Usefulness of Rigid Bronchoscopic Intervention Using Argon Plasma Coagulation for Central Airway Tumors

OBJECTIVES: Argon plasma coagulation (APC) is a noncontact form of electrocautery that utilizes ionized argon as the electrical current. A rigid bronchoscopic use of APC for the management of central airway obstruction could be safe and rapidly effective. This study evaluated the usefulness of rigid bronchoscopy with APC for the management of central airway obstructions due to benign or malignant tumors. METHODS: Twenty patients with obstructing central airway tumors were retrospectively reviewed from February 2008 to February 2013 at Chonnam National University Hospital. All patients received rigid bronchoscopic tumor removal under general anesthesia. APC was applied before and after tumor removal. RESULTS: The median age of patients was 59 years (interquartile range [IQR], 51 to 67 years) and 70% were female. The causes of airway obstruction included malignancy (n=8) and benign tumor (n=12). Airway tumors comprised intraluminal lesions (n=11, 55%) and mixed intraluminal/extraluminal lesions (n=9, 45%). The median tumor size was 15 mm (IQR, 10 to 18 mm). The median degree of airway obstruction was significantly reduced after intervention (90% [IQR, 88% to 96%] vs. 10% [IQR, 0% to 20%], P<0.001). The median American Thoracic Society dyspnea grade (3 [IQR, 1 to 4] vs. 1 [IQR, 0 to 1], P<0.001) and forced expiratory volume in one second (1.03 L [IQR, 0.52 to 1.36 L] vs. 1.98 L [IQR, 1.57 to 2.64 L], P=0.004) were significantly improved after intervention. There were no procedure-related acute complications and deaths. CONCLUSION: Rigid bronchoscopy with APC is an effective and safe procedure to alleviate central airway obstruction caused by tumors.

Prevalence of Chronic Sputum and Associated Factors in Korean Adults

Chronic sputum is a troublesome symptom in many respiratory diseases. The prevalence of chronic sputum varies from 1.2% to 13% according to the country. The purpose of this study was to estimate the prevalence of chronic sputum and to find its associated factors in a general Korean population. We analyzed the data of the Korea National Health and Nutrition Examination Survey 2010 and 2011. A total number of 6,783 subjects aged 40 yr or more were enrolled in this study with 3,002 men and 3,781 women. As a result, the prevalence of chronic sputum was 6.3% (n=430). Significant risk factors for chronic sputum by multivariate analysis were: age (> or =70 yr) (odds ratio [OR], 1.954; 95% confidence interval [CI], 1.308-2.917), current smoking (OR, 4.496; 95% CI, 3.001-6.734), chronic obstructive pulmonary disease (COPD) (OR, 1.483; 95% CI, 1.090-2.018), and tuberculosis (OR, 1.959; 95% CI, 1.307-2.938). In conclusion, the prevalence of chronic sputum in Korea was in the intermediate range compared with other countries. Smoking is a preventable risk factor identified in this study, and major respiratory diseases, such as COPD and tuberculosis, should be considered in subjects with chronic sputum.

Repeated Favorable Responses to Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitors in a Case of Advanced Lung Adenocarcinoma / 결핵및호흡기질환

The presence of epidermal growth factor receptor (EGFR) mutation is a prognostic and predictive marker for EGFR-tyrosine kinase inhibitor (TKI) therapy. However, inevitably, relapse occurs due to the development of acquired resistance, such as T790M mutation. We report a case of repeated responses to EGFR-TKIs in a never-smoked woman with adenocarcinoma. After six cycles of gemcitabine and cisplatin, the patient was treated by gefitinib for 4 months until progression. Following the six cycles of third-line pemetrexed, gefitinib retreatment was initiated and continued with a partial response for 6 months. After progression, she was recruited for an irreversible EGFR inhibitor trial, and the time to progression was 11 months. Although EGFR direct sequencing on the initial diagnostic specimen revealed a wild-type, we performed a rebiopsy from the progressed subcarinal node at the end of the trial. The result of peptide nucleic acid clamping showed L858R/L861Q.

