An unusual thoracic localizations of Erdheim- Chester disease: A case report

Erdheim- Chester disease is a rare non- Langerhans cell histiocytosis that usually involves the bones, heart, central nervous system, retroperitoneum, eyes, kidneys, skin and adrenals. Lungs are affected in up to one-half cases; at CT scan various patterns are described: interstitial disease, consolidations, micronodules and microcysts, with or without pleural involvement. We presented a case of a 59 year-old man with unusual intrathoracic manifestation of Erdheim- Chester disease. Singularities of our report are the lonely thoracic involvement at the onset of the disease and a histiocytic lesion in the posterior mediastinum.

An observational study on the epidemiology of respiratory tract bacterial pathogens and their susceptibility to four injectable beta-lactam antibiotics: piperacillin, piperacillin/tazobactam, ceftazidime and ceftriaxone

Bacterial infections of the respiratory tract account for a large proportion of total medical consultations in general practice. In recent years, antibiotic resistance has increased alarmingly in a number of bacterial species that are common causes of these infections. The aim of this observational study was to determine the antibiotic resistance of microbial agents isolated from patients with acute or acutely exacerbated respiratory infections. Subjects recruited as potential sources of bacteria were either outpatients seen in a number of specialized clinics and hospital practices, or hospitalized patients. Overall, 648 consecutive patients (67% male, mean age 48.1+/-27.0 years) with infection of the upper or lower respiratory tract were observed during a 13-month period. A total of 551 pathogenic microbial strains were isolated and tested for their in vitro susceptibility to piperacillin, piperacillin/tazobactam, ceftazidime, and ceftriaxone. Among all isolates, the four most frequent pathogens were Pseudomonas aeruginosa (132 isolates, 24%), Streptococcus pyogenes (99 isolates, 18%), Staphylococcus aureus (93 isolates, 17%), and Klebsiella pneumoniae (46 isolates, 8%). The susceptibility of gram-positive isolates ranged from 97.5% to 95.1%, and no remarkable difference was found in the antibacterial activity of tested b-lactam antibiotics. The susceptibility of gram-negative isolates to piperacillin and piperacillin/tazobactam was also similar: 96.5% and 97.1%, respectively. In contrast, differences were found between piperacillin (or piperacillin/tazobactam) and either ceftazidime (p=0.003) or ceftriaxone (p<0.0003) in gram-negative isolates. We conclude that, despite the extensive use of beta-lactam antibiotics (piperacillin, ceftazidime, and ceftriaxone) in medical practice during the past three decades, the susceptibility of the most common pathogens involved in the etiology of upper and lower respiratory tract infections to these antibiotics is still high. In particular, bacterial resistance developed by gram-positive organisms against piperacillin is negligible and not alarming.

N-acetylcysteine reduces the exacerbation rate in patients with moderate to severe COPD

OBJECTIVE

This study was performed to confirm the efficacy of a 6-month therapy with a formulation of N-acetylcysteine (NAC; 600 mg/day p.o.) on frequency and severity of exacerbations in patients suffering from chronic obstructive pulmonary disease (COPD).

METHODS

One hundred sixty-nine patients attending five Italian centres were recruited in an open, randomized, controlled study. The patients were randomly allocated to standard therapy plus NAC 600 mg once a day or standard therapy alone over a 6-month period. At baseline, medical history was evaluated, and physical examination was performed; occurrence and severity of exacerbations and side effects of NAC were analyzed after 3 and 6 months.

RESULTS

The results showed a decreased number of exacerbations (by 41%) in the group of patients treated with NAC and standard treatment: 46 patients had at least one exacerbation as compared with 63 patients of the group treated with standard therapy alone. Also the number of the patients with two or more exacerbations was lower in the NAC group (26%) than in the standard-therapy group (49%). The number of sick days was less (82) in the NAC group as compared with the standard-therapy group (155). There was a small but significant improvement in FEV(1) and MEF(50) in the NAC group. NAC once a day was well tolerated. There were no differences in the number of side effects reported in both groups.

