Challenges in the diagnosis of idiopathic pulmonary fibrosis: the importance of a multidisciplinary approach

INTRODUCTION

The diagnosis of Idiopathic pulmonary fibrosis (IPF) requires the careful exclusion of secondary causes of interstitial lung disease (ILD), and the collaboration among different specialists is considered paramount to establish a diagnosis with high diagnostic confidence. The multidisciplinary discussion (MDD) has assumed an increasing importance over the years in the different phases of the IPF diagnostic work-up.

AREAS COVERED

The role of MDD in the diagnosis and management of IPF will be described. Practical insights will be provided into how and when to perform MDD based on the available scientific evidence. Current limitations and future perspectives will be discussed.

EXPERT OPINION

In the absence of high diagnostic confidence, agreement between different specialists during MDD is recognized as a surrogate indicator of diagnostic accuracy. Often, despite a lengthy evaluation, the diagnosis remains unclassifiable in a significant percentage of patients. MDD therefore appears to be pivotal in attaining an accurate diagnosis of ILDs. The discussion among different specialists can also include other specialists, such as rheumatologists and thoracic surgeons, in addition to the core group of pulmonologists, radiologists, and pathologists. Such discussions can allow greater diagnostic accuracy and have important effects on management, pharmacologic therapies, and prognosis.

Drug-induced interstitial lung disease during cancer therapies: expert opinion on diagnosis and treatment

Background

Drug-induced interstitial lung disease (DIILD) is a form of interstitial lung disease resulting from exposure to drugs causing inflammation and possibly interstitial fibrosis. Antineoplastic drugs are the primary cause of DIILD, accounting for 23%-51% of cases, with bleomycin, everolimus, erlotinib, trastuzumab-deruxtecan and immune checkpoint inhibitors being the most common causative agents. DIILD can be difficult to identify and manage, and there are currently no specific guidelines on the diagnosis and treatment of DIILD caused by anticancer drugs.

Objective

To develop recommendations for the diagnosis and management of DIILD in cancer patients.

Methods

Based on the published literature and their clinical expertise, a multidisciplinary group of experts in Italy developed recommendations stratified by DIILD severity, based on the Common Terminology Criteria for Adverse Events.

Results

The recommendations highlight the importance of multidisciplinary interaction in the diagnosis and management of DIILD. Important components of the diagnostic process are physical examination and careful patient history-taking, measurement of vital signs (particularly respiratory rate and arterial oxygen saturation), relevant laboratory tests, respiratory function testing with spirometry and diffusing capacity of the lung for carbon monoxide and computed tomography/imaging. Because the clinical and radiological signs of DIILD are often similar to those of pneumonias or interstitial lung diseases, differential diagnosis is important, including microbial and serological testing to exclude or confirm infectious causes. In most cases, management of DIILD requires the discontinuation of the antineoplastic agent and the administration of short-term steroids. Steroid tapering must be undertaken slowly to prevent reactivation of DIILD. Patients with severe and very severe (grade 3 and 4) DIILD will require hospitalisation and often need oxygen and non-invasive ventilation. Decisions about invasive ventilation should take into account the patient’s cancer prognosis.

Conclusions

These recommendations provide a structured step-by-step diagnostic and therapeutic approach for each grade of suspected cancer-related DIILD.

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There is a lack of guidance for the management of DIILD in cancer patients.

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A multidisciplinary team in Italy developed step-by-step diagnostic and therapeutic guidelines for DIILD in cancer patients.

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Differential diagnosis of DIILD is critical to exclude other forms of interstitial lung disease or infectious causes.

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Usually the antineoplastic agent is discontinued, steroids started and further management dictated by DIILD severity.

Role of Stenotrophomonas maltophilia isolation in patients with non-CF bronchiectasis

INTRODUCTION

Stenotrophomonas maltophilia is a bacteria whose role in patients with cystic fibrosis (CF) bronchiectasis has been previously studied; little is known about its role in non-CF bronchiectasis.

MATERIALS AND METHODS

Aim of our study is to investigate the risk factors for S. maltophilia acquisition and its clinical impact on bronchiectasis patients. A retrospective observational cohort study enrolling patients attending the Bronchiectasis Clinic at the Royal Infirmary of Edinburgh, Scotland, UK. A total of 167 bronchiectasis patients undergoing intravenous (IV) antibiotic therapy were selected and divided according to single or chronic S. maltophilia isolation in sputum. The risk factors and prognostic impact were studied.

