewed the various drugs known to cause pulmonary parenchymal diseases, various patterns of parenchymal diseases observed and their management.

Carvacrol and pomegranate extract in treating methotrexate-induced lung oxidative injury in rats

Background

This study was designed to evaluate the effects of carvacrol (CRV) and pomegranate extract (PE) on methotrexate (MTX)-induced lung injury in rats.

Material/Methods

A total of 32 male rats were subdivided into 4 groups: control (group I), MTX treated (group II), MTX+CRV treated (group III), and MTX+PE treated (group IV). A single dose of 73 mg/kg CRV was administered intraperitoneally to rats in group III on Day 1 of the investigation. To group IV, a dose of 225 mg/kg of PE was administered via orogastric gavage once daily over 7 days. A single dose of 20 mg/kg of MTX was given intraperitoneally to groups II, III, and IV on Day 2. The total duration of experiment was 8 days. Malondialdehyde (MDA), total oxidant status (TOS), total antioxidant capacity (TAC), and oxidative stress index (OSI) were measured from rat lung tissues and cardiac blood samples.

Results

Serum and lung specimen analyses demonstrated that MDA, TOS, and OSI levels were significantly greater in group II relative to controls. Conversely, the TAC level was significantly reduced in group II when compared to the control group. Pre-administering either CRV or PE was associated with decreased MDA, TOS, and OSI levels and increased TAC levels compared to rats treated with MTX alone. Histopathological examination revealed that lung injury was less severe in group III and IV relative to group II.

Conclusions

MTX treatment results in rat lung oxidative damage that is partially counteracted by pretreatment with either CRV or PE.

Subclinical interstitial lung abnormalities in stable renal allograft recipients in the era of modern immunosuppression

BACKGROUND

Interstitial lung abnormalities have been detected in up to 24% of kidney transplant patients receiving traditional immunosuppressive therapies (eg, cyclosporine, azathioprine); they usually occur early after transplantation and tend to resolve over time. Newer immunosuppressants such as mycophenolic acid and, particularly, mammalian target of rapamycin (mTOR) inhibitors (eg, sirolimus) may cause significant lung toxicity. However, the prevalence and severity of interstitial lung lesions in long-term, stable kidney transplant patients receiving either traditional or newer immunosuppressants is not known.

METHODS

We conducted a prospective, cross-sectional study examining high-resolution lung computed tomography (CT) scans in 63 stable kidney transplant recipients whose immunosuppressive therapy had remained unchanged for over 24 months. We compared CT findings of patients taking newer (mycophenolic acid and mTOR inhibitors) and traditional (calcineurin inhibitors and azathioprine) immunosuppressive drugs.

RESULTS

Interstitial lung alterations were observed in only 3/63 patients (4.8%); the prevalence was 11.5% (3/26) versus 0% (0/37) among the newer versus traditional immunosuppressive therapy groups, respectively (P = .065). The CT patterns were usual interstitial pneumonia and nonspecific interstitial pneumonia-like. The median time between transplant and CT was 49 months in the three patients with CT alterations and 95 months in the remaining 23 patients on newer immunosuppressants. It was 75 months for all patients on newer immunosuppressive drugs and 133 months for those on traditional therapies (P = .0015). A follow-up CT, performed in 2/3 patients with interstitial abnormalities, showed that the lesions were stable in one, while they had disappeared in the other.

CONCLUSIONS

Interstitial lung abnormalities are infrequent and mild in stable kidney transplant patients treated with newer as well as traditional immunosuppressive drugs. As such abnormalities were detected in patients screened earlier after transplantation, the time since transplantation rather than the drug type is probably the major determinant.

Methotrexate-induced pneumonitis in Crohn's disease. Case report and review of the literature

Methotrexate (MTX) is a folate-antagonist used in several neoplastic and inflammatory diseases. Reports of pulmonary complications in patients given low-dose MTX therapy are increasing. Pulmonary toxicity from MTX has a variable frequency and can present with different forms. Most often MTX-induced pneumonia in patients affected by rheumatoid arthritis (RA) is reported.In this paper we describe a case of MTX-related pneumonitis in a relatively young woman affected by Crohn's disease who presented non-productive cough, fever and dyspnea on exercise. Chest X-ray demonstrated bilateral interstitial infiltrates and at computed tomography (CT) ground-glass opacities appeared in both lungs. At spirometry an obstructive defect was demonstrated. A rapid improvement of symptoms and the regression of radiographic and spirometric alterations was achieved through MTX withdrawal and the introduction of corticosteroid therapy.

