Respiratory disorders in systemic sclerosis.

Respiratory disorders in systemic sclerosis (SSc) are common. They are also a leading cause of morbidity and mortality in this group of patients. Currently, there are no good clinical or serological parameters that would predict respiratory disorders in SSc. The aims of this study are to review the different patterns of respiratory disorder in Thai SSc and to identify the clinical and serological parameters that may be associated with those respiratory disorders. A retrospective medical records review was performed. Out of 137 scleroderma patients seen by the division of rheumatology at Siriraj Hospital Mahidol University from January 1986 to December 2006, sixty-six (48.2%) had respiratory disorders. The most common respiratory disorder was interstitial lung disease (ILD) (81.8%), followed by secondary pulmonary hypertension (PHT) (24%). A few cases of isolated PHT were found (3%). There were no statistically significant differences in the clinical manifestations, disease subtypes or serological parameters between SSc patients who had ILD with or without secondary PHT. Raynaud’s phenomenon was very commonly seen in the SSc patients with PHT.

Clinical characteristics and outcome of thai patients with acute pulmonary embolism.

BACKGROUND: The incidence and clinical features of acute pulmonary embolism (APE) in Thailand are unknown. There was an unsubstantiated belief that APE in Thailand did not occur as frequently as reported in European countries. With new diagnostic tools and current advanced knowledge, APE was discovered to be much more frequent in Thailand than earlier believed. A subgroup of patients with massive APE who presented with systemic arterial hypotension tended to have poor prognosis. Clinical outcome predictor of massive APE had not been previously firmly identified. STUDY DESIGN: Cross-sectional study. OBJECTIVES: To evaluate common risk factors, symptoms, signs, commonly used investigations, treatment and outcome of Thai patients with APE. To compare the clinical characteristics of non-massive and massive APE patients. To identify the clinical characteristics and treatment that may predict the mortality of massive APE. MATERIAL AND METHOD: All patients with confirmed APE diagnoses who were admitted to Siriraj Hospital, Bangkok, Thailand between January 2001 and October 2005 were selected for analysis in the present study. All APE patients' data, including demographics, symptoms, signs, investigations, treatments, outcome and risk factors such as malignancy, surgery, immobilization, and congenital thrombophilia, were recorded. STATISTICAL ANALYSIS: Patients data is presented in the form of percent and mean. Fisher's exact test was used to compare the categorical data between massive and non-massive APE groups. T-test was used to compare continuous variable i.e. RVSP between subgroups. RESULTS: Seventy-one patients had a confirmed diagnosis of APE, 22 patients were male and 49 were female. Fourteen patients were diagnosed with massive APE. The ages of patients varied from 16 to 90 years old. The mean age was 50 +/- 2.2 years old. The most common presenting symptoms and signs were dyspnea (92%), followed by tachypnea (63%) and tachycardia (54%). Idiopathic APE was found in 42.2% of the patients. Malignancy, especially adenocarcinoma, was the most frequent risk factor (21%). The most frequent radiographic abnormalities noted in the present study were pulmonary parenchymal lesions (23.9%). Echocardiography findings were mostly elevated right ventricular systolic pressure (RVSP), ranging from 18.5 to 98 mmHg (mean RVSP of 54.4 mmHg). The most frequent diagnostic test used was ventilation-perfusion lung scan. Elevated serum troponin-T seemed to be more frequent in the massive APE group. In the non-survivor group, the author found hypotension and underlying malignancy statistically significant different from the survivor group. CONCLUSION: APE was not infrequent. Characteristics of APE patients in Thailand were not different from previous reports in European countries. Malignancy seemed to be the most frequent risk factors of APE in the present study population. Troponin-T measurement may be useful to predict progression of APE.

Diagnostic yield of fluoroscopy-guided transbronchial lung biopsy in non-endobronchial lung lesion.

BACKGROUND: Parenchymatous lung lesions often present as peripheral non-endobronchial lesions, which are not visible through conventional flexible fiberoptic bronchoscopy. Tissue diagnosis from these lesions is usually obtained by transbronchial lung biopsy (TBLB). The lesion location is estimated by chest radiograph (CXR) or computerized tomography (CT) of the chest. The diagnostic yield of TBLB is limited and variable, ranging from 16-80%. Fluoroscopy is used simultaneously with FOB during TBLB for better localization of parenchymatous lesions. Nevertheless, fluoroscopy-guided transbronchial biopsy (Flu-TBLB) is not widely used at present. The advantages and safety of Flu-TBLB have not yet been verified. OBJECTIVE: To compare the diagnostic yields and complications of TBLB with and without fluoroscopy guidance for non-endobronchial lung lesion. STUDY DESIGN: Descriptive study with subgroup analysis. MATERIAL AND METHOD: Medical and bronchoscopic data records of patients who underwent TBLB at Siriraj Hospital from January 2001 to June 2005 were reviewed. The patients were divided into two groups according to the use of fluoroscopy during TBLB. Patient demographic data, underlying diseases, CXR findings, diagnoses, complications and yields of TBLB of the two groups were compared. STATISTICAL ANALYSIS: Student t-test and chi-square test. RESULTS: Six hundred and fifty patients were included in the present study. Three hundred and thirty-one patients were in Flu-TBLB group, 319 patients were in non fluoroscopy-guided transbronchial biopsy (NFlu-TBLB) group. The overall diagnostic yield of Flu-TBLB group was statistically significantly higher than NFlu-TBLB group (43.8% vs. 32.9%; p = 0.003). When comparing the diagnostic yields of the 2 groups by CXR findings, the yields of Flu-TBLB group were statistically significantly higher than NFlu-TBLB group for lung masses (41.4% vs. 29.5%; p = 0.036) and focal infiltrative lesions (46.2% vs. 29.4%; p = 0.008), respectively. The yield of Flu-TBLB group was slightly higher than NFlu-TBLB group for diffuse infiltrative lesion (45.1% vs. 40%; p = 0.289). No significant difference in the rate of pneumothorax discovery between the two groups (1.2% in Flu-TBLB group and 0.6% in NFlu-TBLB group) was observed. CONCLUSION: Flu-TBLB significantly increases the diagnostic yields of non-endobronchial lung masses and focal infiltrates compared to NFlu-TBLB. There is no clinical significant difference in the rate of pneumothorax discovery between the two groups. Flu-TBLB is also more cost-saving.

