Oxygenation during Endobronchial Ultrasound: Where do we stand?

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Bleomycin and perioperative care: a case report

 Bleomycin is associated with pulmonary toxicity ranging from pneumonitis, pulmonary fibrosis, to fatal acute respiratory distress syndrome. Oxygen administration can potentiate or precipitate bleomycin pulmonary toxicity, and the most common setting of oxygen exposure is during anesthesia. We report here the successful management and perioperative care of a patient with documented bleomycin pulmonary toxicity who had to undergo an eight hour long retroperitoneal surgery. With proper preoperative assessment, chest physiotherapy, inhaled steroids and bronchodilators, antibiotics, operative restriction of oxygen and fluids and good postoperative care no further pulmonary insult was inflicted.

Pulmonary Toxicities of Immune Check Point Inhibitors in the Management of Cancer: Mini Review

Immune-checkpoint inhibitors (ICIs) have revolutionized treatment of solid malignancies, leading in some cases to durable responses. However, an unchecked immune response might lead to mild to severe immune-related adverse events (irAEs). Pulmonary toxicity, though often referred to as Immune checkpoint inhibitor–related pneumonitis (ICI-pneumonitis), covers a broad and overlapping spectrum of pulmonary manifestations and has been described in <10% of patients receiving ICI either alone or in combination. However, the actual numbers in real-world populations are high, and are likely to increase as the therapeutic indications for ICIs continue to expand to include other malignancies. Drug withdrawal is the mainstay of treatment for ICI-pneumonitis. However, a good number of patients with higher grades of toxicity may need corticosteroids. Patients with refractory disease need additional immunosuppressive agents. In this brief review, we succinctly discuss the incidence, risk factors, mechanisms, clinical and radiologic manifestations, diagnosis and summarize the current management strategies of ICI-pneumonitis.

COVID, Obstructive Airway Diseases and Eosinophils

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Obstructive sleep apnea in patients with severe asthma: Prevalence and association between severity and asthma control

INTRODUCTION:

Asthma and obstructive sleep apnea (OSA) are common respiratory disorders that can coexist and cause sleep disturbances. The strength of this association and the impact of OSA on asthma severity and control remain unclear. The study aims to estimate the prevalence of OSA in patients with severe asthma in Oman and to examine whether the severity of OSA contributed to the level of asthma control.

METHODS:

Adult patients with confirmed diagnosis of severe asthma who attended the respiratory clinic in a tertiary hospital in Oman over a period of 19 months were enrolled in the study. Eligible participants were screened by asthma control test (ACT) and Berlin questionnaire (BQ). Patients with high risk for OSA were subjected further to level 3 sleep study. The prevalence of OSA in patients with severe asthma and the associations between the severity of OSA and asthma control were calculated.

RESULTS:

We identified 312 adult asthma patients on Global Initiative for Asthma step 4 or 5 management out of 550 who were screened. The mean age of the study population was 56.59 ± 12.40 years and the mean body mass index (BMI) 40.30 ± 12.24 kg/m². The prevalence of OSA in asthma patients with severe asthma was found to be 32.4%. Out of the 138 well-controlled asthma patients (ACT ≥20), 35 had high risk of OSA based on BQ, and 32 were confirmed to have OSA (23%). Of the 174 uncontrolled patients, 80 patients had high risk of OSA and 69 patients were confirmed to have OSA (39.65%). Severe OSA was seen in 63.8% and 9.4% in uncontrolled and controlled asthma patients, respectively (P = 0.002). The median respiratory event index in the uncontrolled group was 43, and it was significantly higher than 12.5 in the controlled group (P < 0.001).

CONCLUSIONS:

The prevalence of OSA was high (32.37%) in patients with severe asthma. Uncontrolled severe asthma was significantly associated with severe OSA.

Percutaneous Ultrasound-guided Pigtail Catheter for Pleural Effusions: Efficacy and Safety

Objectives

Small-bore pigtail catheters are now being used more frequently for draining pleural effusions. This study aimed to measure the efficacy, safety, and tolerability of these devices in different clinical conditions.

Methods

We retrospectively collected data from 141 patients with pleural effusions of various etiologies who underwent ultrasound-guided pigtail catheter insertion at Sultan Qaboos University Hospital, Muscat, Oman.