Comorbidities in rheumatoid arthritis

Rheumatoid arthritis (RA) is often characterized by the burden of swollen joints, pain, and decreased physical function, but less understood are the many manifestations of additional health conditions that are associated with RA and its treatments. First brought to light with observations of increased mortality in RA, studies noted the increased rates of cardiovascular and infection events. The chronic, debilitating, autoimmune nature of RA affects the patient directly or indirectly in almost all organ systems, from cardiovascular problems and infections to depression and gastrointestinal ulcers. On average, the established RA patient has two or more comorbid conditions. It should be the responsibility of the rheumatologist to take these and the risk of additional conditions into account when treating the patient. This chapter reviews important comorbidities in patients with RA, their prevalence, and their relation to RA.

Severe systemic adverse reaction to proton pump inhibitors in an infant

Episodes of respiratory distress with chest retraction and wheezing, sometimes associated with facial edema, were noted after administering the proton pump inhibitors omeprazole and esomeprazole in an infant with gastroesophageal reflux. The disturbances relieved dramatically after withdrawing the proton pump inhibitor.

Pulmonary involvement in lifelong non-smoking patients with rheumatoid arthritis and ankylosing spondylitis without respiratory symptoms

Pulmonary involvement seen in rheumatoid arthritis (RA) and ankylosing spondylitis (AS) has been detected increasingly by using highly sensitive diagnostic techniques such as high-resolution computed tomography (HRCT). However, HRCT findings in healthy controls and the effects of smoking and drugs have not been well studied. The aim of this controlled study was to evaluate the relationships between disease-specific clinical, laboratory, HRCT and pulmonary function test (PFT) findings in 20 RA patients using methotrexate (MTX) and 20 AS patients using sulphasalazine who were non-smokers and exhibited asymptomatic respiratory signs. For this purpose, a total of 60 persons (40 patients and 20 healthy controls) were included in this study. A restrictive pattern on PFT was detected in four patients (20%) with AS, one patient with RA and one control (p<0.05). Fourteen patients (70%) with RA and ten patients (50%) with AS had positive HRCT findings. Only one patient (5%) in the control group had abnormal HRCT findings (p<0.05). Interstitial lung disease (ILD) was the most frequently seen HRCT finding in both the RA (35%) and AS (20%) groups. The chest expansion measurement, the score of the visual analogue scale (VAS) for pain and C-reactive protein (CRP) levels were statistically significantly better in patients with AS having normal HRCT than in those with abnormal findings (p<0.05). There was no correlation detected between HRCT and duration of disease, disease activity markers, functional indexes and PFT in patients with RA and AS. HRCT is a sensitive tool in detecting ILD in patients with RA and AS with no signs and symptoms of pulmonary involvement and may be an integral part of such work-up. However, future prospective studies are needed to better determine if HRCT is in fact a predictor of subsequent MTX toxicity.

Calcification in calcium pyrophosphate dihydrate (CPPD) crystalline deposits in the knee: anatomic, radiographic, MR imaging, and histologic study in cadavers

OBJECTIVE

To demonstrate and determine the frequency and location of calcification within cadaveric knees with or without calcification typical of calcium pyrophosphate dihydrate (CPPD), utilizing histologic, radiographic and MR imaging techniques.

DESIGN AND PATIENTS

Ten cadaveric knees of elderly individuals that demonstrated no radiographic evidence of prior surgery or trauma were studied with MR imaging and subsequently sectioned in planes corresponding to those obtained with MR imaging. The slices were imaged with high-resolution radiography. Two musculoskeletal radiologists correlated the anatomic, MR and radiographic findings. Three of the knees, which did not demonstrate calcifications, were utilized as controls. Histologic sections were obtained from four knees that contained calcifications and from the three controls, and analyzed with special histologic stains that demonstrate phosphorus and calcium.

RESULTS

Radiographic imaging and histologic analysis demonstrated widespread CPPD crystal deposition in four of the 10 knee specimens (40%). MR imaging demonstrated some calcifications only within the articular cartilage of the femoral condyles in three of the four (75%) specimens that had CPPD deposits. In all four specimens radiographs and histologic analysis were more sensitive than MR imaging. Histologic analysis demonstrated no evidence of CPPD crystals in the control specimens.

CONCLUSION

MR imaging is insensitive to the presence of CPPD deposits in the knee, even when such deposits are widespread. Our study suggests that the sensitivity of MR imaging was significantly better in detecting CPPD deposits in the hyaline cartilage of the femoral condyles when compared with other internal structures, even when such structures contained a higher amount of calcification.

