Sarcoidosis-associated pulmonary hypertension in patients with near-normal lung function

SETTING

Tertiary care medical centre in Israel.

BACKGROUND

Pulmonary hypertension (PH) is a predictor of poor outcome in patients with sarcoidosis. Early diagnosis may improve outcome.

OBJECTIVE

To determine factors that might contribute to the early diagnosis of PH in sarcoidosis patients with near normal lung function tests.

DESIGN

Retrospective patient review.

METHODS

Data from 127 patients with sarcoidosis and near normal lung function tests (forced vital capacity > 70%, forced expiratory volume in 1 second > 70% and diffusion capacity of carbon monoxide [D(LCO)] > 60%), who underwent high resolution computed tomography (HRCT) scan, the 6-minute walk distance (6MWD) test and echocardiogram were analysed. Demographic, clinical and HRCT findings were compared between patients with and those without PH.

RESULTS

Thirty-six patients (28.3%) had PH. Patients with PH tended to have lower D(LCO) (68% ± 8 vs. 75% ± 17, P = 0.038), 6MWD (308 m ± 106 vs. 486 m ± 99, P = 0.009) and exercise saturation (91 ± 4 vs. 95 ± 3, P = 0.0001) compared to those without PH. HRCT patterns in PH showed higher frequencies of interstitial thickening (P = 0.004), ground glass appearance (P = 0.01) and fibrosis (P = 0.032). In logistic regression, only 6MWD was predictive of PH (P = 0.005, 95%CI 0.970-0.995).

CONCLUSION

Physiological and radiographic characteristics appeared to differentiate patients with PH from those without. Physicians should be aware of PH in patients with sarcoidosis, even in those with near normal lung function.

A 47-year-old female with shortness of breath and "reversed halo sign"

A 47-yr-old female was referred to a tertiary centre for further evaluation of chronic cough, fever, progressive exertional dyspnoea and fatigue. From a respiratory point of view she had been well until 7 months previously when she had started to experience systemic fatigue, low-grade fever and chronic dry cough. A computed tomography scan of the chest demonstrated diffuse bilateral ground-glass, ill-defined pulmonary opacities affecting all lobes. Some had central ground-glass hazy density with peripheral areas of increased opacity, which is consistent with "reversed halo sign". Cryptogenic organising pneumonia (COP) is a clinical, radiological and pathological diagnosis which is made when no definite cause, such as infection or connective tissue disease, is found. It is characterised histopathologically by the presence of patchy distribution of granulation tissue, which consists of fibroblasts and myofibroblasts embedded in a loose connective matrix, present in the lumen of the distal airspaces including alveoli, alveolar ducts and bronchioles. This case report illustrates the association of the reversed halo sign with COP. Although only seen in one fifth of patients with the disease, it appears to suggest the diagnosis of COP and, with proper clinical correlation, it may be another diagnostic adjunct.

Low-grade systemic inflammation in patients with amyotrophic lateral sclerosis

OBJECTIVE

To prospectively determine the intensity of systemic low-grade inflammation in patients with amyotrophic lateral sclerosis (ALS).

PATIENTS AND METHODS

Patients with ALS and matched healthy controls underwent blood tests for inflammation-sensitive biomarkers: erythrocyte sedimentation rate (ESR), quantitative fibrinogen, wide-range C-reactive protein (wrCRP) concentrations, leukocyte count and neutrophil-to-lymphocyte ratio (NLR). The correlation between these inflammatory biomarkers and disability status of the patients, expressed by the ALS Functional Rating Scale (ALSFRS-R), was evaluated.

RESULTS

Eighty patients with ALS and 80 matched controls were included. wrCRP, fibrinogen, ESR and NLR values were significantly elevated in patients compared with controls. There was a significant correlation between the ALSFRS-R score and wrCRP, ESR and fibrinogen levels. This correlation persisted on sequential examinations.

CONCLUSIONS

A systemic low-grade inflammation was detected in patients with ALS and correlated with their degree of disability. A heightened systemic inflammatory state is apparently associated with a negative prognosis in ALS.

