Pulmonary manifestations of peripheral T-cell lymphoma: case report and review of the literature

INTRODUCTION

Peripheral T-cell lymphomas (PTCL) represent approximately 10% of non-Hodgkin's lymphomas. Pulmonary involvement is an uncommon manifestation of this heterogeneous group of malignancies.

METHODS

Report of a case.

RESULTS

This case report describes a 75-year-old man with fever, weight loss, anemia, enlargement of spleen and liver, atypical lymphocytes and pulmonary nodules. Lung biopsy showed lymphocytic infiltration of the lung parenchyma. T-cell receptor gamma gene rearrangement by polymerase chain reaction confirmed the diagnosis of peripheral T-cell lymphoma. Unfortunately, the patient died because of refractory and aggressive disease.

CONCLUSION

Pulmonary and pleural involvement are seen in patients with PTCL and usually carry a poor prognosis. The subject of pulmonary involvement in peripheral T-cell lymphoma is discussed.

Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares

BACKGROUND

Central venous pressure (CVP) is used almost universally to guide fluid therapy in hospitalized patients. Both historical and recent data suggest that this approach may be flawed.

OBJECTIVE

A systematic review of the literature to determine the following: (1) the relationship between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the ability of the change in CVP (DeltaCVP) to predict fluid responsiveness.

DATA SOURCES

MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.

STUDY SELECTION

Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the associated between CVP/DeltaCVP and the change in stroke volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients.

DATA EXTRACTION

Data were abstracted on study design, study size, study setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator characteristic [ROC]) between CVP/DeltaCVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders. Metaanalytic techniques were used to pool data.

DATA SYNTHESIS

The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/DeltaCVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28). Overall, 56+/-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between DeltaCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7+/-2.32 mm Hg [mean+/-SD] in the responders as compared to 9.7+/-2.2 mm Hg in nonresponders (not significant).

CONCLUSIONS

This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.

Infiltrative lung diseases: complications of novel antineoplastic agents in patients with hematological malignancies

Infiltrative lung disease is a well-known complication of antineoplastic agents in patients with hematological malignancies. Novel agents are constantly being added to available treatments. The present review discusses different pulmonary syndromes, pathogenesis and management of these novel agents.

Pulmonary complications of novel antineoplastic agents for solid tumors

Antineoplastic agent-induced pulmonary toxicity is an important cause of respiratory failure. Although the incidence of antineoplastic agent-induced pulmonary toxicity seems to be low, more cases can be expected, with increasing numbers of patients receiving the new generations of antineoplastic agents. Antineoplastic agents have previously been associated with bronchospasm, hypersensitivity reactions, venous thromboembolism, and pulmonary hemorrhage. Physicians should be aware of the clinical and radiographic presentations of the pulmonary toxicities associated with the newer antineoplastic agents. The approach to diagnosis, risk factors, and possible mechanisms of antineoplastic agent-induced pulmonary toxicity are discussed in this article.

Acute unilateral pneumonitis in a patient with polymyositis: a unique presentation of polymyositis-associated pneumonitis

We describe a unique presentation of polymyositis-associated pneumonitis. A 45-year-old man with a history of polymyositis presented with an episode of fever, cough, dyspnea, rapidly progressive respiratory failure, and unilateral pulmonary infiltrates. Although bacterial pneumonia was initially suspected, all cultures, including bronchoalveolar cultures, remained negative, and the patient's condition worsened despite wide-spectrum antibiotics. Lung biopsy showed organizing pneumonia. The patient was treated with systemic corticosteroids and had complete resolution of respiratory failure and pulmonary infiltrates. We discuss polymyositis/dermatomyositis-associated pneumonitis.

Sarcoidosis of gastrointestinal tract: a rare disease

Gastrointestinal (GI) tract sarcoidosis is an uncommon form of sarcoidosis. The GI tract can be involved as an isolated disease as a part of systemic sarcoidosis. Clinical manifestations of esophageal, gastric, small bowel, colon, and appendicular sarcoidosis are discussed in this review. The differential diagnosis of GI sarcoidosis is extensive. Other granulomatous diseases of the GI tract, like tuberculosis, fungal infections, parasitic diseases, inflammatory bowel disease, and Whipple's disease, should be excluded before making the diagnosis of GI sarcoidosis. Corticosteroid therapy is effective in treatment of GI sarcoidosis. Surgical intervention may be necessary in patients with bowel obstruction, perforation, or massive hemorrhage.

