Transient pulmonary and gastric bleeding after iopamidol administration in a patient with marginal zone lymphoma: a case report

BACKGROUND

Iopamidol is a non-ionic, water-soluble iodine contrast agent that is considered safe for intravenous or intra-arterial administration and is widely used both in the general population and in patients undergoing oncological treatment. While adverse reactions to iopamidol have been documented, to date, no pulmonary and gastric hemorrhages induced by iopamidol have been reported in oncology patients. We report the first case of this complication.

CASE PRESENTATION

We report the case of a 60-year-old woman with marginal zone lymphoma who was receiving antineoplastic therapy. As part of the investigation for the condition, she underwent chest enhancement CT with iopamidol. Shortly thereafter(within five minutes), she experienced hemoptysis and hematemesis. She was intubated and admitted to the intensive care unit. Pre- and post-contrast images demonstrated the course of the hemorrhage. Flexible bronchoscopy and gastroscopy on the following day showed no active bleeding, and the patient recovered completely after antiallergy treatment. We speculate that contrast-induced hypersensitivity was the most likely cause of the transient pulmonary and gastric bleeding.

CONCLUSION

Although rare, the complications of iopamidol, which may cause allergic reactions in the lungs and stomach, should be considered.

Pulmonary haemorrhage and extensive arterial thrombosis with anabolic steroid abuse

Anabolic-androgenic steroids (AASs) are commonly implicated in thromboembolic events but rarely cause diffuse alveolar haemorrhage. We report the case of a Caucasian man in his late 40s who was consuming supratherapeutic doses of AAS and presented with shortness of breath and haemoptysis. Chest imaging showed bilateral patchy infiltrates in the lungs with diffuse blood throughout the airways on bronchoscopy. Extensive infectious and autoimmune workup were unremarkable. The patient then developed right foot ischaemia and was found to have extensive aortic and bilateral lower extremity arterial thrombosis. Anticoagulation was attempted despite haemoptysis. Thrombectomy procedures were unsuccessful and the patient eventually developed worsening rhabdomyolysis requiring intubation and bilateral amputation. His clinical condition continued to worsen and he passed away 10 days after admission. This case highlights the rare synchronous occurrence of two life-threatening complications secondary to anabolic steroid abuse which can pose a significant diagnostic and therapeutic challenge for clinicians.

Successful Pulmonary Artery Embolization for the Management of Hemoptysis in a Patient with Eisenmenger Syndrome Caused by Patent Ductus Arteriosus

The patient was a 19-year-old woman who was diagnosed with patent ductus arteriosus complicating Eisenmenger syndrome at a previous medical institution. She was referred to our hospital and arranged for lung transplantation. She developed hemoptysis after the introduction of i.v. epoprostenol, which was administered as a bridging treatment while the patient awaited lung transplantation. She continued to suffer from recurrent hemoptysis, even after switching from i.v. epoprostenol to i.v. treprostinil. Angiography of the systemic and pulmonary arteries revealed the vessel responsible for the recurrent hemoptysis and pulmonary artery embolization was successfully performed. It is essential to identify the culprit vessel and physicians must not hesitate in performing embolization when patients develop lethal hemoptysis.

A Case Report of Cannabis Induced Hemoptysis

As the principal route of marijuana use is by inhalation, potential harmful consequences on pulmonary structure and function can be anticipated. Here, we present a case of hemoptysis attributed to smoking cannabis in a 38-year-old man. The patient experienced an episode of hemoptysis and shortness of breath immediately after smoking marijuana. Chest radiograph and computed tomography (CT) scans of the chest showed bilateral diffuse ground-glass opacities. A fiber optic bronchoscopy confirmed bilateral diffuse bleeding from respiratory tract. Additional evaluation of hemoptysis indicated no infection or immunological responses. Urine toxicology was positive for cannabis. Chronic marijuana smoking causes visible and microscopic injury to the larger airways responsible for symptoms or chronic bronchitis. We review the beneficial and deleterious effects of marijuana and describe a case of significant hemoptysis attributed to smoking marijuana. In addition to other respiratory complications of marijuana use, physicians should educate their patients about this potentially lethal effect of marijuana smoking in the form of hemoptysis.

