Eosinophilic plastic bronchitis: Case series and review of the literature

Plastic bronchitis is a term used to describe group of life-threatening disorders characterized by the presence of large obstructing casts in the airways. Eosinophilic plastic bronchitis is a subtype of plastic bronchitis that occurs mainly in children and has not been well-described in the literature. Patients may have a history of asthma or atopy, but many do not. They often present with cough and wheezing, and frequently have complete collapse of one lung seen on imaging. The severity of presentation varies depending on the location of the casts, ranging from mild symptoms to severe airway obstruction and death. Bronchoscopy is often required to both diagnose and treat this condition. A variety of medical therapies have been used, although no formal studies have evaluated their efficacy. Symptoms may resolve after initial cast removal, but in some patients, cast formation recurs. Here, we report a case series of nine patients with eosinophilic plastic bronchitis and review the existing literature of this condition.

[Plastic bronchitis]

Plastic bronchitis (PB) is a rare disease caused by abnormal lymphatic vessels in the thorax. These vessels drain into the bronchi creating solid casts and potential life-threatening airway obstruction. This is a case report of a 30-year-old man diagnosed with PB after several years of extensive examinations due to symptoms misconceived as non-allergic asthma. We describe the first interventional treatment in Denmark using special T2 weighed MR imaging and dynamic contrast MR lymphangiography with subsequent embolisation of abnormal lymphatic vessels in the thorax.

Plastic bronchitis secondary to bocavirus in a previously healthy 4-year-old with negative lymphatic evaluation

This case of a child presenting with severe acute respiratory failure requiring extracorporeal membrane oxygenation due to plastic bronchitis demonstrates the possibility of developing this rare condition despite having no known underlying inflammatory or lymphatic issues. The normal lymphatic anatomy and flow in our patient several weeks after the acute illness suggests a transient lymphatic flow abnormality possibly driven by the acute lower respiratory tract infection with human bocavirus-1 (HBoV1). As there are now four patients in the literature identified with Plastic bronchitis (PB) in the setting of HBoV1, it may be beneficial to include HBoV1 in the initial workup of patients with unknown etiology of PB. While routine use of MR lymphangiography is not warranted, we wonder if the procedure might help realize lymphatic flow abnormalities crucial to the pathophysiology if it can be performed safely in the acute setting. The heterogeneous population presents a challenge when studying PB, thus future studies are needed to elucidate the complex pathophysiology, guide management, and better understand prognosis.

Nursing Progress of Hypertonic Saline Inhalation in the Treatment of Infantile Bronchitis Based on Image Enhancement

The onset of bronchiolitis is closely related to the anatomical characteristics of the bronchi in children of this age. This kind of injury is caused by epithelial necrosis, nasal mucosa, and mucosal edema caused by narrowing and blockage of the trachea. Children with this serious phenomenon will have respiratory and heart failure, which threatens the life of children to a large extent. In this paper, based on image enhancement technology, hypertonic saline aerosol inhalation treatment of pediatric bronchiolitis nursing care, through related cases, the application of image enhancement technology in hypertonic saline aerosol inhalation therapy and pediatric bronchiolitis is analyzed, and the tone mapping function is used. Tone mapping functions, hereditary arithmetics, and slope regimes for experimental field capture and detection were used for the objective of therapeutic approaches for the treatment of pediatric capillary pneumonia by hypertonic inhalation. Experimental results show that imaging technology hypertonic inhalation can control the main symptoms of bronchiolitis in infants and young children. Inhalation of 3% saline can shorten the course of moderately chronic children to half a year and can reduce the length of hospital stay by a quarter of the original requires hospitalization time, and the cure rate of pediatric bronchiolitis is increased to 93.7%.

Necrotizing tracheobronchitis causing airway obstruction complicated by pandemic 2009 H1N1 influenza: A case report

RATIONALE

Influenza is an infection caused by the influenza virus, and its symptoms are mostly mild and self-limiting. However, influenza can cause severe or fatal complications in high-risk patients. Although tracheobronchitis is one of the common complications of influenza, necrotizing tracheobronchitis is very rare. Herein, we describe a case of necrotizing tracheobronchitis causing airway obstruction complicated by pandemic 2009 H1N1 influenza.

PATIENT CONCERNS

A 60-year-old man presented with fever and dyspnea. On arrival at the emergency room (ER), the patient received oxygen 4 L/minute via a nasal prolong owing to mild hypoxemia. And invasive mechanical ventilation was needed 5 hours after arrival at the ER due to progressive hypoxemia.

DIAGNOSES

Fiberoptic bronchoscopy was performed owing to bloody secretion in the endotracheal tube and revealed diffuse tracheobronchitis with necrotic and hemorrhagic materials obstructing the trachea and bronchus. The pandemic 2009 H1N1 influenza virus was detected from the bronchial washing sample; no other microorganism was detected.

INTERVENTION

He received peramivir plus oseltamivir and broad-spectrum antibiotics.

OUTCOMES

The bloody secretion continued. He developed cardiac arrest due to airway obstruction on the 6th day of admission. After cardiac arrest, his condition progressed to multi-organ failure, and the patient died on the 10th day of admission.

LESSONS

We suggest that necrotizing tracheobronchitis be considered in patients with influenza who present with unexplained hypoxemia.