Pathologic characteristics of drug-induced lung disease

The surgical pathologist's role in the diagnosis of adverse pulmonary and pleural drug effect requires an appreciation of the clinico-radiologic scenario and particular knowledge of morphologic patterns of lung injury. Bronchoscopic biopsies may be helpful in some cases of DAD, eosinophilic pneumonia, or OP. Extrapolating patterns of lung involvement from small biopsies and cytologic preparations often is difficult and surgical lung biopsy is required. Although lung biopsies are not pathognomonic for drug toxicity and correlation with clinical, laboratory, and radiologic data is required, they can be a powerful tool in the evaluation of suspected drug-induced pulmonary disease by helping to exclude underlying disease or infection and documenting the pattern of lung injury. The latter information is helpful in making the diagnosis of drug toxicity as well as guiding the optimal management of the patient.

[Lung toxicity due to thalidomide]

Although the side effects of thalidomide are well known, lung toxicity has not been reported. We describe the case of a 65-year-old man with multiple myeloma (IgG kappa) in stage IA who, on the thirty-seventh day of treatment with thalidomide, developed acute coughing, general malaise, dyspnea at rest and sudoresis. Blood pressure was 90/60 mm Hg and temperature was normal. An interstitial and alveolar pattern was visible on the right side of a chest film and arterial blood gases indicated partial respiratory insufficiency (pH 7.40, PaCO2 40 mmHg, PaO2 47 mmHg). Blood analysis showed alterations expected for multiple myeloma and microbiology was negative (sputum and blood cultures and urinary antigen detection for Streptococcus pneumoniae and Legionella pneumophila). After thalidomide was withdrawn and oxygen and intravenous corticoids were administered, outcome was good. A chest film 4 days later was normal and arterial blood gases showed that respiratory insufficiency had disappeared. We conclude that severe lung toxicity should be included among the potential adverse effects of thalidomide.

Transient pulmonary infiltrates possibly induced by quinine sulfate

Quinine sulfate, which has been available for many years, has not been implicated definitively in the development of pulmonary toxicity. A variety of adverse effects, however, have been reported with quinine administration. A 45-year-old woman with longstanding rheumatoid arthritis experienced wheezing, severe anxiety, breathlessness, cough, orthopnea, mild fever, chills, and pleuritic chest discomfort after taking a single dose of quinine for nocturnal leg cramps. Radiographic imaging demonstrated diffuse, bilateral pulmonary infiltrates suggestive of pulmonary edema. No cause other than acute quinine ingestion could be identified despite thorough cardiac and infectious disease evaluations. Clinicians should be aware of a possible association between quinine sulfate and pulmonary toxicity.

Drug-induced lung disease: high-resolution CT and histological findings

AIM

To compare the parenchymal high-resolution computed tomography (HRCT) appearances with histological findings in patients with drug-induced lung disease and to determine the prognostic value of HRCT.

MATERIALS AND METHODS

Drug history, HRCT features, histological findings and outcome at 3 months in 20 patients with drug induced-lung disease were reviewed retrospectively. The HRCT images were assessed for the pattern and distribution of abnormalities and classified as most suggestive of interstitial pneumonitis/fibrosis, diffuse alveolar damage (DAD), organizing pneumonia (OP) reaction, or a hypersensitivity reaction.

RESULTS

On histopathological examination there were eight cases of interstitial pneumonitis/fibrosis, five of DAD, five of OP reactions, one of hypersensitivity reaction and one of pulmonary eosinophilia. The most common abnormalities on HRCT were ground-glass opacities (n = 17), consolidation (n = 14), interlobular septal thickening (n = 15) and centrilobular nodules (n = 8). HRCT interpretation and histological diagnosis were concordant in only nine (45%) of 20 patients. The pattern, distribution, and extent of HRCT abnormalities were of limited prognostic value: all eight patients with histological findings of OP, hypersensitivity reaction, or eosinophilic infiltrate improved on follow-up compared to only five of 13 patients with interstitial pneumonitis/fibrosis or DAD.

CONCLUSION

In many cases of drug-induced lung injury HRCT is of limited value in determining the histological pattern and prognosis.

Drug-induced lung injury

Lung injury is an increasing cause of morbidity and mortality in patients treated with cytotoxic and noncytotoxic drugs. Prompt diagnosis is important because early drug-induced lung injury will often regress with the cessation of therapy. Diagnosis requires a high index of suspicion because infection, radiation pneumonitis, and recurrence of the underlying disease can manifest clinically and radiologically in a similar manner. Because the lungs have only a limited number of histopathologic responses to injury, including pulmonary edema/diffuse alveolar damage, NSIP, BOOP, EP, and pulmonary hemorrhage, knowledge of these manifestations and the corresponding radiologic manifestations can often be useful in suggesting a diagnosis of drug-induced lung injury. An understanding of the drugs most commonly associated with lung injury can also facilitate diagnosis.

