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Chaudhury M, Kishore EH, Lingam L, Panda AK. Spectrum of high-resolution computed tomography pattern in lungs in patients with connective tissue disorders. Ann Afr Med 2023; 22:246-251. [PMID: 37417009 PMCID: PMC10445716 DOI: 10.4103/aam.aam_157_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/14/2022] [Indexed: 07/08/2023] Open
Abstract
Background Connective tissue disease associated with interstitial lung disease, or CT-ILD, is a lung condition that affects a large number of patients with a connective tissue disease. Objective Our aim in this study is to correlation between images of high-resolution computed tomography (HRCT) of different connective tissue diseases associated interstitial lung diseases (CTD-ILDs). Methods We shall be aiming to investigate the feasibility of HRCT imaging and thereby avoid lung biopsy in such patients. Results Rheumatoid arthritis predominantly presented with usual interstitial pneumonia (UIP) (47.8%), followed by nonspecific interstitial pneumonia (NSIP) (30.4%). Mixed connective tissue disorder predominantly presented with NSIP and UIP (42.8%), followed by organizing pneumonia (OP) (14.2%). Systemic lupus erythematosus predominantly presented with UIP (38.8%), followed by NSIP (27.7%). Sjogren's syndrome predominantly presented with lymphocytic interstitial pneumonia (40%), followed by UIP (26.6%). Scleroderma predominantly presented with UIP (45.4%), followed by NSIP (36.4%). Sarcoidosis predominantly presented with UIP (75%), followed by NSIP (25%). Dermatomyositis predominantly presented with NSIP (50%), followed by UIP and OP each (25%). Conclusion Both clinicians and radiologists should be aware of the expected evolution of HRCT changes in a variety of CT-ILDs.
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Affiliation(s)
- Maheswar Chaudhury
- Department of Radiodiagnosis, IMS and SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India
| | - E. Hari Kishore
- Department of Radiodiagnosis, IMS and SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India
| | - Likhitha Lingam
- Department of Radiodiagnosis, IMS and SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India
| | - Adya Kinkar Panda
- Department of Radiodiagnosis, IMS and SUM Hospital, SOA Deemed to be University, Bhubaneswar, Odisha, India
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A New Method for the Assessment of Myalgia in Interstitial Lung Disease: Association with Positivity for Myositis-Specific and Myositis-Associated Antibodies. Diagnostics (Basel) 2022; 12:diagnostics12051139. [PMID: 35626295 PMCID: PMC9140063 DOI: 10.3390/diagnostics12051139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/01/2022] [Accepted: 05/02/2022] [Indexed: 02/05/2023] Open
Abstract
In this study, it was found that myositis-specific and myositis-associated antibodies (MSAs and MAAs) improved the recognition of idiopathic inflammatory myopathies (IIMs) in interstitial lung disease (ILD) patients. The objective of this study is to propose a clinical method to evaluate myalgia in respiratory settings as a possible tool for the recognition of MSA/MAA positivity in ILD patients. We prospectively enrolled 167 ILD patients with suspected myositis, of which 63 had myalgia evoked at specific points (M+ILD+). We also enrolled in a 174 patients with only myalgia (M+ILD-) in a rheumatological setting. The patients were assessed jointly by rheumatologists and pulmonologists and were tested for autoantibodies. M+ILD+ patients were positive for at least one MAA/MSA in 68.3% of cases, as were M-ILD+ patients in 48.1% of cases and M+ILD- patients in 17.2% of cases (p = 0.01 and <0.0001, respectively). A diagnosis of IIM was made in 39.7% of M+ILD+ patients and in 23.1% of the M-ILD+ group (p = 0.02). Myalgia was significantly associated with positivity for MSA/MAAs in ILD patients (p = 0.01, X2: 6.47). In conclusion, myalgia in ILD patients with suspected myositis is associated with MSA/MAA positivity, and could support a diagnosis of IIM. A significant proportion of M+ILD- patients also had MSA/MAA positivity, a phenomenon warranting further study to evaluate its clinical meaning.
