Acute severe asthma with thyroid crisis and myasthenia: a case report and literature review.

BACKGROUND AND AIMS: Acute severe asthma, thyroid crisis and acute myasthenia are all medical emergencies that rarely coexistent. Here, we report a young man with severe asthma attack, necessitate invasive mechanical ventilation at the onset, followed by thyroid crisis, rhabdomyolysis, acute kidney injury, thrombocytopenia and progressive myasthenia. The aim of this study is to better understand the relationships among severe asthma, autoimmune thyroiditis and myasthenia. METHODS: The case was presented and former literatures were reviewed. RESULTS: This is the first case report of a young patient presented with severe asthma and autoimmune thyroiditis, followed by thyroid storm, multiple organ dysfunction and myasthenia. Neither conventional treatment for asthma or thyroid storm was effective separately. The patient's clinical condition did not improve until after plasmapheresis. CONCLUSION: Here, we highlighted both the importance of early recognition of thyroid storm and prompt therapies, which likely attenuated organ dysfunction and enabled this patient to recover from the life-threatening attack. Asthmatic patients should be closely controlled when suspected of thyroid disorders, especially those with high levels of anti-thyroid antibodies irrespective of thyroid hormones concentrations.

[Dieulafoy disease of the bronchus: 3 cases report with literature review].

OBJECTIVES: To improve the understanding of bronchial Dieulafoy disease by summarizing the clinical and literature reported cases. METHODS: The clinical data of 3 patients with bronchial Dieulafoy disease diagnosed by pathology from January 1, 2007 to May 31, 2012 in our hospital was collected and summarized. The data of 19 cases from literature case report regarding bronchial Dieulafoy disease both in Chinese and English were also reviewed through databases including Wanfang Data, National Knowledge Infrastructure, National Center for Biotechnology Information and Ovid Technologics from January 1, 2005 to May 31, 2012. The clinical characteristics, diagnosis and treatment of all the 22 cases were summarized and analyzed. RESULTS: The average age of the 22 cases with bronchial Dieulafoy disease was (47 ± 15) years, and the preponderance was in male adults (16/22). Right lung (16/22) was more commonly involved than the left lung (4/22), and rarely in both lungs (2/22). Eight cases had smoking history, and 10 cases had underlying diseases such as tuberculosis.Sudden onset of massive hemoptysis was a common manifestation. Massive or lethal hemorrhage was often caused by biopsy injury. The abnormality of bronchial Dieulafoy disease was usually demonstrated as nodular lesions within the lumen of the bronchus.However, It was unable to determine their originating of the anomalous arteries in half of the cases(11/22). Most anomalous arteries confirmed by pathology were branched from bronchial artery (9/22), and rarely from pulmonary artery (2/22). The definitive diagnosis was made by pathological examination.Selective bronchial artery embolization and pulmonary lobectomy were the major therapeutic strategies, but bleeding may relapse after bronchial artery embolization, and lobectomy of the lung was a cure approach. CONCLUSIONS: Bronchial Dieulafoy disease should be differentiated in patients with massive and unexplained hemoptysis.It takes a very high risk for biopsy, which rarely needs to be implemented. Bronchial arteriography and selective bronchial artery embolization should be promptly carried out to avoid life-threatening hemoptysis.Lobectomy could be an alternative choice for a cure.

[A study on the differential diagnosis of ciliated epithelial cells from Lophomonas blattarum in bronchoalveolar lavage fluid].