Results

The majority 109 (77.3%) of patients had exudates. The mean age was 50.0±18.6 years in patients with exudates and 67.3±15.5 in patients with transudates (p < 0.001). There was no significant difference (p = 0.232) in the median drainage duration between exudates (6.0 days) and transudates (4.5 days). The incidence of pain requiring regular analgesics, pneumothorax, and blockage were 36.2% (n = 51), 2.8% (n = 4), and 0.7% (n = 1), respectively. The overall success rate of pleural effusion drainage was 90.1%. Among the 109 cases of exudative pleural effusion, 89.0% were successful compared to a 93.8% success rate among patients with transudative effusion (p = 0.737). Short-term success rates were high in all causes of effusions: lung cancer (100%), metastasis (90.0%), pleural infections (83.3%), cardiac failure (94.7%), renal disease (85.7%), and liver disease (100%).

Conclusions

Ultrasound-guided pigtail catheter insertion is an effective, comfortable, and safe method of draining pleural fluid. It should be considered as the first intervention if drainage of a pleural effusion is clinically indicated.

Valve Replacement for Massive Hemoptysis in Mitral Stenosis: An Uncommon Course in Modern Practice

Massive hemoptysis is uncommon in mitral stenosis in contemporary practice. We report a patient without any previous illness presenting with life-threatening pulmonary hemorrhage, who was initially managed as cryptogenic hemoptysis. Once mitral stenosis was confirmed, the patient underwent mitral valve replacement with total and complete cessation of bleeding.

Sarcoidosis in the Middle East

Sarcoidosis, a systemic granulomatous disease of unknown cause, has been described worldwide and in all populations with notable differences in clinical characteristics, organ involvement, disease severity, and prognosis among different ethnic and racial groups. While the exact prevalence of sarcoidosis in the Middle East is unknown, studies from various countries in the region have reported the clinical characteristics of affected patients, along with a few anecdotal reports. A search of the MEDLINE and Google Scholar databases was conducted for relevant English-language articles using the terms “sarcoidosis” and “Middle East” or “sarcoidosis” and “Arabs.” Subsequently, the names of individual countries were used as search terms, replacing “Middle East.” Overall, the clinical picture of patients with sarcoidosis in the Middle East is similar to that reported elsewhere; for example, the disease was more frequent among females and respiratory complaints were the predominant symptoms. Within the region, most patients from Oman were older and female, with arthralgia, hypercalcemia, and eye involvement being more common. Constitutional symptoms were frequent, especially among patients from Iran. Cough was more common among patients from Kuwait and Iran, while dyspnea was the predominant symptom for Saudi patients. Erythema nodosum was more common in the Turkish population. Clustering was seen in patients with Stage I and II of the disease in all countries except Oman. Apart from those in Iran, the prognosis of most patients from the Middle East was excellent.

Clinical features of Sarcoidosis in Oman: A report from the Middle East region

BACKGROUND

Though clinical features of sarcoidosis follow a similar pattern, some heterogeneity is seen in different ethnic and racial groups.

OBJECTIVES

To describe for the first time the clinical characteristics of sarcoidosis patients in the Sultanate of Oman.

METHODS

The data on all cases of sarcoidosis followed up in the two tertiary hospitals in Oman were retrieved retrospectively.

RESULTS

Of the 92 patients, for representing the ethnic data only Omani patients (n=83) were included. The mean age was 52.90±12.35 years. Majority were females (72.3%, n=60). Cough (n=44, 53.0%), dyspnea (n=39, 47%), arthralgia (n=26, 31.3%) and fatigue (30.1%) were the major symptoms. Arthralgia was reported by 41.7% of the females and 4.3% of the males (p= 0.001). Uveitis was present in 16 (19.3%), erythema nodosum in 8 (9.6%) and hypercalcemia in 13 (15.7%). The radiological stage at presentation was stage 0, 18.7%; I, 28%; II, 17.3%; III, 24% and IV, 12%. Majority (61.4%) of the patients had tissue diagnosis; intra-thoracic site 70.6%. Pulmonary function showed abnormal diffusion in 75%. Sixty eight received treatment, 81.9% took prednisolone. Based on radiograph good outcome (Resolving) was noted in 20.9%, intermediate (Stable) in 73.1% and poor (Progressive) in 6%. Lung function wise, resolving, stable and progressive disease was seen in 31.4%, 40.0% and 28.6% respectively.