RESULTS

Single isolation was independently associated with lower baseline % predicted forced expiratory volume in 1 s [odds ratio (OR) 0.98; 95% confidence interval (CI) 0.970-1.044; P = 0.025] and with less radiological involvement (OR 0.379; 95% CI 0.175-0.819; P = 0.01). Chronic isolation was associated with the number of IV antibiotic courses in the year before and after the first isolation (OR 1.2; 95% CI 1.053-1.398; P = 0.007) and with the absence of Pseudomonas aeruginosa colonization (OR 0.207; 95% CI 0.056-0.764; P = 0.02). In the chronic isolation group, there were more exacerbations and more need of IV antibiotics in the year after the first isolation.

CONCLUSIONS

Poor lung function is the main independent risk factor for single isolation of S. maltophilia. For chronic colonization, the main independent risk factor is the number of IV antibiotic courses and the absence of P. aeruginosa chronic colonization. Only when chronically present, S. maltophilia had a clinical impact with more exacerbations.

Balancing evidence and frontline experience in the early phases of the COVID-19 pandemic: current position of the Italian Society of Anti-infective Therapy (SITA) and the Italian Society of Pulmonology (SIP)

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19), which has rapidly become epidemic in Italy and other European countries. The disease spectrum ranges from asymptomatic/mildly symptomatic presentations to acute respiratory failure. At the present time the absolute number of severe cases requiring ventilator support is reaching or even surpassing the intensive care unit bed capacity in the most affected regions and countries.

OBJECTIVES

To narratively summarize the available literature on the management of COVID-19 in order to combine current evidence and frontline opinions and to provide balanced answers to pressing clinical questions.

SOURCES

Inductive PubMed search for publications relevant to the topic.

CONTENT

The available literature and the authors' frontline-based opinion are summarized in brief narrative answers to selected clinical questions, with a conclusive statement provided for each answer.

IMPLICATIONS

Many off-label antiviral and anti-inflammatory drugs are currently being administered to patients with COVID-19. Physicians must be aware that, as they are not supported by high-level evidence, these treatments may often be ethically justifiable only in those worsening patients unlikely to improve only with supportive care, and who cannot be enrolled onto randomized clinical trials. Access to well-designed randomized controlled trials should be expanded as much as possible because it is the most secure way to change for the better our approach to COVID-19 patients.

Evaluation of the lung microbiome as a therapeutic target in the management of idiopathic pulmonary fibrosis: role of antioxidant/antibiotic combination therapy

OBJECTIVE

Changes in the composition of the lung microbiome influence many lung diseases, including idiopathic pulmonary fibrosis (IPF), with a demonstrated association between the progression of IPF and the assessed pulmonary microbial community. A hypothesis to explain the pathogenesis of IPF is that an oxidant-antioxidant imbalance causes repeated epithelial cell injury and endogenous and exogenous antioxidants/redox modulators influence fibrogenesis, protect the lung against fibrosis, and prevent its progression.

MATERIALS AND METHODS

The present article is focused on Lung Microbiome in Idiopathic Pulmonary Fibrosis and the role of Antioxidant/Antibiotic Combination Therapy.

RESULTS

N-Acetylcysteine (NAC) at concentrations possibly achievable by nebulization showed an in vitro synergy with colistin against S. maltophilia isolates (a common coloniser of the respiratory tract of patients with chronic lung disease). Combined NAC plus colistin seems to have a beneficial role in restoring oxidant injury which may be related to its antioxidant effect. Progress has been made in the identification of the lung microbiome and the possible causal role of bacteria in the IPF pathogenesis. Recent studies suggest that antibacterial therapy in combination with antioxidant therapy may be a promising avenue for the treatment of this untreatable disease. Novel routes of administration are also an important area of research and studies assessing the use of inhaled NAC in patients with IPF could be considered.

