Peri-engraftment respiratory distress syndrome during autologous hematopoietic stem cell transplantation.

From 1987 to 1998, 19 of 416 patients (4.6%) who underwent autologous hematopoietic stem cell transplantation experienced peri-engraftment (within 5 days of neutrophil recovery) respiratory distress syndrome (PERDS) not attributable to infection, fluid overload, or cardiac dysfunction. The median time from stem cell infusion to onset of PERDS was 11 days (range 4-25). Risk of PERDS or its outcome was not predicted by any pre- or peri-transplant clinical or laboratory feature. The respective median white blood cell and platelet counts at first symptoms were 1.3 x 10(9)/l and 25 x 10(9)/l. No patients had an infectious etiology by bronchoalveolar lavage. Six of the 19 patients had alveolar hemorrhage, which was significantly correlated with high neutrophil count. PERDS was directly implicated in four deaths (21%). Eleven patients received high-dose corticosteroid therapy, including five of the six who required mechanical ventilation. Ten of these patients experienced clinical improvement, which occurred within 24 h in five. The rapid response to corticosteroid treatment and the fact that such therapy was delayed until after intubation in all the mechanically ventilated cases point to a therapeutic benefit.

Tracheobronchial amyloidosis.

OBJECTIVE: To evaluate the presentation and clinical course of patients with tracheobronchial amyloidosis. PATIENTS AND METHODS: We retrospectively reviewed the records of all patients with biopsy-proven tracheobronchial amyloidosis who were evaluated at the Mayo Clinic in Rochester, Minn, between 1973 and 1999. All relevant information, such as clinical, historical, demographic, laboratory, and histological data, was examined. RESULTS: Tracheobronchial amyloidosis was diagnosed in 17 patients (9 women and 8 men), with a mean age of 56.6 years. The most common symptoms at presentation were dyspnea, cough, hemoptysis, and hoarseness. None of the 14 patients who underwent investigation for systemic amyloidosis had any evidence of disease outside the tracheobronchial system except for a man in whom multiple myeloma had been diagnosed 3 years before the development of respiratory disease. Treatment of tracheobronchial amyloidosis consisted of laser or forceps resection, external radiation, systemic therapy, or observation. Two patients died of complications directly related to their disease. CONCLUSIONS: Patients presenting with tracheobronchial amyloidosis have symptoms similar to those caused by various airway disorders. Tracheobronchial amyloidosis is not typically associated with systemic amyloidosis or pulmonary parenchymal involvement. It often recurs and despite repeated attempts with bronchoscopic techniques, airway compromise remains a major problem.

Chest roentgenography after outpatient thoracentesis.

OBJECTIVE: To evaluate the clinical utility of posteroanterior chest roentgenograms after thoracentesis in the outpatient setting. DESIGN: We undertook a retrospective study of clinical records of outpatient thoracentesis performed between January and December 1996 by the Division of Pulmonary and Critical Care Medicine at Mayo Clinical Rochester. MATERIAL AND METHODS: The medical records of 54 men and 39 women who underwent 123 outpatient thoracentesis were reviewed. Exclusion criteria were the need for pleural biopsy at time of thoracentesis or the need for ultrasound-guided assistance for completion of the procedure. Indications for thoracentesis and postthoracentesis chest roentgenography were analyzed. RESULTS: Of 123 thoracentesis performed in the outpatient setting during the specified study period, 104 met the inclusion criteria. Of these 104 thoracentesis, 54 (52%) were followed by chest roentgenography. Pneumothorax occurred in only 5 of these 104 procedures (5%), in 5 separate patients. Three of these patients were asymptomatic and did not require therapeutic intervention; the two symptomatic patients required hospitalization and chest tube drainage. Of the two pneumothoraces in patients with symptoms, one was detected on the same day as the thoracentesis, and the other was diagnosed 2 days later. The patients who did not undergo postthoracentesis chest roentgenography had no reported complications. Of the 54 chest roentgenograms, 52 were obtained in asymptomatic patients, with no suspicion of pneumothorax. These x-ray studies led to a total cost of $4,862 and detection of three pneumothoraces that did not require therapy. CONCLUSION: Routine performance of chest roentgenography after outpatient thoracentesis can incur substantial cost. A more selective approach to this practice is needed, both to optimize patient care and to manage limited medical resources efficiently. Postthoracentesis chest roentgenograms should be limited to patients with symptoms indicative of thoracentesis-induced pneumothorax.

Rheumatic fever revisited. Keep this diagnosis on your list of suspects.

The symptoms of recurrent rheumatic fever in adults can be very different from those in children, and the diagnosis is easy to overlook. Nonetheless, rheumatic fever is still a problem in many parts of the world, as illustrated by this case. Dr Capizzi and associates remind us to keep our options open.