Bronchoscopic diagnosis of solitary pulmonary nodules and lung masses in the absence of endobronchial abnormality.

To evaluate the individual and additive diagnostic yield(s) of several bronchoscopic sampling techniques for the diagnosis of lung lesions with no corresponding airway abnormalities, consecutive patients with lung nodules or masses were prospectively evaluated between December 1989 and November 1994. A CT of the chest was done in all patients before flexible bronchoscopy (FB). Size, location, and character of the border of the lesion were determined. During FB, using biplane fluoroscopic guidance, the lesion was localized and following sampling techniques were done: brushing, transbronchial lung biopsy (TBLB), and Sofcor transbronchial needle aspiration (STBNA). Bronchial washings (BWs) were collected throughout the procedure. Problems associated with each sampling technique were noted. Forty-nine patients underwent 51 FB. A diagnosis was established by FB in 36 (73%). After a nondiagnostic FB, histologic diagnosis was established in 9 of 13 patients by other methods. A benign or malignant nature of lesion was established in other four patients by clinical follow-up. FB was diagnostic in 32 of 40 (80%) patients with primary lung cancer, in 3 of 6 (50%) patients with benign disease, and in 1 of 3 (33%) patients with metastatic disease to lung. All sampling procedures could be done in 33 of 51 (65%) FBs. Overall diagnostic yields were as follows: BW, 18 of 51 (35%); brush, 25 of 48 (52%); TBLB, 23 of 40 (57%); and STBNA, 19 of 37 (51%). In 12 of 51 (24%) FBs, only one sample was diagnostic. Lesions with sharp borders had a lower combined diagnostic yield, 13 of 24 (54%) compared to lesions with fuzzy borders, 20 of 24 (83%) (p=0.03). Yield of TBLB in lesions with fuzzy borders, 14 of 18 (78%), was higher than the yield for lesions with sharp borders, 6 of 19 (32%) (p=0.005). Size of the lesion in centimeters in patients with a positive FB (4.55+/- 2.35; mean +/-SD) was significantly larger than in patients with a nondiagnostic FB (3.14+/-1.31; mean+/-SD) (p=0.009, t test). Diagnostic yield was directly related to the size of the lesion. For lesions less than 2 cm, yield was 6 of 11 (54%) (p=0.19); for lesions less than 3 cm, yield was 12 of 21 (57%) (p=0.07); and for lesions greater than 3 cm, yield was 24 of 30 (80%). Yield from lesions located in the lower lobe basal segments or the apical segment of upper lobes was lower (11/19, 58%) than that from lesions in other parts of the lung (25/30, 83%) (p=0.05). FB was terminated prior to collecting all samples because of severe bleeding after brushing (n=3) or instability of the patient (n=4). None of the patients required intubation. There were no pneumothoraces. Diagnostic yield of FB depends on the location, size, character of the border of the lesion, and the ability to perform all sampling methods. Brushing, TBLB, and STBNA should be performed in all patients to give the best diagnostic yield. Routine cytologic examination of BW is unnecessary. Methods other than FB should be considered for lesions 2 cm or less in size, especially when they have a sharp border and/or are located in the basal segment of a lower lobe/apical segment of an upper lobe.

Open lung biopsy for diffuse infiltrative lung disease.

The purpose of this study was to determine the most appropriate site of biopsy in patients with diffuse infiltrative lung disease (DILD). Twenty patients were evaluated. During open lung biopsy, a representative region (inflamed and least fibrotic) of the radiographically most involved lobe was identified and a biopsy done. A second biopsy specimen was obtained from an adjacent accessible lobe. The biopsy specimen from each lobe was processed separately, and a descriptive histologic report was generated for each of the two lobes. Tissue was cultured for bacteria, fungi, and mycobacteria. In 17 patients, the second biopsy site had fewer roentgenographic abnormalities than the radiographically most involved lobe. In 3 patients, the number of radiographic abnormalities was equal in all lobes. The same pathologic diagnosis was reached by histologic examination of the two biopsy specimens in 8 of 10 patients with acute DILD and in 10 of 10 patients with chronic DILD. In 2 patients, the biopsy specimen from the radiographically most involved lobe showed pathologic features not seen in the other specimen. Cultures from both biopsy specimens were grown separately in 6 patients. Fungi (n = 2) and bacteria (n = 1) were isolated from the radiographically most involved lobe (n = 2) or from the lobe of initial lung infiltration (n = 1) in 3 patients. When biopsy specimens are obtained from a representative region of the radiographically most involved lobe in patients with DILD, biopsy of other lobes is unnecessary.