Severe Fever with Thrombocytopenia Syndrome Complicated with Pseudomembranous Aspergillus Tracheobronchitis in a Patient without Apparent Risk Factors for Invasive Aspergillosis

Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne infectious disease. A 91-year-old woman was admitted to our intensive-care unit with SFTS, and she developed dyspnea with wheezes 5 days after admission. Bronchoscopy showed scattered white mold in her central airway. An airway tissue biopsy and culture of bronchial lavage fluid revealed fungal hyphae in the necrotic tissue, confirmed as Aspergillus fumigatus. She was thus diagnosed with pseudomembranous aspergillus tracheobronchitis. She had no common risk factors for invasive aspergillosis (IA). Patients with SFTS, even those without apparent risk factors for IA, may be at risk of developing IA.

Obstructive bronchitis and recurrent pneumonia in esophageal achalasia in a child: A CARE compliant case report

RATIONALE

Esophageal achalasia is characterized by impaired relaxation of the cardia and dilation of the intrathoracic part of the esophagus. We describe the late presentation of achalasia in an 11-year old girl.

PATIENT CONCERNS

She suffered from recurrent pneumonia, obstructive bronchitis, and problems with swallowing solid food. Her family noted a wet pillow in the morning.

DIAGNOSES

This case report describes the typical symptoms of achalasia in children in order to facilitate earlier diagnosis of this rare disease. Our patient was admitted to a pediatric hospital for treatment of severe pneumonia, low-grade fever, and pancreatitis. A computed tomography (CT) scan of the thorax showed massive dilation of the esophagus and infiltration and partial atelectasis of the right lung. An upper gastrointestinal contrast study confirmed massive dilation of the esophagus and stenosis at the level of the cardia.

INTERVENTIONS

We performed laparoscopic Heller myotomy combined with Dor fundoplication. Bronchoscopic lavages were conducted in the pre- and postoperative period to relief obstruction of bronchi by purulent mucus secretions.

OUTCOMES

A further upper gastrointestinal contrast study demonstrated patency of the cardia and fast propulsive movement of contrast agent into the stomach. At follow up 2 months after the operation, the girl had gained 3 kg of body weight, and her respiratory, gastrointestinal, and swallowing symptoms had subsided. At follow-up 12 months after the operation, no recurrent symptoms of achalasia were recorded.

LESSONS

Late presentation of achalasia in children can mimic respiratory and gastrointestinal diseases. Laparoscopic Heller myotomy combined with Dor fundoplication is feasible and advisable in children suffering from achalasia of the cardia.

Feature selection using ant colony optimization with tandem-run recruitment to diagnose bronchitis from CT scan images

BACKGROUND AND OBJECTIVES

Computer-aided diagnosis (CAD) plays a vital role in the routine clinical activity for the detection of lung disorders using computed tomography (CT) images. It serves as a source of second opinion that radiologists may consider in order to interpret CT images. In this work, the purpose of CAD is to improve the diagnostic accuracy of pulmonary bronchitis from CT images of the lung.

METHODS

Left and right lung fields are segmented using optimal thresholding from the lung CT images. Texture and shape features are extracted from the pathology bearing regions. A hybrid feature selection approach based on ant colony optimization (ACO) combining cosine similarity and support vector machine (SVM) classifier is used to select relevant features. Additionally, tandem run recruitment strategy is included in the selection activity to choose the promising features. The SVM classifier is trained using the selected features and the performance of the trained classifier is evaluated using trivial performance evaluation measures.

RESULTS

The training and testing datasets used in building the classifier model are disjoint and contains 200 CT slices affected with bronchitis, 50 normal slices and 300 slices with cancer. Out of 100 features extracted from each CT slice, a subset of 60 features is used for classification. ACO with tandem run strategy yielded 81.66% of accuracy whereas ACO without tandem run yielded an accuracy of 77.52%. When all the features are used for classifier training without feature selection algorithm, an accuracy of 75.14% is achieved.

CONCLUSION

From the results, it is inferred that identifying relevant features to train the classifier has a definite impact on the classifier performance.

Use of serial rigid bronchoscopy in the treatment of plastic bronchitis in children

AIM

Plastic bronchitis (PB) is a rare disorder characterized by formation of bronchial casts (BC) in the tracheobronchial tree with partial or complete airway obstruction. Although lysis of casts with several fibrinolytic agents has been reported, removal of BC with bronchoscope provides better clearance of airways. A retrospective study was performed to evaluate the use of serial rigid bronchoscopy (RB) in the treatment of PB in children.

PATIENTS AND METHODS

Between 2011 and 2015, children with partial or complete airway obstruction with PB were evaluated for age, gender, underlying disease, clinical findings, results of bronchoscopic interventions and histopathologic findings.

RESULTS

Five patients with 14 RB interventions were evaluated. The mean age of the patients was 7.8years (min: 3years - max: 14years) and male-female ratio was 4:1. All of the patients were diagnosed as asthma and none of them had underlying cardiac disease. Suction of mucus plaques and bronchoalveolar lavage were performed in all patients with flexible bronchoscopy. Also, aerosolized tissue plasminogen activator was used in two patients. During follow-up serial RB was indicated in patients with persistent atelectasis and severe airway obstruction. The most common localization of BC was left main stem bronchus and bilateral cast formation was detected in 7 interventions. Although, removal of BC was challenging in two patients because of cast friability and fragmentation, most of the plugs were successfully removed with optical forceps and rigid suctioning. Two patients underwent repeated RB (min: 3 - max: 8) for recurrent symptoms. Histopathologic evaluation of BC revealed Charcot-Leyden crystals with inflammatory cells in all patients. The time interval between RB interventions was one to five months.