A Case of Miliary Brain Metastasis of Lung Cancer Mimicking Neurocysticercosis / 결핵및호흡기질환

Miliary brain metastasis from the lung is uncommon and has a poor therapeutic response. We report a case of pulmonary adenocarcinoma combined with multiple brain cystic lesions that were initially misdiagnosed as neurocysticercosis. A 53-year-old male who never smoked was admitted to our hospital with complaints of agitation and cognitive impairment. Brain magnetic resonance imaging showed innumerable, small nodular lesions with a central, low signal intensity in whole brain parenchyma. His symptoms were not improved by the empirical praziquantel medication for disseminated neurocysticercosis. After a transbronchial biopsy from the right middle lobe, we could diagnose the primary lung adenocarcinoma with a single nucleotide polymorphism in the epidermal growth factor receptor exon 20 at codon 787 (Q787Q). His neurologic symptoms and imaging findings have been gradually improving with a first-line Gefitinib treatment for five months. We recommend a more active diagnostic approach including biopsy in case of atypical imaging findings.

Analysis of Patients with Hemoptysis in a Tertiary Referral Hospital / 결핵및호흡기질환

BACKGROUND: This study attempted to investigate the main causes of hemoptysis, the type of examinations used for diagnosis, the treatment modalities and outcomes. METHODS: A retrospective study was conducted on the medical records of 221 patients admitted to the Chonnam National University Hospital, between January 2005 and February 2010, with hemoptysis. RESULTS: Bronchiectasis (32.6%), active pulmonary tuberculosis (18.5%), fungus ball (10.8%), and lung cancer (5.9%) accounted for most causes of hemoptysis. Computed tomography scan was the most sensitive diagnostic test when employed alone, with positive yield of 93.2%. There were 161 cases of conservative treatment (72.9%), 42 cases of bronchial artery embolization (BAE) (19.0%), and 18 cases of surgery (8.1%). Regarding the amount of hemoptysis, 70 cases, out of 221 cases, were mild (31.5%), 36 cases moderate (16.2%), and 115 cases massive hemoptysis (52.0%). Most of the patients were treated conservatively, but if there was more bleeding present, BAE or surgery was more commonly performed than the conservative treatment (p< or =0.0001). In the multivariate model, severe hemoptysis and lung cancer were independently associated with short-term recurrence. BAE was independently associated with long-term recurrence, and lung cancer was associated with in-hospital mortality. The overall in-hospital mortality rate was 11.3%. CONCLUSION: Hemoptysis is a common symptom with a good prognosis in most cases. However, patients exhibiting massive bleeding or those with malignancy had a poorer prognosis. In-hospital mortality was strongly related to the cause, especially in lung cancer.

Temozolomide-Associated Bronchiolitis Obliterans Organizing Pneumonia Successfully Treated with High-Dose Corticosteroid

Temozolomide is an oral alkylating agent with clinical activity against glioblastoma multiforme (GM). It is generally well-tolerated and has few pulmonary side effects. We report a case of temozolomide-associated brochiolitis obliterans organizing pneumonia (BOOP) requiring very high-dose corticosteroid treatment. A 56-yr-old woman presented with a 2-week history of exertional dyspnea. For the treatment of GM diagnosed 4 months previously, she had undergone surgery followed by chemoradiotherapy, and then planned adjuvant chemotherapy with temozolomide. After the 1st cycle, progressive dyspnea was gradually developed. Chest radiograph showed diffuse patchy peribronchovascular ground-glass opacities in both lungs. Conventional dose of methylprednisolone (1 mg/kg/day) was begun for the possibility of BOOP. Although transbronchial lung biopsy findings were compatible with BOOP, the patient's clinical course was more aggravated until hospital day 5. After the dose of methylprednisolone was increased (500 mg/day for 5 days) radiologic findings were improved dramatically.