Bronchitis mimicking opportunistic lung infection in patients with human immunodeficiency virus infection/AIDS.

Purulent bronchitis was identified in 19 of 422 patients undergoing fiberoptic bronchoscopy during a 32-month period because of suspicion of an opportunistic lung infection complicating acquired immunodeficiency syndrome or human immunodeficiency virus infection. Five patients had Pneumocystis carinii pneumonia, but other opportunistic lung infections were excluded in the remaining 14 patients. Characteristics of these 14 patients included fever (greater than 38.3 degrees C), cough, and dyspnea in 14 of 14 patients; purulence of expectorated sputum (11/14); and widened alveolar-arterial oxygen gradient (13/14). Rapid (2 +/- 1.4 days) clinical response (defervescence and resolution of pulmonary symptoms) occurred with antibiotic therapy in 10 of 14 patients. In three patients, there was no improvement, and adult respiratory distress syndrome developed. Bacterial isolates from bronchoalveolar lavage included Streptococcus viridans (n = 12), Haemophilus influenzae (n = 7), Staphylococcus aureus (n = 3). Roentgenographic features of bronchiectasis were present in seven patients. Differential cell counts revealed greater than 50% neutrophils in the bronchial washings of all patients with purulent bronchitis. Neutrophil percentages in bronchoalveolar lavage were as follows: patient with purulent bronchitis without P carinii pneumonia (n = 14), 54.53% +/- 29.18%; patients with purulent bronchitis and concomitant P carinii pneumonia (n = 5), 62% +/- 31.9%. In a control group of 17 patients with P carinii pneumonia who did not have purulent bronchitis, the neutrophil percentage was 6.8% +/- 6.17% (p = less than 0.00001, t-test). Purulent bronchitis appears to be a distinct, treatable entity in patients with HIV infection and may accompany bacterial pneumonia, bronchiectasis, and P carinii pneumonia.

Bronchiolitis obliterans organizing pneumonia and scleroderma.

Pulmonary involvement in scleroderma is characterized by interstitial fibrosis and pulmonary hypertension. Although bronchiolitis obliterans organizing pneumonia (BOOP) may be associated with a variety of connective tissue diseases and their treatment, there are only rare reports of bronchiolitis associated with scleroderma. We describe 2 patients with scleroderma and rapidly evolving pulmonary infiltrates, which upon biopsy showed histologic findings of BOOP. Each patient had severe restrictive lung disease and markedly diminished diffusion capacity. Treatment with high dose prednisone showed a good response in one patient. The rapid course of pulmonary findings in these patients differs from the usual course of pulmonary fibrosis in scleroderma. Although BOOP is a rare finding in scleroderma, our findings suggest that rapid pulmonary decompensation or atypical findings for pulmonary fibrosis should prompt consideration for an open lung biopsy. Finding a potentially steroid responsive disorder in an otherwise steroid unresponsive disorder has important clinical implications.

Pneumocystis carinii pneumonia in patients with connective tissue disease.

Four patients with PCP complicating a CTD are described. Rising serum lactate dehydrogenase levels were documented during an asymptomatic period associated with corticosteroid dosage tapering, weeks prior to the development of acute pulmonary symptoms. The diagnosis of PCP was established by FOB in each patient.

Modification of an aerosol mask to provide high concentrations of oxygen in the inspired air. Comparison to a nonrebreathing mask.

With a few simple modifications, an aerosol mask was adapted to deliver high concentrations of oxygen. We compared the delivery of high concentrations of oxygen by this modified aerosol mask (MAM) with that of a nonrebreathing mask (NRM) in five normal volunteers and six patients with respiratory failure. Besides improved oxygenation, the MAM also permitted the following: humidification of the inspired oxygen, nebulization of bronchodilators, oropharyngeal suctioning, and performance of fiberoptic bronchoscopy. In lieu of intubation and mechanical ventilation, MAM may be a better alternative to a NRM for maintaining adequate oxygenation until the clinical situation improves.

Optimal therapy of cryptococcosis in patients with the acquired immunodeficiency syndrome.