Acute respiratory failure in critically ill patients with cancer. Diagnosis and management

Respiratory failure remains a common cause of admission to the ICU for patients with cancer, regardless of the nature of malignancy. The diagnosis and management of ARF in patients with cancer poses special challenges to the intensivist. Depending on the type of cancer, the degree of immunosuppression, underlying comorbidities, the modality of cancer treatment, progression or spread of underlying cancer, and disease- or therapy-associated complications are the most common causes of ARF in these patients. Despite significant advances in antineoplastic therapies and supportive management in the ICU, the mortality rate of patients with cancer with ARF remains high. Severity-of-illness scoring systems and mortality probability models, although useful in discriminating between survivors and nonsurvivors in large groups of critically ill patients, should not be used alone to justify reluctance in admitting individual patients with cancer with potentially reversible respiratory failure to the ICU. Close collaboration between oncologists and intensivists will ensure the establishment of clear goals and direction of treatment for every patient with cancer who requires mechanical ventilation.

Pulmonary drug toxicity: radiologic and pathologic manifestations

Pulmonary drug toxicity is increasingly being diagnosed as a cause of acute and chronic lung disease. Numerous agents including cytotoxic and noncytotoxic drugs have the potential to cause pulmonary toxicity. The clinical and radiologic manifestations of these drugs generally reflect the underlying histopathologic processes and include diffuse alveolar damage (DAD), nonspecific interstitial pneumonia (NSIP), bronchiolitis obliterans organizing pneumonia (BOOP), eosinophilic pneumonia, obliterative bronchiolitis, pulmonary hemorrhage, edema, hypertension, or veno-occlusive disease. DAD is a common manifestation of pulmonary drug toxicity and is frequently caused by cytotoxic drugs, especially cyclophosphamide, bleomycin, and carmustine. It manifests radiographically as bilateral hetero- or homogeneous opacities usually in the mid and lower lungs and on high-resolution computed tomographic (CT) scans as scattered or diffuse areas of ground-glass opacity. NSIP occurs most commonly as a manifestation of carmustine toxicity or of toxicity from noncytotoxic drugs such as amidarone. At radiography, it appears as diffuse areas of heterogeneous opacity, whereas early CT scans show diffuse ground-glass opacity and late CT scans show fibrosis in a basal distribution. BOOP, which is commonly caused by bleomycin and cyclophosphamide (as well as gold salts and methotrexate), appears on radiographs as hetero- and homogeneous peripheral opacities in both upper and lower lobes and on CT scans as poorly defined nodular consolidation, centrilobular nodules, and bronchial dilatation. Knowledge of these manifestations and of the drugs most frequently involved can facilitate diagnosis and institution of appropriate treatment.

Outcomes of prospective drug-use review of beta-agonist inhaler use in an elderly Medicaid population

In 1990 Congress mandated that all state Medicaid programs implement both retrospective and prospective drug-use review (DUR). Nearly a decade later, implementation of prospective DUR (ProDUR) remains incomplete, and few of the implemented systems have been rigorously evaluated. This study was undertaken to analyze the impact of ProDUR screening of beta-agonist inhaler use in the Maryland Medicaid program from 1994 through 1996. The study used a pre/postcomparison series cohort design with data from Maryland, Georgia, and Iowa. Regression analysis was used to control for population differences between states in the year before the ProDUR intervention. The analysis used Medicaid and Medicare enrollment and claims data to select the study cohorts, assess exposure to the ProDUR intervention, develop patient risk profiles, and tabulate rates of adverse clinical outcomes for each subject. The study compared incidence rates for adverse outcomes for 2 1/2 years after implementation of the beta-agonist screens in Maryland, Georgia, and Iowa. Descriptive time plots and regression models were used to test the hypothesis that ProDUR screening reduces the incidence of adverse effects associated with misuse of beta-agonist inhalers. The study end points included 10 clinical outcomes related to therapeutic duplication and drug-drug interactions involving beta-agonist inhaler use by elderly individuals with chronic lung disease. No significant changes in the incidence of these outcomes could be linked to ProDur screening.

Pulmonary manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common of the classic connective tissue diseases. Its manifestations in the chest are varied as the pleura, lung parenchyma, airways, and pulmonary vasculature can all be involved. The approach to a patient with RA and respiratory complaints, radiographic findings, or physiologic abnormalities requires a broad understanding of these manifestations. Moreover, the potential for therapy-related toxicity adds further complexity to the pulmonary evaluation of these patients.