Diffuse Alveolar Hemorrhage Associated with Makyo-kanseki-to Administration

We herein describe the first known case of diffuse alveolar hemorrhage (DAH) associated with the administration of Makyo-kanseki-to, a Chinese herbal drug. A 64-year-old man with bronchial asthma presented with persistent cough. Makyo-kanseki-to was prescribed as an adjunctive treatment for bronchial asthma. Immediately after drug ingestion, the patient expectorated bloody sputum. DAH was diagnosed based on the presence of bilateral ground-glass opacity which was identified on chest computed tomography and bloody bronchoalveolar lavage fluid. We diagnosed that the administration of Makyo-kanseki-to was the responsible medication because the hemorrhage developed immediately after drug ingestion and resolved after the cessation of such medication with no subsequent recurrence.

[Hemoptysis during concomitant treatment with rivaroxaban and amiodarone in a patient with a history of pulmonary disease]

Rivaroxaban, a selective inhibitor of active factor X, is metabolized by cytochrom P450 3A4 (CYP3A4) and is a substrate for transporter protein--P-glycoprotein (P-gp). Amiodarone, an antiarrhytmic agent, is classified as moderate CYP3A4 and P-gp inhibitor.

A CASE REPORT

A 75-year-old male, who underwent lobectomy for bronchiectasis many years ago, is presented. For one year the patient was treated with rivaroxaban (20 mg/d) due to venous thromboembolism and recurrent episodes of atrial fibrillation. Two weeks after amiodarone initiation (200 mg/d) hemoptysis occurred and computed tomography revealed unilateral pulmonary infiltrates with ground-glass opacities limited to the lower lobe of the left lung. The symptoms disappeared following discontinuation of the two medications and did not recur while rivaroxaban was reintroduced in a dose of 15 mg/d; measurement of anti-Xa activity confirmed it as a therapeutic dose. Amiodarone, that had been used for a short time and well tolerated a few years before, was definitely withdrawn.

CONCLUSIONS

The authors suggest, that the concomitant use of rivaroxaban and amiodarone should be very careful in patients with a history of pulmonary disease.

Hemoptysis due to aspirin treatment alternative to warfarin therapy in a patient with atrial fibrillation

An 80-year-old female with a history of hypertension and atrial fibrillation had been receiving warfarin anticoagulant therapy and had stably maintained an international normalized ratio (INR) within the 2.0-3.0 range. Due to dental extractions, she was prescribed aspirin (100 mg/day) as an alternative therapy to warfarin. Three days later, the patient complained of hemoptysis without obvious inducement and the INR was 3.51. The aspirin was immediately discontinued and intravenous vitamin K was administered. Hemoptysis did not reappear and the INR returned to the normal limits. According to the Drug Interaction Probability Scale, a causal relationship between aspirin and warfarin and an increased INR value is possible.

Alveolar hemorrhage associated with pemetrexed administration

We herein describe a 67-year-old man with advanced adenocarcinoma of the lung who developed an alveolar hemorrhage (AH) associated with pemetrexed. He received four courses of pemetrexed therapy with carboplatin and seven courses of pemetrexed maintenance therapy. One week after the last pemetrexed administration, the patient developed hemoptysis with deteriorating dyspnea and anemia. Chest images showed diffuse ground-glass attenuation. The diagnosis of AH was based on findings of bloody bronchoalveolar lavage (BAL) fluid, hemosiderin-laden macrophages in the BAL fluid, and a transbronchial lung biopsy sample. This report is the first to describe AH associated with pemetrexed.

Inhaled mannitol and cystic fibrosis. Unnecessary bronchial irritation

Cystic fibrosis is a life-threatening genetic disease mainly characterised by accumulation of viscous secretions in the airways. In the absence of a better alternative, inhaled dornase alfa is used to liquefy bronchial secretions and thereby facilitate their drainage. Mannitol, in the form of capsules of powder for inhalation, is authorised in the European Union for use as a mucolytic in adults with cystic fibrosis. Two double-blind randomised trials have compared two doses of inhaled mannitol (400 mg or 50 mg, twice a day) in a total of 642 patients (57% adults) with cystic fibrosis. After 26 weeks of treatment, there was no difference between the groups in terms of clinical criteria such as the frequency of pulmonary exacerbations, quality of life, hospitalisation, or rescue antibiotic use. Inhaled mannitol increases the risk of bronchospasm and can also cause coughing and haemoptysis. A pretreatment test, used to exclude patients with bronchial hyperresponsiveness to mannitol, can also have noteworthy adverse effects. Treatment is inconvenient, requiring inhalation of the contents of 10 mannitol capsules morning and evening; the capsules have to be placed one by one in the inhalation device, and the device must be replaced every week. In practice, patients with cystic fibrosis would be well advised to avoid inhaled mannitol.