Although amphotericin B (AB) is the primary therapeutic agent for cryptococcosis complicating the acquired immunodeficiency syndrome (AIDS), the total dose administered is extremely variable, and the end point of therapy has not been well defined. Since these patients require life-long suppressive therapy following the primary therapy, the definition of treatment "end point" becomes crucial. To delineate more effective treatment approaches, we reviewed the medical records of 48 patients with cryptococcosis complicating AIDS. Fever (81%) and headache (77%) were the predominant symptoms. A clinical response to AB (defervescence and resolution of symptoms) was noted in 46% of the febrile patients. The cumulative AB dose administered to the time of clinical response was variable (0.1-1.76 g), but was noted early in the majority of the patients (less than 0.4 g). Repeat fungal cultures from the initial positive site for Cryptococcus neoformans (CN), obtained after observation of the clinical response, were negative in 7/7 patients. Nosocomial bacterial infections were quite common and often complicated intravenous AB therapy. Bacteremias were documented in 10/14 febrile episodes occurring during AB therapy in the 22 patients with an initial clinical response. Bacteremias were identified in 6/21 patients who failed to defervesce with AB therapy. Staphylococcus aureus (N = 9) and Salmonella species (N = 2) were the most common pathogens causing bacteremia. An algorithm for the treatment of cryptococcosis complicating AIDS may shorten the duration of primary intravenous AB therapy. This might reduce secondary infectious complications and the costs of hospitalization.

Necrotizing tracheobronchitis: complication of mechanical ventilation in an adult.

A 51-year-old woman had localized interstitial pneumonia that rapidly progressed to involve all lung fields. After 9 days of conventional mechanical ventilation, pneumothorax developed in the presence of an obstruction of the right main bronchus. Bronchoscopy and endobronchial biopsies revealed NTB involving the tracheobronchial tree distal to the tip of the endotracheal tube, with complete obstruction of the right main bronchus by hard, eschar-like material. Tracheal mucosa proximal to the tip of the endotracheal tube was normal. Subsequent bronchoscopy, 20 days later, showed marked resolution of NTB. Though a frequent complication of mechanical ventilation in the neonate, NTB as a complication of conventional mechanical ventilation has not previously been recognized in an adult. Necrotizing tracheobronchitis should be suspected in adults who have had mechanical ventilation and who are experiencing ventilatory difficulties, after routine problems have been treated or excluded.

Pneumocystis carinii pneumonia in patients with AIDS: evaluation of lavage and staining techniques in diagnosis.

The diagnostic yield of unilateral vs. bilateral bronchoalveolar lavage (BAL) was prospectively evaluated in 65 consecutive patients suspected of having Pneumocystis carinii pneumonia (PCP) complicating acquired immune deficiency syndrome (AIDS). Gram-Weigert (GW), Papanicolaou (PAP), and Gomori's methenamine silver (GMS) stains were used for identification of P. carinii in all cases. Forty-eight patients had PCP that was identified by GW staining of BAL in 47/48 patients followed by PAP/GMS staining of BAL in 44/48 patients and PAP/GMS staining of bronchial washings in 40/48 patients. In patients with bilateral interstitial infiltrates, unilateral lavage was sufficient for diagnosis of PCP when GW stain was utilized. In patients with PCP complicating AIDS, the diagnostic yield of BAL may be increased by use of both GW and GMS stains.

Corticosteroids in asthma.

Corticosteroids have a definite role in acute and chronic asthma therapy. The benefits of intravenously administered corticosteroids in acute asthma have been shown in many randomized and nonrandomized trials. Indications for corticosteroid use, corticosteroid preparation used, dosage, frequency of administration, and duration of therapy differ in every study. Analysis of these studies suggests that hydrocortisone (4 mg/kg) or methylprednisolone (125 mg) as the initial dose, followed by a continuous infusion of hydrocortisone (12 mg/kg over 24 hours), or bolus injections of methylprednisolone (125 mg every 6 hours) may be the most appropriate corticosteroid therapy in acute asthma. Methylprednisolone may have some pharmacologic advantages over hydrocortisone. A clinical approach to tapering of corticosteroids after treatment of an acute exacerbation is outlined. Hypothalamic-pituitary-adrenal-axis suppression with chronic oral and inhaled corticosteroid use and the management of corticosteroid therapy in such patients are discussed. Inhaled corticosteroids are extremely useful in management of asthma poorly controlled with bronchodilators, and physicians may consider adding them to bronchodilators from the earliest phases of therapeutic intervention for adult asthma. A practical guide to the use of inhaled corticosteroids in asthma is presented.

Pulmonary manifestations of disseminated cryptococcosis in patients with AIDS.