An animal model for chemotherapy-associated steatohepatitis (CASH) and its prevention by the oral administration of fatty acid bile acid conjugate (FABAC)

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Background: Preoperative chemotherapy (irinotecan and oxaliplatin), used in patients undergoing hepatic resection of colorectal liver metastases, is associated with the development of CASH. This hepatic injury increases the risk of perioperative morbidity and mortality. An animal model for CASH has not yet been described. Fatty acid bile acid conjugates (FABACs) are novel synthetic lipid molecules that were shown to prevent the formation of diet induced fatty liver. The present study was designed to establish an animal model of CASH and to use it to study the effect of FABAC on its occurrence. Methods: C57B1/6 mice were given different doses of intraperitoneally injected oxaliplatin and irinotecan. Once weekly administered oxaliplatin at a dose of 6mg/m2 for a total dose of 24mg/ m2, was best tolerated and most consistently associated with CASH in comparison to higher doses of oxaliplatin or different irinotecan regimens. Thus it was chosen as the induction model for CASH. Subsequently, 32 mice were divided into a control group (no treatment, n=6), oxaliplatin group (n=14), and a CASH prevention group (n=12) treated by oxaliplatin and C20-FABAC (arachidyl-amido-cholanoic acid) at a dose of 150 mg/kg/day administered by gavage. The animals were sacrificed after 28 days. Their livers were homogenized and analyzed for fat content (measured as mg lipid/g liver tissue). Results: There were no significant differences in animal or liver weights between the groups. Liver fat content, was significantly lower (P<0.0001) among the control (51.63 mg/g) and prevention (62.13 mg/g) groups versus the oxaliplatin group (95.35 mg/g). The difference between the control and prevention groups was not significant. To the best of our knowledge this is the first description of a model and a potential preventive treatment for CASH. Conclusions: C57B1/6 mice treated by intraperitoneal injection of weekly oxaliplatin at a dose of 6mg/m2 for a total of 24mg/m2, can be used as a model for CASH. Oral FABAC therapy reduces the development of chemotherapy associated steatohepatitis in animals treated with oxaliplatin.

No significant financial relationships to disclose.

Antibacterial class is not obviously important in outpatient pneumonia: a meta-analysis

The aim of the present study was to systematically compare outcomes between antibiotic classes in treating outpatient community-acquired pneumonia, with regard to antibacterials active against atypical organisms, as well as between various antibacterial classes with similar atypical coverage. A meta-analysis was performed on randomised controlled trials of antibacterials for community-acquired pneumonia in outpatients aged > or = 18 yrs. The studies were independently reviewed by two reviewers. Clinical success and mortality were compared between different oral antibiotic classes, and antibacterials with atypical coverage (macrolides and fluoroquinolones) were specifically compared with other antibacterials. In total, 13 eligible studies involving a total of 4,314 patients were included. The quality of the studies was variable. Five studied macrolides and fluoroquinolones, three macrolides and beta-lactams, three fluoroquinolones and beta-lactams and two cephalosporins versus beta-lactams/beta-lactamase inhibitors. No significant difference was detected regarding clinical success or mortality, regardless of atypical coverage or between antibacterial classes with similar atypical coverage. It was not possible to demonstrate any advantage of specific antibacterials for mild community-acquired pneumonia in relatively healthy outpatients. The need for coverage of atypical pathogens in this setting was not apparent. In mild-to-moderate cases of outpatient-treated community-acquired pneumonia, it might be most appropriate to select antibacterials according to side-effects, patient preferences, availability and cost.

Reversed halo sign in lymphomatoid granulomatosis

Lymphomatoid granulomatosis is a rare lymphoproliferative disorder which affects extranodal sites, most commonly lung. Radiologically, it typically presents with multiple nodular opacities that may wax and wane. The reversed halo sign has previously been reported in cryptogenic organizing pneumonia and more recently in South American blastomycosis. We describe a case of histologically proven lymphomatoid granulomatosis in a patient who presented initially with the more typical nodular opacities, which subsequently progressed into the reversed halo sign. To the best of our knowledge, this association has not been previously described.

[Gram-negative enteric bacteremia in children in the Negev (1989-1994)]

During 1989-1994, there were 322 episodes of Gram-negative enteric bacteremia in 308 children. The incidence increased from 31/100,000 in children younger than 15 years of age during 1989-1991, to 50/100,000 during 1992-1994. The most common pathogens were Klebsiella, E. Coli, Salmonella and Enterobacter. 39% of episodes were nosocomial and a significant increase was recorded for each species during the last 3 years of the study. Klebsiella represented the most common pathogen causing nosocomial bacteremia, while E. coli and Salmonella were the main pathogens causing community-acquired bacteremia. In this study in southern Israel, the incidence of Gram-negative enteric bacteremia was significantly higher in Bedouin children, with the exception of bacteremia due to Salmonella, which occurred mainly in Jewish children.