How we will diagnose IPF in the future

The recent approval of two safe and effective treatments for patients with idiopathic pulmonary fibrosis (IPF) had as a direct consequence the absolute need for an accurate and early diagnosis. The standard approach to IPF diagnosis has proven to be effective and emphasized the importance of clinical and laboratory evaluations to exclude known causes of pulmonary fibrosis. At the same time, chest high-resolution computed tomography (HRCT) has proven to be the crucial initial diagnostic test, by identifying those patients who should undergo surgical lung biopsy to secure a confident diagnosis and an adequate treatment. However, this diagnostic approach showed over the years some limitations. First, many suspected IPF patients present with atypical HRCT appearances and at the same time are unfit (or unwilling) for surgical lung biopsy, therefore making a confident diagnosis of IPF impossible. Although the current recommendations indicate the need for an iterative multidisciplinary process incorporating available clinical, laboratory, imaging and histological features, recent work has identified new tools which might improve the overall accuracy of this process. Genomic techniques have been already applied to molecularly phenotype patients with interstitial lung disease and it is likely that in the near future clinicians will utilize blood or lung-specific molecular markers in combination with other clinical, physiological, or imaging features. The availability of new sampling procedures (e.g. transbronchial cryobiopsies), together with innovative imaging technologies (e.g. microCT) will most likely support and enhance diagnostic efforts, refine prognostic recommendations and ultimately influence therapeutic options.

Multidrug-resistant tuberculosis outbreak in an Italian prison: tolerance of pyrazinamide plus levofloxacin prophylaxis and serial interferon gamma release assays

The optimal treatment for latent tuberculosis infection (LTBI) in subjects exposed to multidrug-resistant (MDR) tuberculosis (TB) remains unclear, and the change in response of the QuantiFERON-TB Gold In-Tube (QTB-IT) test during and after treatment is unknown. Between May 2010 and August 2010, 39 prisoners at the 'Casa Circondariale' of Modena, Italy, were exposed to a patient with active pulmonary MDR TB. All contacts were tested with the tuberculin skin test and QTB-IT. Upon exclusion of active TB, subjects positive to both tests were offered 6 months' treatment with pyrazinamide (PZA) and levofloxacin (LVX). QTB-IT testing was repeated at 3 and 6 months after initial testing in all subjects who were offered LTBI treatment. Seventeen (43.5%) of 39 subjects tested positive to both tuberculin skin test and QTB-IT test, and 12 (70.5%) agreed to receive therapy with PZA and LVX at standard doses. Only five (41.6%) of 12 subjects completed 6 months' treatment. Reasons for discontinuation were asymptomatic hepatitis, gastritis and diarrhoea. The QTB-IT values decreased in all subjects who completed the treatment, in two (33%) of six of those who received treatment for less than 3 months and in one (50%) of two patients who discontinued therapy after 3 months. The QTB-IT test results never turned negative. Despite the small number of subjects, the study confirmed that PZA plus LVX is a poorly tolerated option for MDR LTBI treatment. We observed a large degree of variation in the results of the QTB-IT test results among participants. The study confirmed that the interferon gamma release assay is not a reliable tool for monitoring the treatment of MDR LTBI in clinical practice.

Long-term management of IPF with pirfenidone - a clinical case study with 5 years follow-up

Idiopathic pulmonary fibrosis (IPF) is a progressively fibrotic interstitial lung disease that is associated with a median survival of 2-5 years from initial diagnosis. To date, the search for an effective treatment has involved numerous clinical trials of investigational agents but without significant success. Nevertheless, research over the past 10 years has provided us with a wealth of information on its histopathology, diagnostic work-up, and a greater understanding of its pathophysiology. Specifically, IPF is no longer thought to be a predominantly pro-inflammatory disorder. Rather, the fibrosis in IPF is increasingly understood to be the result of a fibroproliferative and aberrant wound healing cascade. The development of therapeutic targets has therefore shifted in accordance with this paradigm change. Emerging clinical data from recently published and ongoing trials investigating new potential pharmacological agents should be considered in the routine clinical management of these patients. Based upon encouraging results from randomised-controlled trials showing a positive effect in slowing decline in pulmonary function and reducing disease progression, pirfenidone was approved in 2011 as the first treatment in patients with IPF. This case study describes the clinical course of a patient enrolled into the Phase III and open-label extension studies of pirfenidone.