Difference in the yields of bronchial washing cytology before and after forceps biopsy for lung cancer diagnosis.

OBJECTIVES: Fiberoptic bronchoscopy (FOB) has been one of the essential procedures used in the diagnosis of lung cancer Diagnostic yields of FOB related procedures such as bronchial washing (BW), bronchial brushing (BB), bronchial biopsy (BBx), and transbronchial biopsy (TBBx) depend on the location and extent of the tumors. The yields of BW vary among different studies (39-79%). Some reported that the yield might increase in post-bronchoscopic sputum. Since samples from BW are obtained directly from the respiratory tract, we hypothesized that post bronchoscopic forceps biopsy BW might further increase the yield as well. The objective of this study was to compare the diagnostic yields of bronchial washing before and after forceps biopsy for lung cancer. MATERIAL AND METHOD: 114 patients, 70 with endobronchial lesions (42 exophytic lesions, 28 submucosal lesions) and 44 with non-endobronchial lesions, suspected to have lung cancers were evaluated at Siriraj Hospital between March and October 2000. All the patients underwent FOB with initial BW then forceps biopsy (BBx or TBBx) of the lesions followed by re-BW. The cytological specimens were blinded to the cytopathologists. Positive cytologic results of each procedural specimen were compared to final malignancy diagnosis (by positive specimens from FOB, transthoracic needle aspiration, surgery, clinical and radiological follow-up) to determine the sensitivity of each test. STATISTICAL ANALYSIS: Chi-square test comparing sensitivity of each test. RESULTS: 82/114 patients (39 patients had exophytic lesions, 24 patients had submucosal lesions, and 19 patients had peripheral lung lesions) had a final diagnosis of malignancy. The sensitivity of initial BW before forceps biopsy was 37.8% (31/82), re-BW after forceps biopsy was 37.8% (31/82), both initial BW and re-BW was 46.3% (38/82), and forceps biopsy alone was 79.3% (65/82). There was no statistically significant difference (p > O.05) in the sensitivity of initial BW re-BW and combined initial BW and re-BW. No major complications such as massive hemorrhage, respiratory failure, or death occurred. CONCLUSION: The diagnostic yields of BW before and after forceps biopsy for malignancy were not different in our study. However, the yield seemed to be higher when combined pre and post-forceps biopsy BW was used.

An actor with fatal violaceous plaques.

We report a case of homosexual Thai AIDS patient who presented with mucocutaneous Kaposi\'s sarcoma (KS) and developed pulmonary involvement which rapidly progressed to a fatal outcome. Although AIDS-KS has been reported as the most common cancer occurring in HIV-infected patients, it has rarely been reported in Thai patients. The characteristic mucocutaneous lesions, histopathological and bronchoscopic findings are demonstrated. Tha clinical differentiation and management are discussed.

The prevalence of obstructive sleep apnea among professional hospital drivers.

Background : Several reports have suggested that about one-fifth of car accidents are sleep-related and obstructive sleep apnea (OSA) is one of the major causes of increased daytime sleepiness. Various reports from western countries have shown that different groups of drivers, especially truck drivers have a high prevalence of OSA, which may play a part in the occurrence of car accidents. Objectives : To determine the frequency of OSA and other sleep related problems in a group of professional drivers. Study design : Descriptive study. Methods : All 21 male professional drivers at one government hospital, aged between 27-57 years old, were recruited to the study. Data were collected by clinical examination, questionnaire and overnight polysomnography. OSA was defined as a Respiratory Disturbance Index (RDI) or an apnea / hypopnea index of over 5 events per hour. Results : The prevalence of OSA was 4%. Only 1 subject had severe OSA with an RDI of 102. None of them reported having car accidents but 71% reported symptoms of daytime sleepiness. Conclusion : OSA was not very common among professional drivers in this study but there were other sleep related problems reported which might relate to an increased risk of car accident. Further study of sleep disorders and their association with car accidents in a larger and broader group of drivers is needed.

Disseminated tuberculosis.

Tuberculosis usually causes symptoms. Many patients may first be aware of fatigue, anorexia, weight loss, irregular menses, or a low grade fever that persists over weeks to months. Symptomatic patients with disease can be characterized as having generalized or systemic signs and symptoms, pulmonary signs and symptoms, signs and symptoms related to other organs, or a combination of these features, namely miliary or disseminated tuberculosis. Acute symptoms may be superimposed on a more chronic pattern which may simulate many other diseases. Tuberculosis may mimic, or occur concurrently, with pneumonia, sarcoidosis, fungal infection, or neoplasm. However, medical attention should be sought in order that appropriate treatment for tuberculosis can be given to the patients.