CONCLUSION

The clinical picture of the patients with sarcoidosis from Oman was similar to that reported from the rest of the world. Region wise, our patients were older and arthralgia and hypercalcemia were more common. The management of sarcoidosis needs a more organized approach in the country with clear guidelines on monitoring and treatment.

Hughes-stovin syndrome and massive hemoptysis: a management challenge

Hughes-Stovin syndrome is a very rare clinical entity characterized by pulmonary artery aneurysms and deep vein thrombosis (DVT). Here we report the case of a 53-year-old man, admitted to Sultan Qaboos University Hospital, Muscat, Oman, with bilateral pulmonary artery aneurysms and lower-limb DVT who developed massive hemoptysis. He was managed successfully with high-dose steroids in combination with cyclophosphamide.

Varicella zoster virus pneumonitis and brainstem encephalitis without skin rash in an immunocompetent adult

Varicella zoster virus (VZV) pneumonitis and brainstem encephalitis developed in an immunocompetent adult without rash. Chest computed tomography exhibited nodularity; lung biopsy revealed multinucleated giant cells, Cowdry A inclusions, VZV antigen, and DNA. Varicella zoster virus central nervous system disease was verified by cerebrospinal fluid (CSF) anti-VZV IgG antibody with reduced serum/CSF ratios.

Asthma control: importance of compliance and inhaler technique assessments

OBJECTIVES

The available assessment tools to determine asthma control do not include components assessing factors that may directly affect control. Our aim was to evaluate the relationship between patient compliance, inhaler technique and the level of asthma control.

METHODS

Scores from the Asthma Control Test, individual inhaler device checklists and a novel questionnaire on the patient's medication regimen were used to measure control, inhaler technique and compliance, respectively, in patients with asthma attending Sultan Qaboos University Hospital, Muscat, Oman during a 3-month period.

RESULTS

All of the 218 patients were receiving inhaled steroids, either in combination with long-acting beta agonists (86.2%) or alone. Asthma control was good in 92 (42.2%) patients; with 38 males (50%) and 54 females (38%), respectively (p = 0.059). Compliance and inhaler technique were poor in 40.8% (89) and 18.3% (40) of the patients. 60% (36) of the patients with good and 59.4% (41) with partial compliance had good control while 83.1% (74) with poor compliance had poor control (p < 0.001). Of the 92 patients with good control, 86 (93.5%) exhibited good inhaler techniques. In contrast, 85% (34) of the patients with poor inhaler techniques demonstrated poor control (odds ratio [OR] = 5.3; 95% confidence interval [CI]: 2.05-14.8; p < 0.001). A total of 93.3% (56) with good and 89.9% (62) with partial compliance demonstrated good inhaler techniques (p < 0.001). In patients with good control, 35 (38%) exhibited both good inhaler techniques and compliance and 38 (41.3%) had a good technique and partial compliance.

CONCLUSION

Patients with good inhaler techniques and compliance have better control of their asthma. Asthma control will remain suboptimal unless the reasons for this lack of control are identified, assessed and eliminated. We recommend that inhaler technique assessment and measurements of patient compliance with their prescribed treatments should be considered for inclusion in the current assessment tools.

Severe Pulmonary Involvement in Leptospirosis: Alternate antibiotics and systemic steroids

Pulmonary complications in leptospirosis, though common, are often unrecognized in a non-endemic area. We report here a patient with leptospirosis and severe pulmonary involvement who was treated with meropenem (1 g every 8 hours), moxifloxacin (400 mg once daily), and high doses of corticosteroids. Systemic steroids were continued for 3 months because of persistent pulmonary lesions.

Is Clinical Judgment of Asthma Control Adequate?: A prospective survey in a tertiary hospital pulmonary clinic

OBJECTIVES

Asthma control is often difficult to measure. The aim of this study was to compare physicians' personal clinical assessments of asthma control with the Global Initiative for Asthma (GINA) scoring.

METHODS

Physicians in the adult pulmonary clinics of a tertiary hospital in Oman first documented their subjective judgment of asthma control on 157 consecutive patients. Immediately after that and in the same proforma, they selected the individual components from the GINA asthma control table as applicable to each patient.