CONCLUSION

BC are tenacious mucus plugs which are firmly wedged to the tracheobronchial tree. The use of optical forceps with rigid suction provides adequate removal of BC during RB. Because of underlying disease, it is difficult to cure cast formation. Therefore, most of the patients require serial RB when they become unresponsive to standard therapy or develop partial or complete airway obstruction.

High-resolution CT in chronic pulmonary changes after mustard gas exposure

Purpose: To identify the findings of high‐resolution CT (HRCT) of the lung in patients with previous sulfur mustard gas exposure, and to correlate these findings with clinical and chest X-ray (CXR) results.

Material and Methods: 50 consecutive patients were studied prospectively. The clinical data were recorded. Standard p.a. CXR and HRCT of the lung and spirometry were performed. The findings of CXR, HRCT and clinical and spirometry results were scored between 0 and 3 according to the severity of the findings.

Results: HRCT abnormality was detected in all 50 patients (100%), while CXR was abnormal in 40 patients (80%). The most common HRCT findings was airway abnormalities (bronchial wall thickening in 100% of cases). Other important findings were suggestive of interstitial lung disease (ILD) (80%), bronchiectasis (26%), and emphysema (24%). A statistically significant correlation was found between the severity of clinical presentation and that of the HCTR scores in patients with bronchiectasis, bronchitis and ILD ( p< 0.05), but not with severity scores of HRCT in patients with emphysema. No significant correlation was found between severity scores of CXR findings. HRCT evidence of bronchial wall thickening and with a lower frequency ILD were present despite normal CXR in 20% of the patients.

Conclusion: The results of this study suggest that bronchial wall thickening, ILD and emphysema are common chronic pulmonary sequelae of sulfur mustard injury. HRCT of the chest should be considered as the imaging modality of choice in chemical war injury.

Asthmatic bronchitis for 2 years: A case report

Longstanding asthmatic bronchitis, without evidence of underlying disease, occurring in middle-aged patients, is usually attributed to chronic obstructive pulmonary disease and is treated appropriately.

We report a case of 2-year asthmatic bronchitis with recurrent attacks of wheezing, in a 60-year-old patient. He had three repeated hospitalizations, in different institutions, where he was treated for exacerbations of chronic bronchitis complicated by lower respiratory tract infections. During his final hospitalization, a tracheal hamartoma was found and removed, releasing him from his symptoms.

Clinical presentation of a patient with cutis laxa with systemic involvement: a case report

Cutis laxa (CL) or elastolysis is a rare inherited or acquired connective tissue disorder in which the skin becomes inelastic and hangs loosely in folds (Mitra et al., 2013). The clinical presentation and the type of inheritance show considerable heterogeneity (Shehzad et al., 2010). We aimed to present the atypical case of a young male patient diagnosed at 36-year-old with CL with systemic involvement. The complex medical history, with a suspected but unconfirmed progeria at nine months, repeated lung and urinary infections, complicated inguinoscrotal hernia, prostatic hypertrophy, bilateral entropion, colorectal diverticula and heart failure, suggested a systemic genetic disease, but the absence of family history made the diagnosis of CL difficult. The skin biopsy and the characteristic features discovered during anatomopathological exam made possible the positive and differential diagnosis, creating the link between the various organ involvement and CL diagnosis. Because of the age of our patient, of normal growth and mental development, and negative family history, we suspected an autosomal dominant form of CL with early onset and severe manifestation. Of course, we cannot exclude a recessive form, due to the heterogeneity of this disease.

PECULIARITIES OF THE COURSE OF THE UPPER ALIMENTARY TRACT DISEASES IN CHILDREN WITH BRONCHOOBSTRUCTIVE SYNDROME

The aim of the study was to improve the tactics of treatment of bronchoobstructive syndrome (BOS) in associative course with gastroesophageal reflux disease (GERD) in children.

MATERIALS AND METHODS

180 children aged 6-16 with diseases of the respiratory organs with BOS and GERD symptoms were examined: 85 of them--with bronchial asthma (BA), 34--with an acute course of pneumonia, 29--with recurrent obstructive bronchitis. Comparison groups were composed of 93 children, the number of practically healthy children (the control group) was 28 persons. The analysis of risk factors of associative pathology development, roentgenographic study, investigation of the function of external respiration (FER) (peak flowmetry, spirometry), intracavitary pH-metry, esophagofibrogastroduodenoscopy (EFGDS) and ultrasonic investigation (USI) of the organs of the gastro-intestinal tract (GIT) were carried out.

RESULTS

Diseases of the respiratory organs with BOS in the groups of the patients under investigation in 43.9% of cases on an average associated with GERD. In a severe course of bronchial asthma GERD was detected 3,4 times more frequently in the boys, while in a lengthy course of pneumonia with BOS--1,9 times more frequently in the girls. Chronic gastritis (ChG) and chronic gastroduodenitis (ChGD) in BA were revealed in 40.6% of the patients, in pneumonia--in 45.7%, in recurrent bronchitis--in 33.3% of the patients. Peculiarities of pre-morbid background of BA and GERD associative course were exhibited by gestosis, threat of abortion, intrauterine hypoxia of the fetus, social troubles of the family. Manifestations of BA in children in 36% of cases were observed 6-12 months after the onset of GERD. The designed individual anti-reflux programs in complex therapy of respiratory organs' diseases with BOS associated with GERD reduce the frequency of exacerbations and hospitalizations of patients with BA, improve their life quality.