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Sambataro D, Sambataro G, Libra A, Vignigni G, Pino F, Fagone E, Fruciano M, Gili E, Pignataro F, Del Papa N, Vancheri C. Nailfold Videocapillaroscopy is a Useful Tool to Recognize Definite Forms of Systemic Sclerosis and Idiopathic Inflammatory Myositis in Interstitial Lung Disease Patients. Diagnostics (Basel) 2020; 10:E253. [PMID: 32344844 PMCID: PMC7277171 DOI: 10.3390/diagnostics10050253] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/21/2022] Open
Abstract
Nailfold videocapillaroscopy (NVC) is an easy tool used for the assessment of patients with Raynaud's phenomenon (RP) as possibly associated with systemic sclerosis (SSc). Recent insights have also highlighted its role in the diagnostic assessment of idiopathic inflammatory myopathies (IIMs). The aim of this study is to describe the diagnostic role of NVC in a series of 361 consecutive patients with interstitial lung disease (ILD). All the patients were assessed by clinical pulmonary and rheumatic examinations, blood exams, high-resolution computed tomography and NVC. NVC was considered positive only in the presence of avascular areas or giant capillaries, but also, the presence of bushy capillaries (BCs) was recorded. NVC was positive in 17.7% of ILD patients and in 78.1% of ILD patients associated with a diagnosis of connective tissue disease (CTD). In 25% of SSc-ILD patients, NVC proved necessary for a correct diagnosis. The presence of BCs and/or NVC positivity in ILD patients with normal levels of creatine phosphokinase is associated with amyopathic IIM, regardless the presence of RP. In conclusion, NVC is useful for the diagnostic assessment of incomplete forms of CTD and in amyopathic IIMs. NVC should be considered in the diagnostic assessment of ILD patients regardless of the presence of RP.
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Affiliation(s)
- Domenico Sambataro
- Artroreuma S.R.L., Outpatient of Rheumatology associated with the National Health System corso S. Vito 53, 95030 Mascalucia, Italy
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy
| | - Gianluca Sambataro
- Artroreuma S.R.L., Outpatient of Rheumatology associated with the National Health System corso S. Vito 53, 95030 Mascalucia, Italy
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Alessandro Libra
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Giovanna Vignigni
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Fabio Pino
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Evelina Fagone
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Mary Fruciano
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Elisa Gili
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Francesca Pignataro
- Scleroderma Clinic, Department of Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
| | - Nicoletta Del Papa
- Scleroderma Clinic, Department of Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
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4
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Sambataro D, Sambataro G, Pignataro F, Zanframundo G, Codullo V, Fagone E, Martorana E, Ferro F, Orlandi M, Del Papa N, Cavagna L, Malatino L, Colaci M, Vancheri C. Patients with Interstitial Lung Disease Secondary to Autoimmune Diseases: How to Recognize Them? Diagnostics (Basel) 2020; 10:E208. [PMID: 32283744 PMCID: PMC7235942 DOI: 10.3390/diagnostics10040208] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023] Open
Abstract
The diagnostic assessment of patients with Interstitial Lung Disease (ILD) can be challenging due to the large number of possible causes. Moreover, the diagnostic approach can be limited by the severity of the disease, which may not allow invasive exams. To overcome this issue, the referral centers for ILD organized Multidisciplinary Teams (MDTs), including physicians and experts in complementary discipline, to discuss the management of doubtful cases of ILD. MDT is currently considered the gold standard for ILD diagnosis, but it is not often simple to organize and, furthermore, rheumatologists are still not always included. In fact, even if rheumatologic conditions represent a common cause of ILD, they are sometimes difficult to recognize, considering the variegated clinical features and their association with all possible radiographic patterns of ILD. The first objective of this review is to describe the clinical, laboratory, and instrumental tests that can drive a diagnosis toward a possible rheumatic disease. The secondary objective is to propose a set of first-line tests to perform in all patients in order to recognize any possible rheumatic conditions underlying ILD.