Mortality and Prognostic Factors in Acute Respiratory Distress Syndrome due to Tuberculosis / 대한내과학회지

BACKGROUND/AIMS: Acute respiratory distress syndrome (ARDS) due to tuberculosis (TB) is a rare disease, but its mortality is believed to be high. The aim of this study was to evaluate the mortality rate and prognostic factors of ARDS. METHODS: We retrospectively reviewed the demographic, clinical, radiologic, and laboratory data of 19 patients with ARDS due to active pulmonary TB at Chonnam National University Hospital between January 2000 and December 2010. RESULTS: The median age of patients was 71.1 (interquartile range [IQR] 51-74) years. None had a history of TB treatment. The most common symptoms were dyspnea (90%), fever (68%), and cough (53%). The overall in-hospital mortality was 73%. The median acute physiologic assessment and chronic health evaluation (APACHE) III score and pneumonia severity index (PSI) were 81.9 (IQR 59.0-92.0) and 111.0 (IQR 77.0-131.0), respectively. The PSI was significantly higher in non-survivors than in survivors (55.0 vs. 122.0; p = 0.016). The rate of TB treatment before admission was significantly higher in survivors than in non-survivors (75% vs. 13%; p = 0.037). The time from admission to treatment initiation was significantly longer in non-survivors than in survivors (3 vs. 0 days; p = 0.049). The median duration of mechanical ventilation was 11 days (IQR 5-16 days). The most common cause of death was a refractory shock (53%). CONCLUSIONS: The overall mortality rate of ARDS due to pulmonary TB was high. A high PSI score and delay of TB treatment may be risk factors for a poor outcome of ARDS due to pulmonary TB.

Apoptosis of T Lymphocytes Isolated from Peripheral Blood of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammation of the airways and progressive destruction of lung parenchyma. Apoptosis is critical for the maintenance of normal tissue homeostasis and is in equilibrium with proliferation and differentiation. This study was undertaken to investigate relationship between apoptosis of peripheral blood lymphocytes during exacerbation of COPD and inflammatory response that characterizes this condition. MATERIALS AND METHODS: Seventeen patients with COPD exacerbation, 21 stable COPD, and 12 control subjects were included. T lymphocytes were isolated from peripheral blood using MACS. Apoptosis of T lymphocytes was assessed with FACS using annexin V and 7-aminoactinomycin. Serum levels of interleukin (IL)-6, IL-8 and tumor necrosis factor (TNF)-alpha were determined by an immunoassay technique. RESULTS: There was significantly increased percentage of apoptotic lymphocytes, CD 4+, and CD 8+ T cells in the peripheral blood of patients with exacerbation of COPD compared with stable COPD. Serum levels of IL-6, IL-8, and TNF-alpha were significantly increased in patients with exacerbation of COPD compared with stable COPD. Only TNF-alpha presented a positive correlation with apoptotic lymphocytes in patients with exacerbation of COPD. CONCLUSION: Increased apoptotic lymphocytes may be associated with upregulation of TNF-alpha in the peripheral blood of patients with acute exacerbation of COPD.

Comparison of Therapeutic Efficacy of Gefitinib and Erlotinib in Patients with Squamous Cell Lung Cancer / 결핵및호흡기질환

BACKGROUND: Gefitinib and erlotinib are useful, molecular targeted agents in patients with non-small-cell lung cancer (NSCLC) who failed previous chemotherapy. We compared the efficacy and toxicity of two drugs in patients with squamous cell lung cancer, most of whom are male smokers. METHODS: We retrospectively reviewed the clinical information on patients with NSCLC who were treated with gefitinib or erlotinib treatment at Chonnam National University Hwasun Hospital between July 2002 and November 2009. The overall response rate (ORR), overall survival (OS) and progression-free survival (PFS) were compared between the two drugs. RESULTS: A total of 182 (100 gefitinib vs. 82 erlotinib) of 584 patients treated by targeted agents had squamous histology. Of the 182 patients, 167 (91.7%) were male and 159 (87.4%) were smokers. The ORR and disease control rate (DCR) were 4.9% and 40.6%, and there was no significant difference between gefitinib and erlotinib (ORR, 5.0% vs 4.8%; p=0.970; DCR, 40.0% vs 41.4%; p=0.439). The median OS in the gefitinib group was 12.1 months, and that in the erlotinib was 12.7 months (hazard ratio [HR], 1.282; 95% confidence interval [CI], 0.771~2.134; p=0.339). The median PFS for the gefitinib group was 1.40 months, compared with 1.37 months for the erlotinib group (HR, 1.092; 95% CI, 0.809~1.474; p=0.564). Skin rash > or =grade 3 was more common in erlotinib (12.2%) than gefitinib (1.0%, p=0.003) groups. CONCLUSION: This retrospective study showed that the two drugs appear to have similar antitumor efficacy and toxicity except for skin rash.