Prolonged period of acute bronchitis with late progression to acute respiratory distress syndrome as possible result of influenza A (H1N1) virus infection

Young adults with underlying medical conditions who are infected with the H1N1 virus are at risk of quickly progressing from mild upper airways infection to severe ARDS within 4 to 5 days after the onset of the illness. Here, we report the case of a 46-year-old morbidly obese and diabetic woman infected with the H1N1 virus who developed acute bronchitis that lasted for 4 weeks and then progressed to ARDS. We discuss the month-long persistence of the H1N1 viral bronchitis and its late progression to ARDS which may reflect prolonged viral activity. Such a prolonged, rather than quick, course of deterioration can cause clinicians to misdiagnose the etiology of the ARDS and may cause the patient to receive a prolonged treatment with steroids to treat bronchitis symptoms. These steroids may cause increased viral replication and promote parenchymal involvement and the development of ARDS.

Chest computed tomography findings in severe influenza pneumonia occurring in neutropenic cancer patients

OBJECTIVE

To describe the chest computed tomography findings for severe influenza H1N1 infection in a series of hospitalized neutropenic cancer patients.

METHODS

We performed a retrospective systematic analysis of chest computed tomography scans for eight hospitalized patients with fever, neutropenia, and confirmed diagnoses of influenza H1N1. The clinical data had been prospectively collected.

RESULTS

Six of eight patients (75%) developed respiratory failure and required intensive care. Prolonged H1N1 shedding was observed in the three mechanically ventilated patients, and overall hospital mortality in our series was 25%. The most frequent computed tomography findings were ground-glass opacity (all patients), consolidation (7/8 cases), and airspace nodules (6/8 cases) that were frequently moderate or severe. Other parenchymal findings were not common. Five patients had features of pneumonia, two had computed tomography findings compatible with bronchitis and/or bronchiolitis, and one had tomographic signs of chronicity.

CONCLUSION

In this series of neutropenic patients with severe influenza H1N1 infection, chest computed tomography demonstrated mainly moderate or severe parenchymatous disease, but bronchiolitis was not a common feature. These findings associated with febrile neutropenia should elicit a diagnosis of severe viral infection.

[A case of follicular bronchiolitis in which progressive bronchiectasis developed over 7 years]

A 53-year-old man presented to our hospital with cough in August 2004. Chest computed tomography showed an anterior mediastinal tumor, centrilobular nodules and mild bronchiectasis. Centrilobular nodules were improved by the administration of clarithromycin, and we resected an anterior mediastinal tumor (thymoma). Partial lung resection was also performed, and a diagnosis of follicular bronchiolitis was established. The number of centrilobular nodules increased after cessation of the clarithromycin, and its administration was reinitiated; however, the patient's bronchiectasis and airway obstruction worsened. Steroid administration was begun in January 2010; thereafter, pulmonary function, bronchial wall thickness, cough and shortness of breath improved. Since April 2004, the patient has experienced 12 episodes of airway infection. Careful attention should be paid to recurrent airway infection, progressive bronchiectasis and airway obstruction in patients with follicular bronchiectasis.

Diagnosing and preventing chronic suppurative lung disease (CSLD) and bronchiectasis

Current diagnostic labelling of childhood bronchiectasis by radiology has substantial limitations. These include the requirement for two high resolution computerised tomography [HRCT] scans (with associated adversity of radiation) if criteria is adhered to, adoption of radiological criteria for children from adult data, relatively high occurrence of false negative, and to a smaller extent false positive, in conventional HRCT scans when compared to multi-detector CT scans, determination of irreversible airway dilatation, and absence of normative data on broncho-arterial ratio in children. A paradigm presenting a spectrum related to airway bacteria, with associated degradation and inflammation products causing airway damage if untreated, entails protracted bacterial bronchitis (at the mild end) to irreversible airway dilatation with cystic formation as determined by HRCT (at the severe end of the spectrum). Increasing evidence suggests that progression of airway damage can be limited by intensive treatment, even in those predestined to have bronchiectasis (eg immune deficiency). Treatment is aimed at achieving a cure in those at the milder end of the spectrum to limiting further deterioration in those with severe 'irreversible' radiological bronchiectasis.

Gastro-esophageal studies in relationship to respiratory problems

Gastroesophageal reflux represents a physiological phenomenon in the first year of life. The reflux associated with clinical complications is defined as "gastroesophageal reflux disease" (GERD), that may be esophageal or extra-esophageal, as is for respiratory problems. Nuclear medicine investigations have given an important contribution to the diagnostic assessment and therapeutical management of GERD in children, by means of the following procedures: scintigraphy of the gastroduodenal transit and reflux detection, scintigraphic quantification of gastric emptying, scintigraphy of the esophageal transit, radioisotopic salivagram, scintigraphy of lung perfusion, ventilation and of mucociliary clearance. All of these investigations are among the less irradiating nuclear medicine procedures, therefore particularly adapted to paediatrics. The main clinical advantages of this body of information include: improvements in the management of many asthmatic children, surgical anti-reflux intervention success-rate increase, prompt regional lung alterations detection for preventing stable tissue damage, and many others.