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Affiliation(s)
- Domenico Sambataro
- Artroreuma S.R.L., Outpatient clinic of Rheumatology associated with the National Health System Corso S. Vito 53, 95030 Catania, Italy
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy; (L.M.); (M.C.)
| | - Gianluca Sambataro
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
| | - Francesca Pignataro
- Scleroderma clinic, Department of Rheumatology, ASST G. Pini, 20122 Milan, Italy; (F.P.); (N.D.P.)
| | - Giovanni Zanframundo
- Division of Rheumatology, Hospital IRCCS Policlinico S. Matteo Foundation of Pavia, 27100 Pavia, Italy; (G.Z.); (V.C.); (L.C.)
| | - Veronica Codullo
- Division of Rheumatology, Hospital IRCCS Policlinico S. Matteo Foundation of Pavia, 27100 Pavia, Italy; (G.Z.); (V.C.); (L.C.)
| | - Evelina Fagone
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
| | - Emanuele Martorana
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
| | - Francesco Ferro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Martina Orlandi
- Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50139 Florence, Italy;
| | - Nicoletta Del Papa
- Scleroderma clinic, Department of Rheumatology, ASST G. Pini, 20122 Milan, Italy; (F.P.); (N.D.P.)
| | - Lorenzo Cavagna
- Division of Rheumatology, Hospital IRCCS Policlinico S. Matteo Foundation of Pavia, 27100 Pavia, Italy; (G.Z.); (V.C.); (L.C.)
| | - Lorenzo Malatino
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy; (L.M.); (M.C.)
| | - Michele Colaci
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy; (L.M.); (M.C.)
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
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Hammoda HMB, Al Saleh J, Mahmood K, Darwish OAHM, Musa MEA, Rezzek MS. Polymyalgia Rheumatica (PMR) and Lung Involvement: The Forgotten Association. Oman Med J 2020; 35:e105. [PMID: 32181007 PMCID: PMC7060987 DOI: 10.5001/omj.2020.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 12/19/2018] [Indexed: 11/16/2022] Open
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology, commonly occurring in the elderly and is associated with a good prognosis. Patients usually present with pain in the neck, shoulders, and hips. The onset is often abrupt and is associated with depression and flu-like symptoms. Lung involvement in patients with PMR is unusual. Here we report a rare case of a 66-year-old man who presented with clinical features of PMR and respiratory symptoms, namely exertional dyspnea and dry cough.
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Tirelli C, Morandi V, Valentini A, La Carrubba C, Dore R, Zanframundo G, Morbini P, Grignaschi S, Franconeri A, Oggionni T, Marasco E, De Stefano L, Kadija Z, Mariani F, Codullo V, Alpini C, Scirè C, Montecucco C, Meloni F, Cavagna L. Multidisciplinary Approach in the Early Detection of Undiagnosed Connective Tissue Diseases in Patients With Interstitial Lung Disease: A Retrospective Cohort Study. Front Med (Lausanne) 2020; 7:11. [PMID: 32133362 PMCID: PMC7040230 DOI: 10.3389/fmed.2020.00011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/13/2020] [Indexed: 12/23/2022] Open
Abstract
Interstitial lung disease (ILD) encompasses a wide range of parenchymal lung pathologies with different clinical, histological, radiological, and serological features. Follow-up, treatment, and prognosis are strongly influenced by the underlying pathogenesis. Considering that an ILD may complicate the course of any connective tissue disease (CTD) and that CTD's signs are not always easily identifiable, it could be useful to screen every ILD patient for a possible CTD. The recent definition of interstitial pneumonia with autoimmune features is a further confirmation of the close relationship between CTD and ILD. In this context, the multidisciplinary approach is assuming a growing and accepted role in the correct diagnosis and follow-up, to as early as possible define the best therapeutic strategy. However, despite clinical advantages, until now, the pathways of the multidisciplinary approach in ILD patients are largely heterogeneous across different centers and the best strategy to apply is still to be established and validated. Aims of this article are to describe the organization of our multidisciplinary group for ILD, which is mainly focused on the early identification and management of CTD in patients with ILD and to show our results in a 1 year period of observation. We found that 15% of patients referred for ILD had an underlying CTD, 33% had interstitial pneumonia with autoimmune feature, and 52% had ILD without detectable CTD. Furthermore, we demonstrated that the adoption of a standardized strategy consisting of a screening questionnaire, specific laboratory tests, and nailfold videocapillaroscopy in all incident ILD proved useful in making the right diagnosis.