Hemoptysis and respiratory failure following sildenafil use for pulmonary hypertension

Sildenafil, usually a well-tolerated drug traditionally used for erectile dysfunction (ED), was recently approved for pulmonary arterial hypertension. In the literature, there are few cases of hemoptysis following sildenafil use for ED; however, to our knowledge, we are reporting the first case of hemoptysis following sildenafil use for pulmonary hypertension. We are documenting a case of a 90-year-old male patient who was admitted to the intensive care unit with hemoptysis and respiratory failure two weeks after he was started on sildenafil.

Study on incidence of bleeding in hospitalized patients after antithrombotic therapy at a tertiary care hospital

OBJECTIVES

To monitor the different antithrombotic drug combinations, determine the incidence, magnitude of bleeding and the association of HAS-BLED risk scoring schema with the magnitude of bleeding as defined using TIMI bleeding criteria.

METHODS

A prospective observational study in a cohort of patients for a period of 8 months, at one of the tertiary care center-Krishna Institute of Medical Sciences, Hyderabad, was conducted. Consecutive patients were enrolled and followed from the date of admission till the adverse events are perceived/date of discharge. Pearson Correlation Statistics (Fisher's z Transformation) is applied to assess the association between HAS-BLED risk factors and the total risk score with bleeding criteria.

RESULTS

A total of 400 cases were collected during the 8-month study period, of which 372 satisfied the inclusion criteria. Among them 34 (9.1%) bleeding cases were reported with mean (+/- SD) age of 57.8 (+/- 14.19) years. Bleeding occurred mostly in males 79.4% and a HAS-BLED Score of > or = 3 has been observed in 67.6% (n = 23) patients out of 34 bled patients. Two antiplatelets + One anticoagulant is the most common combination which caused bleeding in 41.2% (n = 14). Stroke history, bleeding predisposition, labile INR's are the HAS-BLED risk factors which are significant (< 0.05) with the TIMI Bleeding Criteria.

CONCLUSION

There was a linear correlation between the HAS-BLED risk score and the TIMI bleeding criteria-higher the risk score the more frequent is the incidence of major bleeding. A HAS-BLED risk score of > or = 3 is associated with TIMI major bleeding.

Churg-Strauss syndrome related to montelukast

A young male with complaints of cough, dyspnea and hemoptysis was admitted. He was using fluticasone propionate and salmeterol for two years for his asthma. Leukotriene receptor antagonist was prescribed two weeks prior to his admission and no reduction of his inhaled steroid therapy was performed. Eosinophil count was detected as 1460/mm³ (15%) and immunoglobulin E level was 547 IU/mL. Thorax computerized tomography revealed patchy infiltration. Increased eosinophilic inflammation were detected in bronchoalveolar lavage fluid and transbronchial biopsy. He received prednisolone treatment for Churg-Strauss syndrome. Improvement was observed on three months follow up period. He has no complaint in his follow up.

[Hemoptysis and dyspnea in a woman treated with acenocoumarol due to venous thrombosis]

A case report of young woman diagnosed as having microscopic polyangiitis (MPO) presenting with diffuse alveolar hemorrhage (DAH). DAH is a rare, but life-threatening disorder. The patients presented with dyspnea, cough, hemoptysis (not constant). The radiographic features are very characteristic and reveal the signs of diffuse, bilateral alveolar filling in chest HRCT especially in middle and lower zones. Anaemia with iron deficiency and hypoxic respiratory failure. Elevation of diffuse capacity (above 30% of predicted) is often recognized as a result of presence of blood in the alveoli. Broncho-alveolar lavage reveal haemosiderin laden macrophages. It may occurs most frequently as a secondary condition due to microscopic polyangiitis (MPA), Wegener's granulomatosis (WG), Goodpasture syndrome. Among the many conditions it can accompany connective tissue disorders, antiphospholipid antibody syndrome, some medicines or toxic exposures.

Levofloxacin-induced severe thrombocytopenia

BACKGROUND

Thrombocytopenia following drug administration is commonly found in clinical practice. Recognition of this condition is important for further management of the patients. Many drugs were reported to be the cause of drug induced thrombocytopenia but levofloxacin was rarely reported.