LONG-TERM CLEARANCE FROM SMALL AIRWAYS IN PATIENTS WITH CHRONIC BRONCHITIS: EXPERIMENTAL AND THEORETICAL DATA

Long-term clearance (21 days) from small airways was studied in 9 patients with chronic bronchitis (CB), 65 +/- 10 (mean +/- SD) years, and was compared to 15 age-matched healthy subjects of 67 +/- 7 (mean +/- SD) years. Six of the CB patients were studied twice. All subjects inhaled monodisperse 6 microm Teflon particles labelled with 111In with an extremely slow inhalation flow, 0.05 L/s. With this inhalation technique, particles are deposited mainly in the small conducting airways. Lung retention was measured at 0 and 24 hours, and at 7, 14, and 21 days after inhalation. Lung retention at 24 hours (% of deposition) was highly reproducible for the CB patients, studied twice, but it was not significantly different from that found for healthy subjects and, furthermore, not related to airway resistance (Raw), nor FEV1% predicted. Both healthy subjects and CB patients showed significant clearance in the period between 24 hours and day 21. The mean retention were higher (P<.001) in CB patients, 90%, 89%, 87% of 24 hours retention at 7, 14, and 21 days, compared to 80%, 76%, 71% of 24 hours retention at 7, 14, and 21 days measurements for healthy subjects. Clearance after 24 hours (retention at 21 days) was significantly related to FEV1% predicted, but not Raw. Reduced FEV1% predicted values was associated with slower clearance rates. Model calculations were performed to estimate intrapulmonary deposition patterns. A limited effect was shown for airway dimension and uneven ventilation. The differences between healthy and CB patients were, however, limited. It is not possible to conclude whether the difference in clearance after 24 hours is an effect of change in regional deposition, or slower small airway clearance in diseased airways. This technique to target the smallest ciliated airways, using an extremely slow inhalation flow, provides new possibilities to investigate smallest airway function and drug delivery that merits further investigations.

High-resolution computed tomography features in patients with chronic obstructive pulmonary disease

INTRODUCTION

In recent years, there has been increasing interest in diagnosing various components of chronic obstructive pulmonary disease (COPD) using high-resolution computed tomography (HRCT). The present study was undertaken to evaluate HRCT features in patients with COPD.

METHODS

40 male patients with COPD (age 40 years or older) and with a significant smoking history (20 pack-years or more) were included in the study. They were evaluated for HRCT features including vascular attenuation and distortion, mosaic attenuation pattern, directly visible small airways, low attenuation areas of emphysema and measures of hyperinflation of the lungs: tracheal index, sterno-aortic distance, thoracic cage ratio and thoracic cross-sectional area.

RESULTS

The tracheal index ranged from 0.46 to 0.94; Saber-sheath trachea was found in 14 patients. The mean thoracic cage ratio at two levels, carina and 5 cm below carina, were 0.69 (range 0.61-0.78) and 0.73 (range 0.62-0.83), respectively. Sterno-aortic distance at carinal level ranged from 1.43 to 4.55 cm, with a mean of 3.00 cm. Directly visible small airways was the commonest finding (36 patients), followed by vascular attenuation (25 patients), mosaic attenuation pattern (16 patients) and vascular distortion (8 patients). Among various subtypes of emphysema, centriacinar emphysema was commonest (16 patients), followed by paraseptal (13) and panacinar emphysema (11).

CONCLUSION

There are certain specific HRCT features of emphysema and it is possible on HRCT to identify the subtypes of emphysema, such as centriacinar, panacinar and paraseptal emphysema. Various features of hyperinflation can also be well identified and quantified on HRCT.

[Plastic bronchitis: report of a pediatric case]

Plastic bronchitis (PB) is a rare disease, characterized by the formation of obstructive branching airways tracheobronchial casts. Commonly, PB often complicates the course of cardiac or respiratory disorders. The occurrence of PB before manifestation of the underlying respiratory disease is unusual. We report on the case of a boy, aged three years and eight months, free from underlying pulmonary disease, who presented with extensive atelectasis of the left lung during an acute respiratory tract infection. Bronchoscopy revealed the obstruction of the left tracheobronchial tree with large purulent casts. After bronchoscopic removal of the casts, the boy became asymptomatic. Initial aetiological investigations were negative. Two years later, the patient developed an asthma.

Volumetric measurements of lung nodules with multi-detector row CT: effect of changes in lung volume

Objective

To evaluate how changes in lung volume affect volumetric measurements of lung nodules using a multi-detector row CT.

Materials and Methods

Ten subjects with asthma or chronic bronchitis who had one or more lung nodules were included. For each subject, two sets of CT images were obtained at inspiration and at expiration. A total of 33 nodules (23 nodules ≥ 3 mm) were identified and their volume measured using a semiautomatic volume measurement program. Differences between nodule volume on inspiration and expiration were compared using the paired t-test. Percent differences, between on inspiration and expiration, in nodule attenuation, total lung volume, whole lung attenuation, and regional lung attenuation, were computed and compared with percent difference in nodule volume determined by linear correlation analysis.

Results

The difference in nodule volume observed between inspiration and expiration was significant (p < 0.01); the mean percent difference in lung nodule volume was 23.1% for all nodules and for nodules ≥ 3 mm. The volume of nodules was measured to be larger on expiration CT than on inspiration CT (28 out of 33 nodules; 19 out of 23 nodules ≥ 3 mm). A statistically significant correlation was found between the percent difference of lung nodule volume and lung volume or regional lung attenuation (p < 0.05) for nodules ≥ 3 mm.