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Affiliation(s)
- Claudio Tirelli
- Division of Pneumology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Valentina Morandi
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Adele Valentini
- Institute of Radiology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Claudia La Carrubba
- Division of Pneumology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Roberto Dore
- Radiology Unit, Isituti Clinici Città di Pavia, Pavia, Italy
| | - Giovanni Zanframundo
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Patrizia Morbini
- Pathology Unit, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Silvia Grignaschi
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Andrea Franconeri
- Institute of Radiology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Tiberio Oggionni
- Division of Pneumology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Emiliano Marasco
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Ludovico De Stefano
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Zamir Kadija
- Division of Pneumology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Francesca Mariani
- Division of Pneumology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | | | - Claudia Alpini
- Laboratory of Biochemical-Clinical Analyses, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Carlo Scirè
- Division of Rheumatology, Arcispedale Sant'Anna, Ferrara, Italy
| | | | - Federica Meloni
- Division of Pneumology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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Ciancio N, Pavone M, Torrisi SE, Vancheri A, Sambataro D, Palmucci S, Vancheri C, Di Marco F, Sambataro G. Contribution of pulmonary function tests (PFTs) to the diagnosis and follow up of connective tissue diseases. Multidiscip Respir Med 2019; 14:17. [PMID: 31114679 PMCID: PMC6518652 DOI: 10.1186/s40248-019-0179-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/15/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction Connective Tissue Diseases (CTDs) are systemic autoimmune conditions characterized by frequent lung involvement. This usually takes the form of Interstitial Lung Disease (ILD), but Obstructive Lung Disease (OLD) and Pulmonary Artery Hypertension (PAH) can also occur. Lung involvement is often severe, representing the first cause of death in CTD. The aim of this study is to highlight the role of Pulmonary Function Tests (PFTs) in the diagnosis and follow up of CTD patients. Main body Rheumatoid Arthritis (RA) showed mainly an ILD with a Usual Interstitial Pneumonia (UIP) pattern in High-Resolution Chest Tomography (HRCT). PFTs are able to highlight a RA-ILD before its clinical onset and to drive follow up of patients with Forced Vital Capacity (FVC) and Carbon Monoxide Diffusing Capacity (DLCO). In the course of Scleroderma Spectrum Disorders (SSDs) and Idiopathic Inflammatory Myopathies (IIMs), DLCO appears to be more sensitive than FVC in highlighting an ILD, but it can be compromised by the presence of PAH. A restrictive respiratory pattern can be present in IIMs and Systemic Lupus Erythematosus due to the inflammatory involvement of respiratory muscles, the presence of fatigue or diaphragm distress. Conclusions The lung should be carefully studied during CTDs. PFTs can represent an important prognostic tool for diagnosis and follow up of RA-ILD, but, on their own, lack sufficient specificity or sensitivity to describe lung involvement in SSDs and IIMs. Several composite indexes potentially able to describe the evolution of lung damage and response to treatment in SSDs are under investigation. Considering the potential severity of these conditions, an HRCT jointly with PFTs should be performed in all new diagnoses of SSDs and IIMs. Moreover, follow up PFTs should be interpreted in the light of the risk factor for respiratory disease related to each disease.
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Affiliation(s)
- Nicola Ciancio
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.,Respiratory Physiopathology Group. Società Italiana di Pneumologia. Italian Respiratory Society (SIP/IRS), Milan, Italy
| | - Mauro Pavone
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sebastiano Emanuele Torrisi
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ada Vancheri
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Domenico Sambataro
- Artroreuma S.R.L. Outpatient Clinic accredited with the Italian National Health System, Corso S. Vito 53, 95030 Mascalucia (CT), Italy
| | - Stefano Palmucci
- 4Department of Medical Surgical Sciences and Advanced Technologies- Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Carlo Vancheri
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Fabiano Di Marco
- 5Department of Health Sciences, Università degli studi di Milano, Head Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Gianluca Sambataro
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.,Artroreuma S.R.L. Outpatient Clinic accredited with the Italian National Health System, Corso S. Vito 53, 95030 Mascalucia (CT), Italy
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