CASE REPORT

We present a seventy-eight-year-old male patient who developed severe thrombocytopenia with hemoptysis after taking levofloxacin for 4 days due to infected bronchiectasis. His platelet count was gradually recovered to normal value after the discontinuation of levofloxacin.

CONCLUSION

Levofloxacin can cause severe thrombocytopenia. Specific antibody to platelet surface glycoproteins caused by levofloxacin should be further studied to confirm the association.

Recurrent haemoptysis following sildenafil administration

Sildenafil is widely used in the treatment of male erectile disorder and is generally well-tolerated. Its adverse effects are reported to be mild and include flushing, headache, dyspepsia and visual disturbances. We document a case of recurrent haemoptysis observed soon after self administration of sildenafil in a 38-year-old male with no other causative factors. The episodes of haemoptysis stopped following stoppage of sildenafil.

Biomass smoke induced bronchial anthracofibrosis: presenting features and clinical course

BACKGROUND

The presenting features and clinical course of biomass smoke induced bronchial anthracofibrosis (BAF) are not well known.

PATIENTS AND METHODS

333 patients who had a history of long-term exposure to biomass smoke, having BAF confirmed by a bronchoscopy from January 1998 to December 2004, were included in this study. The clinical features, associated diseases, and clinical outcomes were investigated through the analysis of medical records.

RESULTS

There were 51 males (15.3%) and 282 females (84.7%), having a mean age of 72.3 years, ranging from 47 to 90. 33% of patients had a past history of pulmonary tuberculosis. Dyspnea (38.4%) and cough (29.8%) were most common presenting symptoms, followed by hemoptysis (8.9%). Baseline pulmonary function showed mild airflow obstruction. Among patients with forced expiratory volume in 1s (FEV(1))/forced vital capacity (FVC)<0.7, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages I and II were most common. Associated diseases were active tuberculosis in 33.9% of patients, pneumonia in 29.5%, acute exacerbation of chronic airways disease in 22.5%, and malignancy in 4.8%. Among the 18 patients who died at a hospital during the follow-up period, acute infection and malignancy were common causes of death.

CONCLUSIONS

These findings suggest that biomass smoke induced BAF usually appears clinically as a form of obstructive airways disease. Since various pulmonary diseases, including tuberculosis, pneumonia, and malignancy, can be associated with BAF, thorough clinical evaluation and close follow-up of these patients are required.

[Respiratory symptoms after the use of a painting primer product spray]

The use of waterproofing spray has been associated with the development of respiratory symptoms, but the pathogenetic mechanisms are unclear. We describe a case of acute respiratory disease with impaired diffusion developed after the use of a painting primer product spray (stain stop). Further investigation in aerosol-toxicology is needed.

Interstitial Pneumonitis and Alveolar Hemorrhage Complicating Use of Rituximab

The use of rituximab has been uncommonly associated with delayed pulmonary toxicity. We present a case of interstitial pneumonitis and diffuse alveolar hemorrhage, which represents the second such case reported in the literature.

[Catamenial hemoptysis during hormone replacement treatment]

INTRODUCTION

Catamenial haemoptysis is a rare clinical entity resulting from the presence of ectopic intra pulmonary endometrial tissue, either parenchymatous or endobronchial. The main diagnostic criterion is the periodic character of the haemoptysis which is synchronous with menstruation.

CASE REPORT

The authors report a case of catamenial haemoptysis due to endobronchial endometriosis in a 46 year old menopausal woman receiving hormone replacement treatment (HRT). She presented with 3 episodes of haemoptysis synchronous with the first days of her menstrual cycle. A thoracic CT scan showed ground glass lesions with micronodulation. Bronchoscopy showed violacious lesions bleeding on contact. The endobronchial and CT abnormalities had disappeared by day 5. After withdrawal of the HRT the haemoptysis did not recur during a follow-up of 2 years.

CONCLUSION

Endobronchial endometrioisis remains a rare occurrence. This is the first case reported in a menopausal woman with artificial cycles receiving hormone replacement therapy.

Elevated relapse rate under oral methotrexate versus leflunomide for maintenance of remission in Wegener's granulomatosis

OBJECTIVES

Results from open-label trials suggest that methotrexate (MTX) and leflunomide (LEF) are effective for maintenance of remission in Wegener's granulomatosis (WG), but data from randomized controlled clinical trails are not yet available.