RESULTS

The same classification of asthma control was achieved by physicians' clinical judgment and GINA classification in 106 cases (67.5%). In the other 32.5% (n = 51), the degree of control by clinical judgment was one level higher than the GINA classification. The agreement was higher for the pulmonologists (72%) as compared to non-pulmonologists (47%; P = 0.009). Physicians classified 76 patients (48.4%) as well-controlled by clinical judgment compared to 48 (30.6%) using GINA criteria (P <0.001). Conversely, they classified 34 patients (21.7%) as uncontrolled as compared to 57 (36.3%) by GINA criteria (P <0.001). In the 28 patients who were clinically judged as well-controlled but, by GINA criteria, were only partially controlled, low peak expiratory flow rate (PEFR) (46.7%) and limitation of activity (21.4%) were the most frequent parameters for downgrading the level of control.

CONCLUSION

Using clinical judgment, physicians overestimated the level of asthma control and underestimated the uncontrolled disease. Since management decisions are based on the perceived level of control, this could potentially lead to under-treatment and therefore sub-optimal asthma control.

Acute drug overdose: clinical profile, etiologic spectrum and determinants of duration of intensive medical treatment

OBJECTIVES

Acute drug overdosing is an important cause of organ dysfunction and metabolic derangements and the patients often require intensive care. This study aims to determine the clinical pattern of severe drug overdose as well as the factors influencing the duration of intensive care

METHODS

The clinical characteristics and course of consecutive adult patients admitted with a diagnosis of acute drug poisoning in the ICU of a tertiary hospital in Oman from January 2007 to December 2008 were reviewed retrospectively from the electronic case records.

RESULTS

Acute drug poisoning (n=29) constituted 3.9% of admissions to the ICU. Mean age was 29.38±7.9 years. They were brought in by their relatives (72%) or the state services (24%). Accidental poisoning was noted in 21 patients (72%) and suicidal overdosing in 6 (21%). The commonest drug was an opioid (65.5%). Glasgow Coma Scale score of ≤8 was recorded in 18 (62.1%). Sixty two percent of patients required mechanical ventilation. The prominent complications were hypotension in 9 (31%), pulmonary in 19 (65.5%), hepatic in 18 (62.1%) and renal in 12 (41.4%) patients. The major electrolytes abnormalities were low bicarbonate in 11 (37.9%), hyponatremia in 5 (17.2%) and hypokalemia in 4 (13.8%). Patients stayed in the ICU for 1 to 20 days (median-2 days). Factors associated with a longer ICU stay included hypotension upon arrival (p=0.048) and the need for mechanical ventilation on the first (p=0.001) and second (p=0.001) days of hospitalization. There was no mortality.

CONCLUSION

Early and prompt intensive medical therapy in acute drug poisoning can favorably influence the outcome. In addition, the presence of hypotension and requirement of mechanical ventilation on the first two days of hospitalization were responsible for prolonged ICU stay.

Management and control of asthma in patients attending a specialist centre in oman

OBJECTIVES

The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control.

METHODS

All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol.

RESULTS

Of the 207 patients, (mean age 40.64 ±14.8), 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E (IgE) was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists (LABA), antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority (40.1%) was receiving medium dose inhaled steroids. Although asthma was controlled in 162 (78.3%), during the previous month 66 (31.9%) patients had visited the emergency department and 31 (15.0%) patients were hospitalised at least once during the previous year. Only 63 (30.4%) patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 (25.6%) patients.

CONCLUSION

Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored.

Normal spirometric reference values for Omani adults

International guidelines recommend the use of population-specific reference values to eliminate the well-recognized influence of ethnic variation on lung function. This study was designed to derive spirometric prediction equations for healthy Omani adults. Forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)), peak expiratory flow rate (PEFR), and forced expiratory flow at 25% to 75% of FVC (FEF(25-75%)) were measured in 419 "healthy" nonsmoking Omani adults (256 men, 163 women), aged 18-65 years. Multiple linear regression analysis was performed for each spirometric parameter against age, height, and weight for men and women separately, and prediction equations for all the above parameters were derived and compared with values derived using equations published from other populations. All measured spirometric parameters increased with height and decreased with age, and they were all significantly higher in men. In contrast, FEV(1)/FVC% values decreased with height and increased with age and were higher in women. The predicted normal values of FVC and FEV(1) for our subjects using the derived equations were lower by 7-17% compared with respective Caucasian values, with smaller difference in the predicted values of PEFR, FEV(1)/FVC%, and FEF(25-75%). This report presents previously unavailable spirometric reference equations for the Omani adults. Our findings highlight the need to use reference values based on updated data derived from relevant populations.