Conclusion

Volumetric measurements of pulmonary nodules were significantly affected by changes in lung volume. The variability in this respiration-related measurement should be considered to determine whether growth has occurred in a lung nodule.

Radiología de las infecciones fúngicas invasoras del aparato respiratorio

Invasive fungal infections of the respiratory tract are a major cause of serious morbidity and mortality especially in immunocompromised patients due to neutropenia, corticosteroids, or hematologic malignancy. The role of imaging is very important in the management of patients with fungal infections and chest x-ray is still the most used exploration. Nevertheless, new approaches recommend the systematic use of computed tomography scan for early documentation of invasive fungal infection. Combination of clinical setting with recognition of radiological pattern is the best approach to pulmonary fungal diseases. The following is a review of the imaging features of different invasive fungal infections we can face in our daily practice.

Acute and repeated inhalation lung injury by 3-methoxybutyl chloroformate in rats: CT-pathologic correlation

OBJECTIVES

To investigate the acute and repeated pulmonary damage in Sprague-Dawley rats caused by the inhalation of 3-methoxybutyl chloroformate (3-MBCF) using computed tomography (CT), and to correlate these results with those obtained from a pathological study.

METHODS

Sixty, 7-week-old rats were exposed to 3-MBCF vapor via inhalation (6 h/day) for 1 day (N=20), 3 days (N=20), and 28 days (5 days/week) (N=20) using whole body exposure chambers at a concentration of 0 (control), 3, 6 and 12 ppm. CT examinations including densitometry and histopathologic studies were carried out. For the follow-up study, the rats exposed for 3 days were scanned using CT and their pathology was examined at 7, 14, and 28 days.

RESULTS

There was a significant decrease in the parenchymal density in the groups exposed to the 3-MBCF vapors for 1 day at 3 ppm (p=0.022) or 6 ppm (p=0.010), compared with the control. The parenchymal density of the rats exposed to 12 ppm was significantly higher. The pathological findings in this period, the grades of vascular congestion, tracheobronchial exfoliation, and alveolar rupture were significant. In the groups exposed for 3 days, there was a large decrease in the parenchymal density with increasing dose (control: -675.48+/-32.82 HU, 3 ppm: -720.65+/-34.21 HU, 6 ppm: -756.41+/-41.68 HU, 12 ppm: -812.56+/-53.48 HU) (p=0.000). There were significant density differences between each dose in the groups exposed for 28 days (p=0.000). The CT findings include an irregular lung surface, areas of multifocal, wedge-shaped increased density, a heterogeneous lung density, bronchial dilatation, and axial peribronchovascular bundle thickening. The histopathology examination revealed the development of alveolar interstitial thickening and vasculitis, and an aggravation of the mainstem bronchial exudates and bronchial inflammation. The alveolar wall ruptures and bronchial dilatation became severe during this period. On the follow-up study, the groups exposed for 3 days showed diffusely increased parenchymal density on the 7 days study, but the lung densities were lower at 14 and 28 days than at 3 days. In the rats exposed to lowest concentration, the pulmonary parenchymal density and pathologic findings rapidly returned to normal within 1 week.

CONCLUSIONS

Decreased parenchymal density of the lung was a common CT finding in acute and repeated inhalation injury. The air accumulation is believed to be the results of tracheolaryngeal inflammatory edema, bronchial dilatation, and alveolar rupture from the early period.

Case of pseudomembranous necrotizing tracheobronchial aspergillosis in an immunocompetent host

A 44-year-old Korean male died of rapidly progressive respiratory failure and refractory hypoxemia in 8 days after being admitted with a fever and dyspnea. The patient was diagnosed with pseudomembranous necrotizing tracheobronchial aspergillosis by fibroptic bronchoscopy and it was not related to an invasion of the pulmonary parenchyma. To the best of our knowledge, this case represents a patient with pseudomembranous necrotizing tracheobronchial aspergillosis that developed in an immunocompetent host, rapidly resulting in airway obstruction with acute respiratory failure and refractory hypoxemia without an invasion of the pulmonary parenchyma.

The spectrum of tuberculosis and non-tuberculous mycobacterial infection

The spectrum of radiographic findings in pulmonary infections due to M. tuberculosis (TB) and non-tuberculous mycobacteria (NTM) are being increasingly discussed, primarily as a result of the increasing prevalence of these infections. The NTM organisms are often overlooked as potential infecting organisms, diagnosis is often delayed and radiologists tend not to include NTM in their differential diagnosis. The literature on the imaging appearances of NTM pulmonary infections is now sufficiently large as to identify some features that would help to distinguish an NTM infection from conventional pulmonary tuberculosis, allowing the radiologist at least to raise the possibility of NTM infection. This review article is intended to describe the radiological features, in the immunocompetent host, that accompany TB and NTM pulmonary infections and highlight the imaging features that would favour an NTM as the causative organism.

Ultrasonographic study of postcibal gastro-esophageal reflux and gastric emptying in infants with recurrent respiratory disease

AIM

To check the utility of postcibal ultrasonography for the evaluation of reflux in relation to gastric emptying in infants with recurrent respiratory symptoms and to link imaging with clinical data.