METHODS

In this multicentre, prospective randomized controlled clinical trial, patients with generalized WG were treated either with oral LEF 30 mg/day or oral MTX (starting with 7.5 mg/week reaching 20 mg/week after 8 weeks) for 2 yrs following induction of remission with cyclophosphamide. The primary endpoint was the incidence of relapses. Secondary outcome parameters were DEI, BVAS, SF-36, cANCA-titre, ESR and CRP.

RESULTS

Fifty-four patients were included in the study, 26 in the LEF-limb, 28 in the MTX-limb. In the LEF-group, six patients relapsed after a median time of 7 months, thereof one major relapse with a new pulmonary manifestation. In the MTX-group, 13 relapses occurred in 6 months, of which seven were major: rapidly progressive glomerulonephritis (n = 4), pulmonary haemorrhage (n = 2) and one cerebral granuloma. The significantly higher incidence of major relapses in the MTX-limb (P = 0.037) led to premature termination of the study. In the LEF-limb, four patients were withdrawn due to hypertension (n = 2), peripheral neuropathy (n = 1) and leucopenia (n = 1).

CONCLUSION

LEF at a dosage of 30 mg/day appears to be effective in the prevention of major relapses in WG, however, this is associated with an increased frequency of adverse events. Further studies testing other dosing regimens of lower doses of LEF are needed to confirm these promising results in larger patients cohorts.

[Hemoptysis in a young man]

INTRODUCTION

We describe the development of severe and recurrent alveolar hemorrhage in a 30 year old man. The patient had presented with frank hemoptysis, that recurred after an interval of 4 weeks, associated with dyspnea and severe anemia requiring transfusion. The chest x-ray and CT scan showed bilateral diffuse ground glass shadows. Fibreoptic bronchoscopy confirmed bilateral diffuse bleeding. Investigations for the common causes of diffuse alveolar hemorrhage (immunological, infective) proved to be negative on two occasions. Toxicological examination of the urine during the relapse revealed a significant level of cannabis and a trace of cocaine. The patient repeatedly denied the use of illicit drugs.

CASE REPORT

Because of the general condition of this young patient a lung biopsy was performed by video-thoracoscopy. This showed evidence of diffuse alveolar damage compatible with inhalation of cocaine. Faced with these results the patient admitted that he regularly smoked "improved joints".

CONCLUSION

This clinical observation emphasises that the inhalation of cocaine is a cause of diffuse alveolar hemorrhage particularly in young adults.

Bronchoscopy for bevacizumab-related hemoptysis

Bevacizumab is the first anti-angiogenic agent inhibiting vascular endothelial growth factor (VEGF) for treatment of patients suffering from cancer. Life-threatening hemoptysis is the most serious adverse effect of bevacizumab. The inhibition of VEGF is a possible mechanism involved in the destruction of normal lung tissue and subsequent hemoptysis. We report a case of bevacizumab-related hemoptysis and associated bronchoscopic findings that were successfully treated with rigid bronchoscopy and laser photocoagulation.

Abciximab and fatal pulmonary hemorrhage

Abciximab, a platelet glycoprotein IIb/IIIa receptor blocker, is a well-known agent in percutaneous coronary intervention because of its antiplatelet, antithrombotic effects, which allow for good outcome. Major bleeding is a well-recognized complication of abciximab therapy, and pulmonary hemorrhage, although infrequent, is a serious, under-recognized, and often fatal complication. We describe a case of fatal pulmonary hemorrhage in a young woman who presented with acute myocardial infarction and cardiogenic shock and was treated with abciximab in conjunction with percutaneous coronary intervention. The possibility of diffuse pulmonary hemorrhage should be strongly suspected in the presence of hypoxemia, infiltrates on chest radiography, and a decrease in hemoglobin. Awareness about this complication of abciximab therapy on the part of physicians and health care professionals is strongly warranted. Therapy that may be used if diagnosis is promptly made includes bronchoscopic-guided balloon tamponade or iced saline lavage. These therapeutic interventions are still in the developmental stage, and to date there are no trials to document their efficacy and survival benefit.