Demographic pattern and clinical characteristics of patients with smear- positive pulmonary tuberculosis in kuwait

OBJECTIVE

The aim of this study was to document various clinical factors that are likely to be of help in the control of tuberculosis in Kuwait.

SUBJECTS AND METHODS

Details of patients with sputum positive for acid-fast bacilli in the period from January 1998 to December 2000 were collected retrospectively from the case records and population statistics from government sources. The data were then tabulated and analyzed.

RESULTS

Of the 526 cases, 83.5% were expatriates and 16.5% Kuwaiti; 373 (70.9%) were male. Of the expatriates, 66.7% were from Asia and the Far East, 5.7% were > or =60 years. The annual incidence was 8.34 per 100,000 population. The lowest incidence was observed in the Jahrah governorate with an overall incidence of 5 (2.0 among Kuwaitis and 6.4 among expatriates) per 100,000 population. The highest incidence overall (10.2) and among Kuwaitis (4.1) was observed in the Farwaniya governorate, while the highest incidence among expatriates was seen in the Capital governorate (13.4). Radiologically, 94 (19.5%) had minimal, 246 (51.5%) had moderately advanced and 141 (29.3%) far-advanced disease. The majority of the patients (72%) had only + status for AFB in the smear. Hypercalcemia (25.7%), hyponatremia (22.15%) and hyperglycemia (29.9%) were common in the patients. Mean serum albumin was low (28.7 +/- 5.5 g/l). Two hundred and forty-seven (47.2%) were declared cured while 116 (22.2%) completed treatment. Comparison between nationals and expatriates showed a significant difference only for age, smoking status, defaulter rate and place of residence.

CONCLUSION

The lowest regional incidence was found in the Jahrah governorate. Both biochemical abnormalities and radiologically advanced presentations were common. Disease pattern and response to treatment was purely individual and did not differ with respect to nationality or race.

Significance of atypical pathogens among community-acquired pneumonia adult patients admitted to hospital in Kuwait

OBJECTIVES

The aim of this study is to determine the microbial etiology and severity of community-acquired pneumonia (CAP) in Kuwait.

SUBJECTS AND METHODS

The severity of consecutive adult CAP cases admitted to 3 hospitals over a 1-year period was classified according to the Pneumonia Outcome Research Team (PORT) severity index. The microbial etiology was determined using standard methods for bacteria and serological tests for atypical and viral pathogens.

RESULTS

The study population was 124 of the 135 admissions; 63 female, 61 male; mean age 41.3+/-18 years. The severity class distribution was: class I 31%, class II 37%, class III 17%, class IV 13%, and class V 2%. Etiological agents were identified from 44 patients (35%), with one pathogen in 31 (25%), two in 9 (7%), and three or more in 4 (3%). The most common pathogens identified were: Mycoplasma pneumoniae in 14 patients (11%), Legionella pneumophila in 10 (8%), Chlamydia pneumoniae in 8 (6%), influenza B virus in 8 (6%), influenza A virus in 5 (4%), Haemophilus influenzae in 4 (3%), Streptococcus pneumoniae in 3 (2%), Staphylococcus aureus in 3 (2%), gram-negative enterobacteria in 5 (4%), Moraxellacatarrhalis in 2 (2%), and viruses in 4 (3%). The yields from laboratory tests were 48% for paired serology, 20% from adequate sputum sample, and 3% from blood culture.

CONCLUSION

Our study shows that a large percentage of mild CAP cases are admitted to hospitals in Kuwait. Atypical pathogens have a significant role in the etiology of CAP. There is overtreatment of CAP with a combination treatment consisting mainly of third-generation chephalosporins and macrolides.