CONCLUSIONS

These data confirm results of previous studies which reported a reduction in the number of exacerbations in patients having moderate to severe COPD treated with the antioxidant NAC. Further, the once-daily formulation is well tolerated and is likely to improve patient compliance with the prescribed regimen.

Causes of chronic persistent cough in adult patients: the results of a systematic management protocol

Chronic persistent cough (CPC) is a common symptom generally caused by postnasal drip syndrome (PND), bronchial asthma (A), chronic bronchitis (CB), and gastro-oesophageal reflux (GOR). The purpose of this study was to confirm the value of a testing protocol for determining the causes of CPC in adult patients and for evaluating the outcome of its specific therapy. Ninety-two patients with unexplained CPC were sent to our Department between January 1994 and June 1996. The mean (+/- SE) duration of cough was 32.7 (+/- 4.5) months. We studied these patients (number) by applying an anatomical protocol, according to which clinical evaluation they underwent: chest (92) and sinus (90) radiography, spirometry (92), methacholine inhalation challenge (88), skin prick tests (67), oesophagoscopy (28), prolonged oesophageal pH monitoring (14), and bronchoscopy (49), as needed. The results of the standardized specific therapy refer to 87 patients because 5 patients were lost to follow-up. Thus, CPC was due to: sinusitis or chronic rhinitis plus PND in 56% of patients, CB in 18%, A in 14%, GOR in 5%, PND and GOR in 6%, A and GOR in 1%. The cough went away in 79/87 patients after specific treatment, based on the diagnostic findings, giving a success rate of 91%. The results of the present study confirm previous findings indicating that one or more causes of chronic persistent cough can be found, and that an elevated success rate of therapy was reached when an anatomic diagnostic protocol was used.

Airways microbial flora in COPD patients in stable clinical conditions and during exacerbations: a bronchoscopic investigation

Patients affected with chronic obstructive pulmonary disease (COPD) undergo frequent exacerbations of their illness characterized by increased cough and expectoration. The precise aetiology of these episodes often remains unknown. In the absence of clinical or radiographic signs of pneumonia, bacterial or viral cultures of sputum usually provide little useful information. Thus, we performed fibreoptic bronchoscopy using a protected specimen brush (PSB) to obtain uncontaminated secretions for culture from 56 patients with COPD, 16 with stable clinical conditions and 40 affected with exacerbations of the disease. The aim of our study was to evaluate bronchial microbial flora by quantitative aerobic and anaerobic culture of each specimen. Twenty five subjects (45%), 4 (16%) in stable state and 21 (84%) with COPD exacerbations, had specimens which gave rise to significant bacterial growth (> 10(3) colony forming units.mL-1). The predominant bacteria were Streptococcus pneumoniae (in 10 cases) and alpha-haemolytic streptococci (in 6 cases); other bacteria found were coagulase-negative staphylococci and Branhamella catarralis in (2 cases each), and Proteus mirabilis, Haemophilus influenzae, Pseudomonas aeruginosa, Aerococcus viridans and Chromobacterium violaceum (each in a single case only). Although significant bacterial growth was more frequently found in patients with chronic obstructive pulmonary disease exacerbations and in those with a higher degree of bronchial inflammation, the differences between the two groups of patients were not statistically significant. Nevertheless, the results obtained in our study confirm the validity of and the need for reliable sampling methods (like the protected specimen brush) to demonstrate significant bacterial colonization of the airways in chronic obstructive pulmonary disease patients.

A 6-month comparison between formoterol and salmeterol in patients with reversible obstructive airways disease