OBJECTIVE: To validate the authenticity of the cases diagnosed as pulmonary Lophomonas blattarum infection in literatures and Lophomonas blattarum as a kind of pathogen resulting in pulmonary infection. METHODS: From June 2012 to May 2013, mobile cells with cilia at the anterior end of the cells were observed in BALF from 6 patients with pulmonary disease in our hospital. Morphological feature and ultrastructure of the cells were further investigated by optical microscope and electron microscope to determine the type of the cells referring to literature-published photos of Lophomonas blattarum. Literatures about Lophomonas blattarum infection were searched with keyword Lophomonas blattarum from Wanfang Data, China National Knowledge Infrastructure (CNKI) and PubMed. Diagnostic methods and figures provided by the literature were carefully reviewed, and the accuracy of diagnosis of pulmonary Lophomonas blattarum was identified. RESULTS: Mobile cells found in BALF from the 6 patients in our hospital had the morphological features of bronchial ciliate epithelial cells. A nucleus far from the cilia was observed in the middle or at the bottom of the cytoplasm, and these cells did not display the characteristic cytological structures of Lophomonas blattarum: calyx, perinuclear tubules and axial filament. Diagnosis of pulmonary Lophomonas blattarum reported in literatures so far were all based on the morphological features of mobile cells with a cluster of flagellate at anterior end of the cell by optical microscopy. None of the authors did further exploration on the ultrastructure of such a kind of cells and compared with features of Lophomonas blattarum described in the literature. All the active cells reported in literatures had the identical morphological features to those found in our investigation. CONCLUSION: In the past 20 years, all the diagnosed cases as pulmonary Lophomonas blattarum infection reported in our country were misdiagnosed. Currently, there is no evidence to show Lophomonas blattarum as a pathogen resulting in pulmonary infection.

Chronic intermittent hypoxia from pedo-stage decreases glucose transporter 4 expression in adipose tissue and causes insulin resistance.

BACKGROUND: The persistence of sleep disordered breathing (SDB) symptoms after tonsil and/or adenoid (T&A) surgery are common in children with obstructive sleep apnea (OSA). We tested the hypothesis that disturbances of glucose transporters (GLUTs) in intraabdominal adipose tissue caused by chronic intermittent hypoxia (CIH) from the pedo-period could facilitate the appearance of periphery insulin resistance in Sprague-Dawley (SD) rats. We tested the hypothesis that the changes of GLUTs in adipose tissue may be one of the reasons for persistent SDB among clinical OSA children after T&A surgery. METHODS: Thirty 21-day-old SD rats were randomly divided into a CIH group, a chronic continuous hypoxia (CCH) group, and a normal oxygen group (control group) and exposed for 40 days. The changes of weight, fasting blood glucose and fasting blood insulin levels were measured. Hyperinsulinemic-euglycemic clamp techniques were used to measure insulin resistance in each animal. Real-time quantitative PCR and Western blotting were used to measure GLUT mRNA and proteins in intraabdominal adipose tissue. Additional intraabdomial white adipose tissue (WAT) was also processed into paraffin sections and directly observed for GLUTs1-4 expression. RESULTS: When compared with control group, CIH increased blood fasting insulin levels, (245.07 +/- 53.89) pg/ml vs. (168.63 +/- 38.70) pg/ml, P = 0.038, and decreased the mean glucose infusion rate (GIR), (7.25 +/- 1.29) mg x kg(-1) x min(-1) vs. (13.34 +/- 1.54) mg x kg(-1) x min(-1), P < 0.001. GLUT-4 mRNA and protein expression was significantly reduced after CIH compared with CCH or normal oxygen rats, 0.002 +/- 0.002 vs. 0.039 +/- 0.009, P < 0.001; 0.642 +/- 0.073 vs. 1.000 +/- 0.103, P = 0.035. CONCLUSIONS: CIH in young rats could induce insulin resistance via adverse effects on glycometabolism. These findings emphasize the importance of early detection and treatment of insulin insensitivity in obese childhood OSA.

[The efficacy and safety of tulobuterol tape in mild and moderate persistent asthma patients].