Effect of cigarette smoking on sputum smear conversion in adults with active pulmonary tuberculosis

Although factors influencing sputum smear conversion in tuberculosis have been studied well, the effect of smoking is largely unknown. Excluding those with incomplete history or drug resistant isolates, 339 patients out of the 526 sputum positive patients registered between 1998 and 2000 were studied. At the end of 2 months, smokers and non-smokers converted with almost the same frequency to a negative sputum status {P=0.065, OR (95%CI) 0.47 (0.21-1.06)}. Although gender or age had no effect on sputum conversion with respect to smoking status, expatriate smokers as a whole showed a significant difference. (P=0.039). On applying logistic regression model, smokers with far advanced radiographic abnormalities (P<0.038) or with 3+ smear status (P=0.011), were found to have a less chance of an early smear conversion. In conclusion smoking did not influence sputum smear conversion in tuberculosis. However, as expatriate smokers and smokers with advanced disease showed a delay in smear conversion, smoking should be discouraged in patients with pulmonary tuberculosis.

Flexible fiberoptic bronchoscopy. Diagnostic yield

OBJECTIVE

Fiberoptic bronchoscopy is a minimally invasive procedure with a high diagnostic yield. The aim of this study was to document the usefulness of the procedure in the diagnosis of various respiratory disorders in a Middle East country.

METHODS

Data on all bronchoscopies carried out in Chest Diseases Hospital, Kuwait from January 1996 to December 1998 were retrospectively collected.

RESULTS

Out of 968 cases, only 620 (64%) patients had a full follow up. Suspected pulmonary tuberculosis (TB) (51.6%), unresolving pneumonia (16.1%), hemoptysis with a normal chest radiograph (8.4%), lung mass (7.7%) and hilar lymphadenopathy (3.2%) were the most common indications. Eleven percent of patients who underwent bronchoscopy had a normal chest radiograph, the reason being hemoptysis in 75.4%, inhalation injury in 21.8% and suspected upper airway obstruction in 2.9%. In smear negative suspected TB cases, 22.5% proved to have active disease. Acid fast bacillus was identified in bronchoalveolar lavage, either by smear or culture, in 44 (73.3%) patients with suspected pulmonary TB and in 6 (54.5%) patients with miliary shadows. An underlying cause was identified in 28 (28%) patients with unresolving pneumonia. Ninety-four percent of cases with clinical impression of bronchogenic carcinoma could be diagnosed. Transbronchial biopsy was diagnostic in 79% patients with diffuse parenchymal lung disease. No complications other than transient hypoxemia and controllable bleeding were noticed.

CONCLUSION

Generally, the indications for flexible fiberoptic bronchoscopy remained similar to elsewhere. Unlike western series, the majority of the cases were for the diagnosis of pulmonary infections especially TB.

Changes in blood levels of eosinophil cationic protein and tryptase after exercise challenge in adolescents with exercise-induced asthma

BACKGROUND

Exercise-induced asthma (EIA) is increasingly encountered among school children in Kuwait. Available evidence has shown that inflammatory mediators may be involved in the pathogenesis of EIA. Studies on release of inflammatory mediators have been carried out in adult patients with asthma in Kuwait, but no study on EIA involving children has taken place in this region.

OBJECTIVE

To investigate changes in the concentration of some of the mediators involved in EIA in adolescent school children, using exercise challenge.

DESIGN

Prospective, case control study.

SETTING

Respiratory and Cardiology units Mubarak Hospital, Kuwait, between January and June 2001.

SUBJECTS

Nine EIA and 14 non-EIA and 10 normal control subjects, designated as groups one, two and three aged between 13 and 17 years, who were non-smokers, were enrolled for the study.

MAIN OUTCOME MEASURES

Blood eosinophils (EOS), eosinophil cationic protein (ECP) and tryptase were estimated pre-exercise, 5 and 30 minutes after exercise. Spirometry was measured at the same period.

RESULTS

In group one, ECP and tryptase levels fell after exercise, but significant difference in the levels were obtained only in tryptase between pre-exercise and 30 minutes after exercise (4.1 microg/L Vs 3.8 microg/L) P <0.05, while the difference for ECP was not significant (P=0.09). In group two, both tryptase (6.0 microg/L Vs 5.7 microg/L) P < 0.05, and ECP (21.8 microg/L Vs 12.1 microg/L) P<0.01, fell after exercise. However, in group three, no appreciable difference was observed between pre and post exercise. Correlation between tryptase and EOS (r=0.770; P<0.05) and between tryptase and ECP (r=0.850; p<0.05) was observed pre-exercise and after exercise in groups one and two.