METHODS

Esophageal reflux (hyperechoic retrograde filling) and gastric emptying (antral areas) were quantified before and after ingestion of a standard formula in 35 untreated infants (13 with chronic cough, 22 with recurrent bronchitis) and in 31 controls.

RESULTS

The prevalence of abnormal (> or =8 episodes) postcibal refluxes was 74% in patients and 3% in controls. Number, duration of the longest episode and extent of refluxes were significantly higher in patients compared to controls. Number of refluxes was higher in patients with symptomatic refluxes than in those without. Infants with recurrent bronchitis had more refluxes than those with chronic cough and controls. Extent and timing of gastric emptying were similar in patients and controls.

CONCLUSION

Esophageal ultrasonography is a useful and physiological test in infants with recurrent respiratory diseases, which have a high prevalence of abnormal postcibal esophageal reflux and a gastric emptying similar to that of normal controls. Esophageal reflux is more severe in subjects with recurrent bronchitis than in those with chronic cough.

[Matters of roentgen diagnostics of idiopathic interstitial pneumonia]

This article is devoted to roentgen diagnostics of idiopathic interstitial pneumonia. 7 types of idiopathic interstitial pneumonia are described, including clinical, morphological and roentgenological characteristics. X-ray methods are presented as possible techniques for determination of the type of the idiopathic interstitial pneumonia.

Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines

OBJECTIVES

Nonasthmatic eosinophilic bronchitis is a newly recognized cause of chronic cough. Our objective was to review the pathogenesis, natural history, diagnosis, and treatment of this condition.

METHODS

The current literature was reviewed using an Ovid MEDLINE and PubMed literature review for all studies published in the English language from 1963 to December 2004 using the medical subject heading term "eosinophilic bronchitis."

RESULTS

Nonasthmatic eosinophilic bronchitis is a common cause of chronic cough. It is characterized by the presence of eosinophilic airway inflammation, similar to that seen in asthma. However, in contrast to asthma, nonasthmatic eosinophilic bronchitis is not associated with variable airflow limitation or airway hyperresponsiveness. The differences in functional association are related to differences in the localization of mast cells within the airway wall, with airway smooth muscle infiltration occurring in patients with asthma, and epithelial infiltration in patients with nonasthmatic eosinophilic bronchitis. Diagnosis is made by the confirmation of eosinophilic airway inflammation usually with induced sputum analysis after the exclusion of other causes for chronic cough on clinical, radiologic, and lung function assessment. The cough usually responds well to treatment with inhaled corticosteroids. The dose and duration of treatment differ between patients. The condition can be transient, episodic, or persistent unless treated, and occasionally patients may require long-term prednisone treatment.

CONCLUSIONS

Further study of this condition may improve our understanding of airway inflammation and airway responsiveness, leading to novel targets for therapeutic agents for the treatment of both asthma and nonasthmatic eosinophilic bronchitis.

Risk factors and recurrence patterns in 203 patients with hemoptysis

Management of hemoptysis requires prompt diagnosis and patient stabilization especially in massive hemoptysis as a potentially life-threatening condition. This retrospective study was designed to determine the etiologic distribution of hemoptysis, the role of the fiberoptic bronchoscopy (FOB) as a diagnostic tool, and to clarify potential risk factors for massive hemoptysis and recurrences. A total of 203 patients (181 male, 22 female) with hemoptysis admitted to our hospital were evaluated retrospectively. Tuberculosis was the leading cause of hemoptysis (n = 89; 43.8%) followed by lung cancer (21.7%) and chronic bronchitis (n = 11; 5.5%). FOB plays an essential role for localization of bleeding and diagnosis, although no bronchoscopic abnormality was found in our 31 patients (15.3%). Twenty-nine of the patients (14.3%) had recurrent hemoptysis and hemoptysis lasting longer than five days was found as a risk factor for recurrences (p = 0.02). Having lung cancer was an independent negative risk factor for recurrent hemoptysis using multivariate analysis (n = 44; p = 0.034). Twenty two of the patients (10.8%) had severe hemoptysis and managed medically. In our study, tuberculosis, lung cancer and heavy cigarette smoking were revealed as independent predictors of massive hemoptysis (p = 0.016, 0.001, 0.041 respectively). Hemoptysis is a common respiratory symptom that always requires investigation by using FOB and radiography in order to determine exact site of bleeding and etiology. Hemoptysis continuing more than five days and lung cancer diagnosis may indicate recurrent bleeding and need more attention.

Congenital bronchial atresia (CBA). A critical review of CBA as a disease entity and presentation of a case series

PURPOSE

To analyse the state of the art of diagnostic imaging in the rare disease entity known as congenital bronchial atresia (CBA) and to suggest new guidelines for diagnosis.

MATERIALS AND METHODS

From January 2002 to December 2003 we examined 6 patients, 4 males and 2 females. Four of them complained of relapsing bronchitis; one patient was admitted with a diagnosis of pulmonary abscess. All patients underwent chest X-ray and MDCT.

RESULTS

Five patients presented at chest x-ray the typical association of hilar mass and distal parenchymal hyperinflation that raised the suspicion of CBA; the remaining patient presented an area of parenchymal translucency that prompted us to perform MDCT, which showed severe stenosis of the segmental bronchus. CBA involved the left upper lobe (LUL) in 4 patients and the right upper lobe (RUL) in the remaining 2. In 50% of cases there were associated anomalies: distal bronchiectasis, bronchogenic cyst, anomaly of branching of bronchial tree and vascular structure.