Diffuse alveolar hemorrhage associated with antineutrophil cytoplasmic antibody levels in a pregnant woman taking propylthiouracil

Propylthiouracil (PTU) is known to be a potential cause of antineutrophil cytoplasmic antibody (ANCA) positive small vessel vasculitis, resulting in glomerulonephritis and diffuse alveolar hemorrhage (DAH). Herein, we describe a 25-year-old pregnant woman who developed a perinulcear ANCA (p-ANCA) and myeloperoxidase ANCA (MPO-ANCA) positive DAH during PTU therapy. The patient improved after corticosteroid therapy and discontinuation of the PTU. Methimazole was prescribed in spite of the risk of recurrence of DAH because of the pregnancy. The patient is currently free from pulmonary problems. Our case shows that the alternative agent, methimazole, can be used to treat hyperthyroidism in a pregnant patient with PTU associated DAH.

Late respiratory complications of mustard gas poisoning in Iranian veterans

Mustard gas or sulfur mustard (SM) is an alkylating chemical warfare agent that was widely used during the World War I and in the Iran-Iraq conflict. We aimed to study late toxic effects of SM on the respiratory system of severely intoxicated Iranian veterans. Respiratory examination, spirometry, arterial blood gas (ABG) analysis, and high resolution computed tomograpghy (HRCT) of the chest were performed on all severely SM-poisoned veterans in the province of Khorasan, Iran. HRCT abnormalities were classified into four grades based on the number of lung lobes involved. ABG and spirometric results were compared with each other, as well as, with the severity grades of HRCT abnormalities, using Spearman's rank correlation test. Forty male subjects with confirmed SM poisoning 16 to 20 years ago, were studied. Main respiratory complications were diagnosed as chronic obstructive pulmonary disease (COPD) (35%), bronchiectasis (32.5%), asthma (25%), large airway narrowing (15%), pulmonary fibrosis (7.5%), and simple chronic bronchitis (5%) patients. While there was a significant correlation (p<0.05) between ABG and spirometric results, the severity grades of HRCT abnormalities revealed a significant correlation (p<0.05) only with PaO2. We concluded that SM-induced respiratory complications tend to progress over the years. While spirometry is a valuable diagnostic tool for evaluation of pulmonary impairment during regular follow-ups, ABG and HRCT are more objective and should be more considered for evaluation of the severity and for diagnosis of the respiratory complications.

Alveolar Hemorrhage: An Underdiagnosed Complication of Treatment with Glycoprotein IIb/IIIa Inhibitors

OBJECTIVE

Alveolar hemorrhage (AH) is a rare complication of treatment with GP IIb/IIIa inhibitors. Hemoptysis, a constant sign, lacks in specificity, and may occur in confounding syndromes such as pulmonary edema, pulmonary infarction, and pneumonia. Nonspecific symptoms and signs often delay the diagnosis, thereby allowing serious or even fatal disease progression. Here, we performed a large-scale retrospective analysis to define the incidence and risk factors of AH in the setting of GP IIb/IIIa inhibitors therapy.

BACKGROUND

Randomized controlled trials demonstrate that treatment with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors may improve the outcome of acute myocardial infarction (AMI) and angioplastic procedures. However, this treatment may rarely lead to severe hemorrhagic complications, in particular AH. Unfortunately, the incidence and risk factors of AH remain poorly defined.

METHODS

We reviewed for the period extending from August 1998 to January 2005 consecutive histories of AMI patients receiving coronary arteriography and treatment with either eptifibatide or abciximab. Concomitantly admitted AMI patients not treated with GP IIb/IIIa inhibitors were reviewed and served as a control group. The diagnosis of AH required the demonstration of typical symptoms and signs including dyspnea, hemoptysis, arterial hypoxemia, pulmonary radiographic changes, and, when available, bronchoscopic signs for AH. Potential covariates including pulmonary disease, pulmonary hypertension, smoking, and use of other anticoagulant or antiplatelet agents were evaluated.

RESULTS

Six of 1,810 patients (0.33%) receiving eptifibatide and five of 3,648 patients (0.14%) receiving abciximab exhibited typical symptoms and signs of AH. Contrarily, only one of 4,136 patients (0.025%) receiving no GP IIb/IIIa inhibitors presented with similar symptoms and signs. There was no fatal outcome, though two patients required blood transfusions. Statistically significant differences were found between control patients and patients receiving eptifibatide alone (P = 0.004). There was also a significant difference between untreated patients and those receiving eptifibatide and abciximab (P = 0.017). No differences were found between eptifibatide and abciximab-treated patients (P = 0.19) or between abciximab and untreated control patients (P = 0.105).

CONCLUSIONS

AH is a rare complication of treatment with GP IIb/IIIa inhibitors. Its incidence ranged from 0.14% in patients treated with abciximab to 0.33% in those receiving eptifibatide. Compared to a control group, patients treated with GP IIb/IIIa inhibitors had a statistically increased risk for AH.