OBJECTIVE: To evaluate the efficacy and safety of tulobuterol tape in mild and moderate persistent asthma patients. METHODS: A multicenter, randomized, controlled, open label study was performed. A total of 233 adult patients with mild and moderate persistent asthma were enrolled, and 115 patients were treated with tulobuterol tape and 118 with tulobuterol tablet. RESULT: After 4 weeks of treatment, the morning peak expiratory flow (PEF) and evening PEF and the percent change in the tulobuterol tape group were increased significantly as compared to the tulobuterol tablet group (P < 0.05). The rate of improvement in morning PEF with the tape group and the tablet group were 9.1 (0.38 approximately 19.4)% and 4.2 (-6.4 approximately 18.3)%, respectively. The pulmonary function, variation rate of PEF, asthma score and usage of short-acting beta(2) agonist were improved after 4 weeks of treatment, but the differences were not significant between the two groups. The incidence of adverse reactions including palpitations and tremor in the tulobuterol tape group was significantly lower than that in the tablet group (chi(2) = 7.0919, P = 0.0077), and the incidence of local skin adverse reactions in tape group was 2.6%. CONCLUSION: Tulobuterol tape is a newly formulated, effective and safe medication for the treatment of asthma.

[Comparison of tiotropium inhalation capsules and ipratropium metered dose inhaler in a randomized, double-blind, double-dummy, efficacy and safety study in patients with chronic obstructive pulmonary disease].

OBJECTIVE: To compare the efficacy and safety between tiotropium capsule and ipratropium MDI in a 4 week treatment in patients with chronic obstructive pulmonary disease (COPD). METHODS: A multi-center, randomized, double blind, double dummy and parallel comparison clinical trial was conducted in 221 stable moderate to severe patients with COPD. They were randomized into tiotropium 18 microg once per day arm or ipratropium 2 puffs qid. arm for four weeks. The spirometry was conducted at 5 minutes pre-medication; and 30, 60, 120, and 180 minutes post-medication before; 2 weeks and 4 weeks after treatment. RESULTS: The forced expiratory volume in one second (FEV(1)) trough response, the primary endpoint, was significantly higher in the tiotropium arm than that of the ipratropium with (0.063 +/- 0.024) L (95% CI 0.016 - 0.111 L, t = 2.63, P = 0.009) after 4 weeks of treatment. Meanwhile the clinical evidences indicated the continuous improvement of bronchodilation in the tiotropium arm. Forced vital capacity (FVC) trough response was also significantly higher in the tiotropium arm 4 weeks after treatment with (0.133 +/- 0.047) L (t = 2.83, P = 0.005). By comparison with baseline, no significant differences were found between these two arms in the average change of FEV(1) as well as FVC 0 - 3 hours after inhalation (all P > 0.05). There was no significant difference in rescue medication consumptions (t = 0.60, P = 0.548). Adverse events occurred in 12 (10.9%) patients in the tiotropium arm and 18 (16.2%) in the ipratropium arm, without statistical difference (chi(2) = 1.326, P = 0.249). The major adverse event in the tiotropium group was dry mouth (5, 4.5%). No cardiac disorder or abnormal electrocardiogram was reported. CONCLUSION: The results indicated that tiotropium 18 microg once per day is more potent than ipratropium qid. in bronchodilation to COPD patients with the similar tolerance of ipratropium.

[Clinical investigation of the first case of severe acute respiratory syndrome in Beijing in 2004].

OBJECTIVE: To summarize and analyze the clinical manifestation of the first case of severe acute respiratory syndrome (SARS) in Beijing in 2004, and therefore providing clues of differential diagnosis for physicians to diagnose SARS cases in a timely manner and find out its transmission. METHODS: The clinical data of an out-hospital-imported SARS case and its clinical features were analyzed. RESULTS: (1) The delay in diagnosis of this SARS case was largely associated with unclear epidemiologic history; (2) The SARS patient showed characteristics of typical pneumonia in the early stage. The numbers of peripheral white blood cells and lymphocytes were in the normal range without any specific changes typical of SARS. CONCLUSION: It is very important for physicians to be alert to the epidemiological data for an early diagnosis of SARS, and therefore early isolation and initiation of appropriate treatment.