The aim of this randomized, open, parallel group study was to compare the clinical efficacy of formoterol dry powder capsule 12 micrograms b.i.d. and salmeterol dry powder 50 micrograms b.i.d. in the treatment of patients with reversible obstructive airways disease. The 6-month treatment was preceded by a 2 week run-in period. Morning pre-dose peak expiratory flow (PEF) during the last 7 days of treatment was the primary variable. Throughout the study, patients recorded morning and evening pre-dose PEF, use of rescue medication, respiratory symptoms and adverse events. Clinic visits were scheduled at monthly intervals. Of the 482 patients randomized (equal numbers in the two treatment groups), 428 completed the study. Four hundred and twenty-five patients were included in the efficacy analysis for the primary variable. For mean morning pre-dose PEF during the last 7 days of treatment, the 95% confidence interval (CI) for the treatment contrast formoterol minus salmeterol was included entirely in the pre-defined range of equivalence (CI limits = -8.69, +9.841 min-1). This was also the case for the morning PEF during the last week before each clinic visit. For mean evening pre-dose PEF, the estimated treatment contrasts showed a trend towards superiority of formoterol over salmeterol, which became statistically significant at 2, 3 and 4 months (P < 0.05; estimated contrasts 7.27, 10.45 and 10.511 min-1, respectively). No treatment group differences were found in use of rescue medication and respiratory symptom scores. The incidence of adverse events was similar in the two groups. These findings demonstrate that formoterol 12 micrograms b.i.d. and salmeterol 50 micrograms b.i.d., both formulated as dry powders, have similar long-term efficacy and safety profiles in patients with reversible obstructive airways disease.

Pulmonary arteriovenous fistula in a patient with Rendu-Osler-Weber syndrome

Pulmonary arteriovenous fistula (PAVF) is an abnormal connection between pulmonary arteries and veins. Patients with PAVF may have the Rendu-Osler-Weber syndrome, a disease transmitted by autosomal dominant mechanisms. Here we describe a case of PAVF in a 56-year-old woman, who was admitted to our department because of dyspnea, hemoptysis, and a mass in the left lower lung found on chest X-ray. The diagnosis of PAVF was suspected according to clinical and physiological criteria and confirmed by magnetic resonance imaging of the chest. The PAVF was removed by left lower lobectomy. Anamnestic and clinical investigations of the patient's relatives led to the diagnosis of the Rendu-Osler-Weber syndrome.

Localized fibrous pleural tumour of the interlobular pleura

Localized fibrous tumours of the pleura (LFTP) are rare, generally benign and asymptomatic neoplasms, which originate from the pleural layers. We report on the case of a 67 year old woman who had a 1.5 cm diameter pulmonary nodule in the right upper lobe, which had been found by chance. Video-assisted thoracoscopy (VAT) was used to excise the nodule. The diagnosis of localized fibrous tumour of the interlobar pleura was made on microscopic evaluation. After 17 months, the patient is well and her chest radiographic image is normal.

Bronchoalveolar lavage fluid level of carcinoembryonic antigen in the diagnosis of peripheral lung cancer

The objective of this study was to verify whether the assay of carcinoembryonic antigen (CEA) in bronchoalveolar lavage fluid (BALF) can increase the sensitivity and specificity of serum CEA for the diagnosis of lung cancer. We examined 72 subjects, 53 males and 19 females, 18 affected with peripheral lung cancer (10 adenocarcinoma, 6 squamous cell carcinoma, 1 small cell lung cancer, 1 adenosquamous carcinoma), 19 with acute pneumonia, 14 with chronic obstructive pulmonary disease (COPD), 6 with interstitial lung disease (ILD), and 15 healthy subjects. CEA was assayed in blood and in BALF using microparticle enzyme immunoassay (MEIA) (IMX Abbott). The mean serum CEA value in the lung cancer group did not differ from that in each group of non-neoplastic subjects, neither was it different from that in healthy subjects. The mean BALF CEA in patients with lung cancer, pneumonia, and COPD was significantly increased compared with that in healthy subjects, whereas there was no difference between the three groups of patients. The ratio of BALF CEA was not significantly different in the three groups of patients. There were no differences according to the histological type of the tumour (adenocarcinoma or squamous cell carcinoma). Based on the results in healthy subjects, the upper limits of normal were defined for serum CEA, BALF CEA, and CEA/albumin ratio. Thus, the sensitivity of BALF CEA in detecting lung cancer (50%) was higher than that of serum CEA (33%), although clinically not useful. In addition, BALF CEA had only 59% specificity compared to 100% of serum CEA. The diagnostic accuracy was 79% for serum CEA and 56% for BALF CEA.(ABSTRACT TRUNCATED AT 250 WORDS)