Plasma proGRP Concentration is Sensitive and Specific for Discriminating Small Cell Lung Cancer from Nonmalignant Conditions or Non-small Cell Lung Cancer

To date, most clinical data on pro-gastrin-releasing peptide (proGRP) have been based on serum concentrations. This study evaluated the agreement between proGRP levels in fresh serum and plasma in patients with various lung diseases. Pairs of serum and EDTA plasma were collected from 49 healthy individuals. At the same time, EDTA plasma of 118 lung cancer patients and 23 patients with benign pulmonary diseases were prospectively collected. Compared to serum, plasma proGRP concentrations were higher by an average of 103.3%. Plasma proGRP was higher in malignancy (336.4 +/- 925.4 pg/mL) than in benign conditions (40.1 +/- 11.5 pg/mL). Small cell lung cancer (SCLC) patients showed higher levels of proGRP (1,256.3 +/- 1,605.6 pg/mL) compared to other types of lung cancer. Based on the ROC curve analyses at a specificity of 95%, the diagnostic sensitivity of plasma proGRP was estimated to be 83.8% in distinguishing SCLC from all the other conditions, and 86.5% for discriminating SCLC from the nonmalignant cases. Among the SCLC cases, limited stage disease had lower levels of plasma proGRP than extensive disease. When measuring circulating levels of proGRP, the use of plasma is preferred over serum. Plasma proGRP has a potential marker for discriminating SCLC from nonmalignant conditions or non-small cell lung cancer.

Influence of Diaphragmatic Mobility on Hypercapnia in Patients with Chronic Obstructive Pulmonary Disease

A reduction in diaphragm mobility has been identified in patients with chronic obstructive pulmonary disease (COPD) and has been associated with a decline in pulmonary function parameters. However, little information exists regarding the potential role of diaphragm mobility on hypercapnia in COPD. A new method of assessing the mobility of the diaphragm, using ultrasound, has recently been validated. The purpose of the present study was to investigate the relationship between diaphragm mobility and pulmonary function parameters, as well as that between arterial blood gas values and diaphragm mobility, in COPD patients. Thirty seven COPD patients were recruited for pulmonary function test, arterial blood gas analysis and diaphragm mobility using ultrasound to measure the craniocaudal displacement of the left branch of the portal vein. There were significant negative correlations between diaphragmatic mobility and PaCO2 (r = -0.373, P = 0.030). Diaphragmatic mobility correlated with airway obstruction (FEV1, r = 0.415, P = 0.011) and with ventilatory capacity (FVC, r = 0.302, P = 0.029; MVV, r = 0.481, P = 0.003). Diaphragmatic mobility also correlated significantly with pulmonary hyperinflation. No relationship was observed between diaphragm mobility and PaO2 (r = -0.028, P = 0.873). These findings support a possibility that the reduction in diaphragm mobility relates to hypercapnia in COPD patients.

A Case of Successful Management of Lung Cancer Pain Using Ultrahigh-dose Fentanyl Patch / 결핵및호흡기질환

A 55-year old woman with advanced stage non-small cell lung cancer was admitted to hospital for the management of severe chest pain, which measured 7 out of 10 on a numerical rating scale (NRS). Despite palliative radiation and the application of multiple epidural blocks, she continued to experience severe cancer pain. We gradually increased the dose of transdermal fentanyl patches from 500 microgram/hr to 3,650 microgram/hr, for 3 months without any significant side effects. Concomitantly, adjuvant therapy with antidepressants and anticonvulsants were added, decreasing the patient's pain to NRS 3~4 down from 7. After being transferred to a hospice clinic, her chest pain was well-controlled below NRS 4 by means of strong opioid medications, including the highest dose of transdermal fentanyl 4,050 microgram/hr for more than 16 months.