[Patient with haemoptysis, dyspnoea, fever and lung infiltration]

In this study we presented the case of 55 years old man who was admitted to the Dept. of Lung Diseases and Tuberculosis in Zabrze with haemoptysis, dyspnoea, fever and lung infiltration. Initially the neoplastic disease was diagnosed. From the information gathered from the patient's family it was stated that the patient has been taking acenocoumarol for a considerably long time without any professional supervision. In this study we emphasize the importance of motivating and informing patients about the purposefulness of control examinations while using this kind of drugs.

[Recurrent hemoptysis following thienopyridines and amiodarone administration. therapeutic dilemma]

The authors describe a case of a 74-year-old man with advanced coronary heart disease in whom pulmonary hemorrhagic complications during therapy with ticlopidine and subsequently with clopidogrel and amiodarone were observed. Fever and massive hemoptysis following five days of ticlopidine treatment, before elective coronary angiography, were noticed. Transient interstitial X-ray changes of the right lung were visible. Three months later a new episode on the third day of clopidogrel administration was manifested. He was after PCI, performed because of ACS complicated with ventricular fibrillation. Two days following clopidogrel discontinuation hemoptysis remitted but after ten days occurred again (this time with bilateral X-ray changes). Amiodarone, given after VF, was stopped. Spectacular improvement with steroid treatment was observed. Indobufen (reversible COX- 1 inhibitor) as an antiplatelet therapy was availed. The authors discuss therapeutic dilemma concerning the patient with coexisting different diseases.

[Recurrent hemoptysis secondary to an aortobronchial fistula]

Aortobronchial fistula is a rare but serious cause of hemoptysis. It can develop from an aneurysm of the descending thoracic aorta in the context of infections or it may appear as a sequel of surgical repair of congenital heart defects. Presenting symptoms include mild bronchial hemorrhages and recurrent chest pain, culminating in a normally fatal massive hemorrhage. Diagnosis by imaging is not always conclusive and clinical suspicion based on medical history is essential. Surgical placement of an endovascular stent graft is the treatment of choice. Post-surgical prognosis is good although there is a risk of recurrence in the case of superinfection.

Randomized, double-blind, placebo-controlled, dose-escalating study of aerosolized interferon gamma-1b in patients with mild to moderate cystic fibrosis lung disease

Interferon gamma-1b (IFN-gamma1b) is a pleiotropic cytokine with immunomodulatory activities that could decrease bacterial burden, inflammation, and obstruction in patients with CF. Patients with CF (> or =12 years old, FEV1 > or =40% predicted) were randomly assigned to sequential dose cohorts inhaling 500 microg IFN-gamma1b, 1,000 microg IFN-gamma1b, or placebo by Respirgard II nebulizer thrice weekly for 12 weeks. Sputum bacterial density and spirometry were measured. Safety, antibiotic use, hospitalization, and sputum neutrophils, elastase, DNA, IL-8, and myeloperoxidase were also evaluated. Sixty-six patients (mean age, 24 years, with mean baseline FEV1 of 74 +/- 20 (SD) percent predicted) were studied. One patient had bronchospasm after the first dose of IFN-gamma1b; the overall withdrawal rate was 15% (5 in the placebo group, 2 in the 500-microg IFN-gamma1b group, and 3 in the 1,000 microg IFN-gamma1b group). The 500-microg IFN-gamma1b dose was well-tolerated, but the 1,000-mug dose cohort, who had a higher baseline bacterial density than placebo patients (mean difference, 1.2 log(10) CFU/g sputum, 95% confidence interval (CI), 0.1,2.8, P=0.04), had 24% more hospitalizations for exacerbation than placebo patients (95% CI, 2,45%, P=0.05). There was a 0.12-l difference between the 500-microg IFN-gamma1b and placebo groups with respect to the 12-week change in FEV1 (active group minus placebo group, 95% CI, -0.03,0.26, P=0.11), as compared to a 0.01-l difference between the 1,000-microg IFN-gamma1b and placebo groups (95% CI, -0.16,0.17, P=0.96). No effects of IFN-gamma1b were seen in sputum bacterial density or inflammatory biomarkers at 12 weeks. Aerosolized IFN-gamma1b did not improve pulmonary function, reduce sputum bacterial density, or affect inflammatory sputum markers in patients with mild-moderate lung disease.