CONCLUSIONS

CBA is a relatively rare, generally oligosymptomatic malformation. Knowledge of the signs present at chest X-ray can prompt the radiologist to perform a CT scan. MDCT with multiplanar reconstruction is fundamental for the characterisation, localisation and study of the distribution of the lesion, helping to make a precise diagnosis. Surgery is seldom required and at any rate only performed in case of complications.

Differences in radiological/HRCT findings in eosinophilic bronchitis and asthma: implication for bronchial responsiveness

BACKGROUND

Airway hyperresponsiveness in asthmatics is considered to be one of the major consequences of airway inflammation and remodelling. Airway responsiveness is normal in patients with eosinophilic bronchitis (EB), despite eosinophilic inflammation of the airways comparable to that which occurs in asthmatics. Comparisons between asthma and EB should clarify the changes in airway morphology that are related specifically to AHR in asthmatics.

METHODS

Eighteen asthmatic patients, 15 patients with EB, and 11 healthy subjects were recruited. Airway wall area percentage (WA%), centrilobular prominence, and air trapping were compared using thin slice section computed tomography.

RESULTS

WA% was significantly greater in asthmatics than in patients with EB (72 (3.1)% v 54 (2.1)%, p = 0.032) and was similar in EB patients and controls (54 (2.1)% v 57 (1.8)%, p>0.05). Centrilobular prominence and air trapping were similar in EB patients and asthmatics and were significantly greater than in controls.

CONCLUSION

WA% rather than air trapping or centrilobular prominence may be associated with the airway hyperresponsiveness that occurs in asthmatics but not in patients with EB.

Endobronchial histoplasmosis: a masquerade of primary endobronchial neoplasia--a clinical study of four cases

BACKGROUND

Histoplasma capsulatum is a dimorphic fungus with both hyphal and microconidial elements and is endemic in certain areas of the central United States. Most clinically recognized syndromes are self-limited, presenting in more than 80% of cases as an influenza-like acute pulmonary illness. We encountered four patients with an endobronchial presentation of histoplasmosis masquerading as a bronchogenic malignancy.

METHODS

The patient files from one of the authors (PR) uncovered four patients diagnosed with, and treated for, endobronchial histoplasmosis; all cases were referred for a presumptive diagnosis of endobronchial neoplasia.

RESULTS

The case study group comprised three women, ages 52, 68, and 81 years, respectively, and one man age 29 years, all presenting with recurrent hemoptysis. An obstructing adherent lesion was apparent on bronchoscopy in three, involving the right upper lobe bronchus in two, and right mainstem bronchus in one. In one patient, blood was observed in the bronchus intermedius; there was no gross lesion. Recurrent hemoptysis necessitated a right upper sleeve lobectomy in one, a right upper lobe lobectomy and right lower wedge resection in one, a right middle lobectomy in one, and wedge resection of the right upper lobe in one.

CONCLUSIONS

Endobronchial histoplasmosis may mimic primary bronchogenic carcinoma, presenting as a fixed obstructing endobronchial lesion associated with hemoptysis; the latter potentially necessitating surgical intervention. Endobronchial histoplasmosis should be considered in the differential diagnosis of obstructing endobronchial lesions associated with hemoptysis, especially when prior and(or) concurrent biopsies fail to disclose malignancy.

[Detection of airways stenoses: comparison of virtual and flexible bronchoscopy]

PURPOSE

To compare virtual with flexible bronchoscopy for the detection of bronchial stenoses.

MATERIALS AND METHODS

In a retrospective study, we compared the results of 26 patients, who had clinical suspected pathologies of the tracheobronchial airways and underwent both flexible bronchoscopy and multislice CT with 3D surface rendering of the airways. Flexible bronchoscopy and virtual bronchoscopy were compared as to the rate of detecting bronchial stenoses. For statistical analysis, we divided the tracheobronchial tree in the following sections: trachea, 2 main bronchi, 6 lobar bronchi, 18 segmental bronchi and 36 subsegmental bronchi, corresponding to 63 bronchial sections for each patient (on average) and a total of 1638 bronchial sections for all 26 patients. We graded the bronchial stenosis as less than 50 %, as 50 to 95 % and as complete obstruction.

RESULTS

Virtual bronchoscopy detected 25 bronchial stenoses, while flexible bronchoscopy only revealed 17 stenoses. Stenoses with a diameter less than 50 % were found with virtual bronchoscopy 14 times and with flexible bronchoscopy 10 times. Stenoses with a diameter between 50 and 95 % were detected 7 and 4 times, respectively, and complete obstructions 4 and 3 times, respectively. Tracheobronchial stenoses were well recognized with virtual bronchoscopy. Moreover, the virtual method enabled the visualization of high-grade stenoses and post-stenotic areas that could not be passed by the fiberoptic bronchoscope. Virtual bronchoscopy detected stenoses at a higher rate but the difference was not statistically significant (stenoses < 50 %: p = 0.352, 50 - 95 %: p = 0.339, complete obstruction: p = 0.696).

CONCLUSION

Virtual bronchoscopy is a useful non-invasive method for the diagnostic evaluation of the tracheobronchial tree. In comparison with flexible bronchoscopy, virtual bronchoscopy is superior in revealing high-grade stenoses and visualizing post-stenotic areas.