A Case of Rectus Sheath Hematoma Complicated with Hypovolemic Shock in a Critically-Ill Patient / 결핵및호흡기질환

Rectus sheath hematoma (RSH) is a rare condition caused by hemorrhage into the rectus sheath. It is usually associated with severe cough, abdominal surgery, coagulopathy, and anticoagulation treatment. RSH can be difficult to diagnose and can be misdiagnosed as acute appendicitis, as diverticulitis, or as an ovarian mass. Although RSH usually presents as a benign condition, it can be life threatening, especially in the critically-ill patient. Here, we report a case of fatal RSH due to hypovolemic shock in a critically-ill 73-year-old woman, who had received heparin treatment due to acute myocardial infarction in the intensive care unit and who had been successfully treated by conservative management.

Significance of Repeated Polymerase Chain Reaction (PCR) Testing for Diagnosis of Pulmonary Tuberculosis / 결핵및호흡기질환

BACKGROUND: The polymerase chain reaction (PCR) test is important for the confirmatory diagnosis of tuberculosis (TB) caused by Mycobacterium tuberculosis. The aim of this study was to analyze the yield of repeated PCR testing in patients with confirmed pulmonary TB. METHODS: The medical records of 130 patients, who had more than two consecutive PCR tests and a M. tuberculosis-positive sputum culture from August, 2006 to December, 2007, were retrospectively reviewed for the purposes of this study. A positive TB-PCR test was defined as at least one positive test result. RESULTS: The cumulative positive PCR test rate was 80% (104/130), with gradually increasing rates of positive findings upon the first, second and third TB-PCR tests with 52.3%, 68.5% and 75.4%, respectively. However, further testing did not increase the positive rate further. CONCLUSION: Repeated PCR testing at least three times for M. tuberculosis is helpful for diagnosis of pulmonary TB.

A Case of Ischemic Colitis Associated with Paclitaxel Loaded Polymeric Micelle (Genexol-PM(R)) Chemotherapy / 결핵및호흡기질환

Paclitaxel has been widely used for treating many solid tumors. Although colonic toxicity is an unusual complication of paclitaxel-based chemotherapy, the reported toxicities include pseudomembranous colitis, neutropenic enterocolitis and on rare occasions ischemic colitis. Genexol-PM(R), which is a recently developed cremophor-free, polymeric micelle-formulated paclitaxel, has shown a more potent antitumor effect because it can increase the usual dose of paclitaxel due to that Genexol-PM(R) does not include the toxic cremophor compound. We report here on a case of a 57-year-old man with advanced non-small cell lung cancer and who developed ischemic colitis after chemotherapy with Genexol-PM(R) and cisplatin. He complained of hematochezia with abdominal pain on the left lower quadrant. Colonoscopy revealed diffuse mucosal hemorrhage and edema from the sigmoid colon to the splenic flexure. After bowel rest, he recovered from his symptoms and the follow-up colonoscopic findings showed that the mucosa was healing. Since then, he was treated with pemetrexed monotherapy instead of a paclitaxel compound and platinum.

Plasma C-Reactive Protein and Endothelin-1 Level in Patients with Chronic Obstructive Pulmonary Disease and Pulmonary Hypertension

Pulmonary hypertension is a frequent complication of chronic obstructive pulmonary disease (COPD) and associated with a worse survival and increased risk of hospitalization for exacerbation of COPD. However, little information exists regarding the potential role of systemic inflammation in pulmonary hypertension of COPD. The purpose of the present study was to investigate the degree of C-reactive protein (CRP) and endothelin-1 (ET-1) levels in COPD patient with and without pulmonary hypertension. The levels of CRP and ET-1 were investigated in 58 COPD patient with pulmonary hypertension and 50 patients without pulmonary hypertension. Pulmonary hypertension was defined as a systolic pulmonary artery pressure (Ppa) > or =35 mmHg assessed by Doppler echocardiography. Plasma CRP and ET-1 levels were significantly higher in patients with pulmonary hypertension than in patients without hypertension. There were significant positive correlations between the plasma ET-1 level and CRP level in the whole study groups. For COPD patients, systolic Ppa correlated significantly with plasma CRP levels and plasma ET-1 levels. These findings support a possibility that CRP and ET-1 correlate to pulmonary hypertension in COPD patients.