Role of CD8 lymphocytes and neutrophilic alveolitis in Pneumocystis jiroveci pneumonia

We described the characteristics of bronchoalveolar inflammatory cells and their correlation with lung injury in patients with Pneumocystis jiroveci pneumonia. We reviewed all cases of patients with Pneumocystis jiroveci pneumonia in newly diagnosed HIV infected patients admitted to a large metropolitan referral hospital during June 2003 to December 2004. Nine patients (5M, 4F) with Pneumocystis jiroveci pneumonia diagnosed with bronchoscopy and cytological examination of bronchoalveolar lavage (BAL) were identified. There was a positive correlation between peripheral CD8 count and BAL neutrophilia and negative correlation with hypoxemia. Although the number patients in this case series is small, our findings suggest that CD8 cells and alveolar neutrophilic inflammation have a role in lung injury in Pneumocystis jiroveci pneumonia. These findings are consistent with data from animal studies.

Erlotinib-associated acute pneumonitis: report of two cases

Two cases of erlotinib-associated acute pneumonitis are described. The first patient was started on erlotinib treatment for metastatic non-small cell lung cancer. The second patient was treated with erlotinib for metastatic adenocarcinoma of unknown origin. Both patients developed dyspnea and hypoxemia five to six days after initiation of erlotinib treatment. In both cases, computed tomography scan of the chest showed extensive bilateral ground-glass infiltrates consistent with pneumonitis. In both patients, acute pneumonitis resulted in respiratory failure requiring intubation and mechanical ventilation. Diffuse alveolar hemorrhage was excluded by bronchoscopy in both cases. Bronchoalveolar lavage cultures were negative. Erlotinib treatment was stopped and both patients were treated with corticosteroids. The first patient improved gradually and finally was discharged to a rehabilitation centre, but unfortunately the second patient died of Klebsiella sepsis. Naranjo causality scale in both cases suggested a probable association between erlotinib and pneumonitis. Literature on erlotinib-associated pneumonitis is sparse. The clinical presentation and radiographic findings of erlotinib-associated acute pneumonitis are described.

Methicillin-resistant Staphylococcus aureus pneumonia after thoracic surgery: successful treatment with linezolid after failed vancomycin therapy

We describe 3 patients with methicillin-resistant Staphylococcus aureus, hospital-acquired pneumonia who demonstrated a microbiological and clinical failure with vancomycin despite adequate trough levels. All 3 patients were cured with linezolid.

Unusual complication of heparin-induced thrombocytopenia after mitral valve surgery: spontaneous rupture of spleen

A 64-year-old man presented with cardiac tamponade 2 weeks after mitral valve surgery. The patient was anticoagulated for persistent atrial fibrillation after cardiac surgery. A pericardial catheter was placed. Five days after presentation the patient was started on intravenous heparin infusion. The patient had abdominal pain and hypotension develop. A splenic hematoma was diagnosed and a splenectomy was performed. Pathology showed multiple fibrin thrombi in the spleen. The heparin-associated antibodies were detected. Heparin-induced thrombocytopenia is a potentially fatal condition in patients requiring heparin after cardiac surgery. Evaluation for heparin-associated antibodies in these patients may be warranted before heparin therapy.

A case of fatal necrotizing pancreatitis: complication of hydrochlorothiazide and lisinopril therapy

We report a case of fatal necrotizing pancreatitis associated with hydrochlorothiazide and lisinopril therapy. A 49-year-old man who presented with 2 days of abdominal pain and vomiting was found to have severe pancreatitis. The patient denied any alcohol use. In addition, abdominal ultrasound examinations showed no evidence of cholelithiasis or bile duct dilations. Review of his medication history with the family revealed that he was being treated with hydrochlorothiazide and lisinopril for hypertension. An exploratory laparotomy was performed and revealed no common bile duct stones. Unfortunately, the patient's hospital course was complicated with multiple organ failure, which resulted in death. To the best of our knowledge, there are only 3 other reported cases of hydrochlorothiazide-induced necrotizing pancreatitis reported in the literature.

Osborn wave in hypothermia from Vibrio vunificus sepsis unrelated to exposure

A 58 year old man with history of cirrhosis presented with Vibrio vunificus sepsis. The patient developed multiorgan failure despite appropriate antibiotic therapy and fluid resuscitation. The patient developed moderate hypothermia. Electrocardiography showed Osborn wave. Osborn wave is commonly seen in accidental hypothermia. Although sepsis is known to cause hypothermia, Osborn wave in sepsis is not widely appreciated.