Sirolimus-associated diffuse alveolar hemorrhage

Sirolimus is an immunosuppressive medication used in transplant recipients. To our knowledge, we describe the third reported case of alveolar hemorrhage in association with sirolimus. Fever, dyspnea, hemoptysis, and lung infiltrates resolved rapidly with cessation of sirolimus therapy both initially and after reinstitution of the drug. Unlike previous reports, our patient had no evidence of lymphocytic alveolitis but rather marked macrophage hemosiderosis, suggesting that sirolimus pulmonary toxicity may manifest through 2 separate mechanisms. Our case highlights an uncommon but potentially lethal manifestation of sirolimus pulmonary toxicity.

[Biventricular thrombi dissolution and antibody development with lepirudin therapy]

HISTORY AND ADMISSION FINDINGS

A 50-year-old patient presented with clinical symptoms of heart failure with orthopnoe and edema (NYHA IV).

INVESTIGATIONS

Echocardiography revealed a dilated left ventricle with severely reduced left ventricular function and biventricular floating thrombi, due to dilatative cardiomyopathy.

TREATMENT AND COURSE

With a heart failure medication clinical symptoms reduced and body weight decreased > 10 kg in 3 weeks. Due to the high-risk constellation, anticoagulation was performed with lepirudin and the biventricular thrombi were dissolved within 17 days. At this point in time, the patient suffered from petechial bleedings, hemoptysis and gross hematuria. Despite breaking anticoagulation and substitution of PPSB with not measurable fibrinogen, subarachnoid hemorrhage occurred leading to exitus letalis.

CONCLUSION

Lepirudin is a highly effective anticoagulant, that can induce severe hemorrhagic side effects in individual cases. The present case report demonstrates an immunological reaction as a rare cause with activation of prothrombin and formation of fibrin.

Catamenial haemoptysis and clomiphene citrate therapy

Case reports of catamenial haemoptysis are uncommon. We report the first case of thoracic endometriosis associated with clomiphene citrate therapy and previously unpublished endobronchial and angiographic findings.

[Alveolar hemorrhage caused by exposure to pesticides]

17 years old boy was admitted because of cough, hemoptysis and mild fever. These symptoms appeared a day after exposure to Decis-pesticide of relatively low toxicity for people. In hospital respiratory failure (pO2 48.5 mmHg) and alveolar haemorrhage (the presence of bloody fluid with hemosiderin loaded macrophages, the signs of alveolar filling in chest HRCT scan and elevation of diffuse capacity) were recognised. All symptoms completely disappeared after 5 month of corticosteroids therapy.

Diffuse alveolar hemorrhage following administration of tirofiban or abciximab: a nemesis of platelet glycoprotein IIb/IIIa inhibitors

We describe three patients who developed severe pulmonary hemorrhage following administration of tirofiban (one patient) and abciximab (two patients). Pulmonary hemorrhage associated with abciximab use has been described, but to the best of our knowledge there has been no previous reports of this complication with tirofiban. Cathet. Cardiovasc. Intervent. 49:181-184, 2000.

[Acute pulmonary edema associated with the use of beta2-mimetic tocolytic agents]

A case of severe pulmonary oedema during beta2-adrenergic agonist tocolytic therapy (salbutamol) in a pregnant woman admitted for preterm labor at 32 weeks of amenorrhoea is reported. Echocardiography and haemodynamic investigations did not show any left ventricular systolic or diastolic dysfunction. Pulmonary oedema is an exceptional complication of beta2-adrenergic agonist tocolytic therapy. The diagnosis is considered in pregnant patients presenting with respiratory distress, associated with or following tocolytic therapy. Anaesthetic management of patients treated with a beta2-adrenergic agonist should take into consideration the delay between discontinuation of tocolytic therapy and anaesthetic induction, as well as volume expansion.

Hemoptysis due to MDI therapy in a patient with permanent tracheostomy: treatment with mask AeroChamber

Persistent minor hemoptysis resulted from extensive granulation tissue on the main carina and adjacent bronchi due to frequent spraying of metered-dose inhaler (MDI)-generated aerosol medications directly into a permanent tracheostomy. Salbutamol, containing oleic acid, was considered the most likely cause. After an AeroChamber equipped with an infant mask was interposed between the MDI and the tracheal stoma, hemoptysis and the pathologic changes gradually resolved.