A Case of Bronchiolitis Interstitial Pneumonitis / 결핵및호흡기질환

Bronchiolitis interstitial pneumonitis (BIP), an unclassified and newly described interstitial pneumonia, has a combined feature of prominent bronchiolitis, interstitial inflammation, and fibrosis. It is distinct from bronchiolitis obliterans or bronchiolitis obliterans organizing pneumonia (BOOP). BIP has a better prognosis than common cases of interstitial pneumonia. However, BIP has a poorer prognosis than BOOP. BIP's response to corticosteroids is not as successful as BOOP's response to this treatment. We encountered the case of a 31-year-old woman with BIP with an initial presentation of dyspnea and a cough that had lasted for 3 months. The patient's chest CT scan demonstrated patchy ground glass opacities and multiple ill-defined centrilobular nodules in both lungs, suggesting military tuberculosis or nontuberculous mycobacterial infection. A video-assisted thoracoscopic lung biopsy resulted in the diagnosis of BIP. Clinical symptoms, pulmonary lesions, and pulmonary function tests were improved after oral glucocorticoid therapy.

A Case of Tracheal Carcinoma Diagnosed by Rigid Bronchoscopy in Lidocaine Anaphylaxis Patient / 결핵및호흡기질환

The majority of flexible bronchoscopies are performed under topical anesthesia with lidocaine being the most commonly used agent. Anaphylaxis rarely occurs after local administration of lidocaine, but can be a fatal complication. We experienced a case of unexpected anaphylaxis. A 66-year-old woman was scheduled for flexible bronchoscopy to evaluate a tracheal mass and stenosis. The oral and nasal mucosa were pretreated with lidocaine. About 2~3 minutes later, the patient developed hypotension and we treated for anaphylaxis in the emergency room. Then, we decided to perform rigid bronchoscopy in this patient, under conditions of general anesthesia. A rigid bronchoscopy was performed in this patient, safely and successfully. The tracheal mass was determined to be squamous cell carcinoma.

Sinus Histiocytosis with Massive Lymphadenopathy: A Case Report with Pleural Effusion and Cervical Lymphadenopathy

Sinus histiocytosis with massive lymphadenopathy (SHML) is a rare disorder characterized by a nonneoplastic proliferation of distinctive histiocyte cells within lymph node sinuses and lymphatics in extranodal sites. SHML occurs worldwide and is primarily a disease of childhood and early adulthood. A 26-yr-old man presented with painless palpable lymph node in cervical area. Radiographic studies revealed pleural effusion with lymphadenopathy and calcification in mediastinum. The cervical lymph node biopsy showed dilated sinuses filled with histiocytes with clear cytoplasm. The cells stained positive with CD68 and S-100. These cytologic and immunohistochemical findings were considered consistent with the diagnosis of SHML.

A Case of Pulmonary Paragonimiasis with Recurrent Pleural Effusion and Cured by Four Cycles of Chemotherapy / 결핵및호흡기질환

Paragonimiasis is a parasitic infection that occurs following the ingestion of infectious Paragonimus metacercariae, which occurs as a result of eating raw or undercooked freshwater crabs or crayfish. Pulmonary paragonimiasis is the most common clinical manifestation of this infection. Human paragonimiasis occurs sporadically. We experienced a case of pulmonary paragonimiasis in a 35-year-old woman with left lower chest pain. The patient had hypereosinophilia and a pleural effusion. The diagnosis was confirmed by positive ELISA (Enzyme-linked immunosorbent assay) that detected Paragonimiasis westermani antibody in the serum. We treated the patient with praziquantel for two days at a daily dosage of 75 mg/kg. Left pleuritic pain and pleural effusion improved after treatment. However, similar symptoms and pleural effusion developed recurrently for the first 3 courses of treatment with praziquantel. Upon the fourth round of treatment, the patient made a full recovery.