Fatal massive hemoptysis in a patient on low-dose oral prednisone: chronic necrotizing pulmonary aspergillosis

We report a case of chronic necrotizing aspergillosis in a 74-year-old man with chronic lung disease, who was on low-dose prednisone. The patient was treated with various antibiotics but had no improvement. Sample obtained via bronchoscopy grew Aspergillus, and the patient was started on lipid formulation amphotericin B. Three days after admission the patient developed fatal massive hemoptysis, presumably secondary to acquired systemic-to-pulmonary vascular communication. This is an unusual presentation of a rare manifestation of pulmonary aspergillosis. A high index of suspicion is needed to diagnose this susceptible patients.

Multiple venous thromboses in a young man with sarcoidosis: is there a relation between sarcoidosis and venous thrombosis?

We describe the case of a 33-year-old African-American male who presented with multiple deep venous thromboses of the upper and lower extremities. Hypercoagulable workup was unrevealing. A chest x-ray showed bilateral hilar lymph node enlargement. Mediastinoscopy with hilar lymph node biopsy was performed. Lymph node histopathologic examination showed noncaseating granulomas. Lymph node tissue culture and special stains were negative for mycobacterial or fungal infection. This is an unusual case of multiple deep venous thromboses and sarcoidosis. The subject of sarcoidosis and venous thrombosis is discussed.

Recurrent episodes of dermatomyositis-associated pneumonitis masquerading as hypersensitivity pneumonitis

This case report describes a unique presentation of dermatomyositis-associated pneumonitis. A 44-year-old man presented with repeated episodes of fever, dyspnea, and hemoptysis accompanied with pulmonary infiltrates, on chest CT scan. Hypersensitivity pneumonitis was suspected. Further work-up showed clinical and serologic evidence of dermatomyositis-associated pneumonitis. The patient was treated with oral prednisone and azathioprine. The subject of dermatomyositis-associated pneumonitis is discussed.

Trastuzumab (Herceptin)-associated lung injury

We report a case of trastuzumab pneumonitis in a patient with metastatic breast cancer. Bronchoalveolar lavage showed marked neutrophilia. A CT scan of the chest showed diffuse ground-glass opacities. The patient was treated with corticosteroids with a partial response. Trastuzumab-associated pneumonitis is not well described, and data in the literature is sparse. We describe the clinical and radiographical findings of trastuzumab-associated pneumonitis.

Positive C-ANCA and cavitary lung lesion: recurrence of Wegener granulomatosis or aspergillosis?

A case of a cavitary lung lesion in the right middle lobe of a 34-year-old woman who presented with hemoptysis is presented. The patient had a 2-year history of Wegener granulomatosis that had been treated with cyclophosphamide and corticosteroids. Although the patient gradually achieved remission of her disease, she developed new pulmonary symptoms and a cavitary lesion in her right lung. Further workup revealed elevated C- and P-ANCA titers. Following partial resection of her right lung, she was found to have an aspergilloma and no evidence of active Wegener granulomatosis. Pulmonary aspergillosis was felt to be the cause of both the hemoptysis and the cavitary lesion. We postulate that C-ANCA and P-ANCA were falsely positive in this case. Although rare, false positive C-ANCA and P-ANCA have been reported in pulmonary fungal infections.

The solitary pulmonary nodule: not always bronchogenic carcinoma

A solitary lung nodule (SLN) is seen in 1 in 500 chest radiographs. Benign causes include infectious granulomas and hamartomas, and less commonly, rheumatoid nodules, intrapulmonary lymph nodes and sarcoidosis. Bronchogenic carcinoma and solitary pulmonary metastases are found in 35% and 23% of SLN's respectively. Primary pulmonary non-Hodgkins lymphoma is a rare disease, constituting 0.4% of all lymphomas. We present a case of primary pulmonary non-Hodgkins lymphoma which presented as a SLN in an 87-year old lady with a smoking history of 50 pack years.

Pulmonary blastomycosis masquerading as metastatic disease in the lung: a case report

We report a case of pulmonary blastomycosis appearing as metastatic laryngeal squamous cell carcinoma. Pulmonary blastomycosis was discovered as right lower lobe subpleural activity consistent with metastatic disease on a positron emission tomographic (PET) scan following total laryngectomy and bilateral neck dissection for locally invasive laryngeal squamous cell carcinoma. A computed tomographic (CT) scan of the chest showed a right lower lobe, subpleural pulmonary nodule. CT-guided fine-needle aspiration of the nodule revealed broad-based budding yeast consistent with blastomycosis. To our knowledge, this is the first case of a PET-positive pulmonary blastomycosis lesion mimicking pulmonary malignancy reported in the literature.