Forty-eight patients with disseminated cryptococcosis and AIDS were retrospectively studied to define the pulmonary manifestations. Cryptococcus neoformans (CN) was first isolated from a pulmonary site in 12 patients. Disseminated disease was subsequently documented in all these patients. Symptoms and roentgenographic manifestations (normal, nodular/circumscribed infiltrates, pleural effusions, lobar consolidation) were diverse. Interstitial infiltrates predicted the presence of another opportunistic lung infection besides cryptococcosis in five patients (three untreated and two treated patients). Infectious causes other than cryptococcosis were established by culture and clinical course in five of the ten patients who developed chest roentgenographic abnormalities during amphotericin B therapy. Endobronchial abnormalities were identified in four patients at bronchoscopy. Bronchoalveolar lavage (9/9) and pleural fluid (3/3) cultures were sensitive tests for detection of pulmonary involvement with CN.

Pulmonary non-Hodgkin's lymphoma mimicking infection.

Progressive pulmonary shadows prompted investigations which provided the diagnosis of pulmonary non-Hodgkin's lymphoma in three patients (two with the acquired immunodeficiency syndrome). Rapid progression of radiographic abnormalities seen in these three patients is unusual for pulmonary non-Hodgkin's lymphoma and mimics disease evolution commonly associated with pulmonary infections.

Disseminated histoplasmosis in AIDS. Clinicopathologic features in seven patients from a non-endemic area.

Although the clinical and epidemiologic features of progressive disseminated histoplasmosis (PDH) in the acquired immunodeficiency syndrome (AIDS) have been well described, the pathologic and pulmonary aspects remain to be fully defined. A retrospective review of three patients and a prospective study of four more with PDH and AIDS recently admitted to an inner city hospital in a non-endemic area were used to elucidate these features more fully. All patients were men aged 23 to 46 years, born in endemic areas, who had immigrated to the US seven to 15 years before the onset of their illnesses. Five had been exposed to human immunodeficiency virus (HIV) through intravenous drug use (one was also a homosexual), and two through heterosexual contacts. Respiratory symptoms were evident in five of the seven patients, fever in seven, weight loss in seven, hepatomegaly in four, splenomegaly in three, peripheral adenopathy in three, and gastrointestinal symptoms in three. PDH was the initial or only opportunistic infection in five patients. Bilateral nodular infiltrates (4/7), bilateral interstitial infiltrates (2/7), and mediastinal adenopathy associated with pleural effusion (1/7) were the chest roentgenographic findings. Histoplasma capsulatum was isolated from five of five bronchoalveolar lavages, four of four transbronchial biopsies, one of one endobronchial biopsy, one of one brushing, one of one pleural biopsy, three of three lymph node biopsies, two of two bone marrow biopsies, one of one liver biopsy, and three of four peripheral blood smears. Granuloma formation was seen in only three of 12 biopsies. There were ten or more fungi per monocyte in almost all tissues, some with extracellular forms.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic cavitary Pneumocystis carinii pneumonia in a patient with AIDS.

A 39-year-old man with AIDS presented with cough, chest pain, dyspnea on exertion, fever, and a cavitary lesion in the upper lobe of the left lung. The cavity increased in size over the next five months with disease involvement limited to the left upper lobe. Pneumocystis carinii infection was then diagnosed. Symptoms and cavity resolved with trimethoprim/sulfamethoxazole therapy.

Effect of simultaneous administration of betamethasone and triiodothyronine (T3) on the development of functional pulmonary maturation in fetal rabbit.

Recent experimental evidence suggests that a combination of glucocorticoid and thyroid hormone may be more effective than either hormone alone in accelerating morphologic as well as biochemical mammalian fetal lung maturation. We have demonstrated that IM administration of T3 to the rabbit doe is associated with enhanced functional fetal lung maturation. We investigated the effect of simultaneous administration of T3 and betamethasone on the development of functional fetal lung maturation and the duration of survival after premature delivery. On day 25 and 26 of pregnancy, T3 (175 micrograms/kg/dose) betamethasone (85 micrograms/kg/dose), T3 plus betamethasone or the appropriate amount of the vehicles were injected. The functional fetal pulmonary maturity and the duration of survival after premature delivery were assessed on day 27 of gestation. Although enhanced functional fetal lung maturation was observed after T3 or betamethasone administration, there was no additive effect after simultaneous administration of both. The duration of survival on premature delivery was enhanced in betamethasone but not T3 or T3 plus betamethasone group when compared to control. Further animal experimentation seems necessary before a clinical trial of T3 plus betamethasone therapy is considered.