CONCLUSION

A fall in the level of the mediators was observed after exercise challenge, but the relevance of this finding in the pathogenesis of EIA remains unclear. Further studies are required to verify this finding.

Clinical patterns of diffuse parenchymal lung disease in Kuwait: a prospective study

OBJECTIVE

To report our experience of the clinicopathological patterns of diffuse parenchymal lung disease (DPLD).

SUBJECTS AND METHODS

Over a 4-year period, 75 patients (41 males, 34 females), aged 13-76 years, who were referred to Mubarak Al-Kabeer and the Chest Diseases Hospitals, Kuwait with a diagnosis of diffuse lung disease, were included in the study. After a comprehensive history and physical examination, further investigations were done, including hematological and immunological profiles, sputum and bronchoalveolar lavage fluid examination, chest radiograph, high resolution computed tomography (HRCT), pulmonary function test and lung biopsy.

RESULTS

Of the 75 patients 60 (80%) were over 40 years of age. The duration of symptoms in 34 patients (45%) was less than 6 months and longer than 1 year in 28 (37.7%) patients. Twenty-five of the patients were cigarette smokers. The mean forced lung capacity (FVC), total lung capacity and diffusing capacity for carbon monoxide were less than 60% of the predicted values in most patients. There was a significant difference in mean FVC value between smokers and nonsmokers (p < 0.05). The HRCT findings were at an advanced stage in 65 patients, with additional honeycombing in 21 of the 65 patients. Idiopathic pulmonary fibrosis was the most common cause of DPLD, occurring in 52 patients, followed by sarcoidosis and collagen vascular diseases.

CONCLUSION

DPLD was observed predominantly in middle aged and elderly patients, due probably to increasing industrialization in the country. The role of cigarette smoking as a contributory factor remains unclear.

Clinicopathological and therapeutic patterns of idiopathic pulmonary fibrosis in Kuwait: a prospective study

Though common, the exact incidence and clinical pattern of idiopathic pulmonary fibrosis (IPF) in Gulf countries are not known. The results of a four-year prospective study undertaken in two tertiary hospitals in Kuwait are presented. The mean age at diagnosis of the 52 patients studied was 55.40 +/- 11.87 years. Thirty-two (61.5%) patients were male and 22 (42.3%) were smokers. The mean duration of symptoms at diagnosis was 2.1 +/- 0.92 years. Digital clubbing was found in 34 (65%) patients. The mean FVC, TLC and TLCO were 57%, 64.4% and 55% of predicted normal, respectively. The FVC value showed a significant difference between smokers and non-smokers (p < 0.05). HRCT findings were abnormal in all patients. Typical histological and high-resolution computed tomography findings of usual interstitial pneumonia, desquamative interstitial pneumonia and non-specific interstitial pneumonia were observed. This study revealed that IPF is prevalent in Kuwait, with patterns showing some similarities to those established elsewhere. The response to treatment was not encouraging, especially in the usual interstitial pneumonia subtype.

Chronic lobar consolidation

Lobar consolidation in a chest X-ray is often thought to be due to infection. We present the problem of a 66-year-old female with low grade non-Hodgkin's lymphoma of the mucosa associated lymphoid tissue (MALT) type who had features of lobar consolidation that persisted for years. The different causes, both infectious and non-infectious, of this kind of presentation are discussed.

Effect of methotrexate on pulmonary function in patients with rheumatoid arthritis--a prospective study

If given in high doses, methotrexate (MTX), a folate antagonist, could cause pulmonary complications. To evaluate the pulmonary effects of low-dose methotrexate, 55 newly diagnosed patients with rheumatoid arthritis (RA) prescribed with MTX were studied prospectively. A significant reduction in percent predicted values of forced expiratory volume (FEV(1)), forced vital capacity (FVC), total lung capacity (TLC), and functional residual capacity (FRC) was observed after 2 years of MTX treatment. A significant increase in the FEV(1):FVC ratio was also observed. In comparison to the normal annual decline in healthy adults, the actual reduction in observed values in the patients was significantly greater (3.2, 6.3, and 6.7 times normal for FEV(1), FVC, and TLC, respectively). PaO(2) and oxygen saturation showed marginal but significant improvement. It was concluded that low-dose MTX treatment in RA might cause an accelerated decline in lung function. Therefore, periodic monitoring of pulmonary function among RA patients started on MTX could be necessary.