The role of FDG PET-CT in differential diagnosis of pleural pathologies.

OBJECTIVE: This study has aimed to evaluate the impact of (F18) Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography (FDG PET-CT) in the differential diagnosis of malignant and benign pleural lesions in patients with suspected malignant pleural mesothelioma (MPM). MATERIAL AND METHODS: Fifty patients (32 females, 18 males; age range 24-79 years) with pleural thickening, fluid, plaques or calcification on previous CT scan were examined with FDG PET-CT. PET-CT imaging was obtained 1 h after FDG injection. In 12 patients, delayed imaging from the thoracic region was performed 2 h after injection. FDG uptake was evaluated visually and semiquantitively using standardized uptake value (SUV). FDG PET-CT findings were compared with histopathologic diagnosis. RESULTS: Thirty-nine patients had increased FDG uptake in pleural lesions but PET-CT results were negative in 11 patients. When compared with histopathological results in FDG positive group, 34 patients had MPM, 5 had benign pathology; in FDG negative group 8 patients had benign pathology, 3 had MPM. Of patients with delayed imaging, 9 showed increased SUV but 3 had a decreased SUV on delayed images. Increased SUV group had 4 MPM, 5 benign pathology (3 chronic granulomatous inflammation, 2 benign asbestotic plaque). Decreased SUV group all had benign pathology (fibrosis, chronic inflammation, myofibrosis). DISCUSSION: FDG PET-CT is a useful imaging modality in differential diagnosis of malignant and benign pleural lesions. Delayed imaging seems to be useful if there is a decrease in SUV suggesting a benign pathology but does not seem to contribute to the differential diagnosis if the SUV is increased.

El papel de FDG PET-TAC en el diagnóstico diferencial de patologías pleurales / The role of FDG PET-CT in differential diagnosis of pleural pathologies

Introducción. El propósito de este estudio fue el de estudiar el impacto de F-18 Fluoro Desoxi Tomografía-Tomografía por Emisión de tomografía computerizada (FDG y PET-TAC) sobre la diagnosis diferencial de lesiones benignas y malignas en pacientes con sospecha de mesotelioma pleural maligno. Pacientes y métodos. Cincuenta pacientes (32 mujeres, 18 hombres, rango de edad 24-79 años, edad media 57,6) con engrosamiento pleural, derrame pleural, placas o calcificaciones vistas en imágenes en estudios previos con TAC fueron sometidos a la PET-TAC con FDG. Tras la inyección intravenosa de la FDG, se realizaron imágenes PET-TAC al cabo de una hora. Se obtuvieron imágenes tardías de la región torácica a las 2 horas de la inyección. Se llevaron a cabo análisis visual y semi cuantitativos con el valor de captación estándar (SUV). Los resultados del FDG PET-TAC fueron comparados con el diagnóstico histopatológico. Resultados. 39 pacientes demostraron captación aumentada en lesiones pleurales. Los resultados en la PET-TAC fueron negativos en 11 pacientes. Al comparar los resultados histopatológicos en el grupo de FDG-positivo, 34 pacientes tenían mesotelioma pleural maligno (MPM), 5 pacientes tenían patologías benignas. En el grupo FDG-negativo, las patologías fueron benignas en 8 pacientes, 3 pacientes tuvieron MPM. En los pacientes con imágenes tardías, 9 demostraron SUV aumentado, pero 3 tuvieron SUV disminuido en las imágenes tardías. En el grupo con SUV aumentado, 4 tuvieron MPM, 5 patología benigna (3, inflamación granulomatosa, y 2 placas asbestosis benignos). En el grupo de SUV disminuido, todos tuvieron patología benigna (la fibrosis, inflamación crónica, miofibrosis). Discusión. La FDG PET-TAC es una modalidad de imágenes útil en el diagnóstico diferencial de lesiones pleurales benignas y malignas. Imágenes tardías parecen ser útiles si existe una disminución en SUV sugerente de una patología benigna. Sin embargo, no parece contribuir a un diagnóstico diferencial si el SUV se aumenta(AU)

Objective. This study has aimed to evaluate the impact of F18 Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography (FDG PET-CT) in the differential diagnosis of malignant and benign pleural lesions in patients with suspected malignant pleural mesothelioma (MPM). Material and methods. Fifty patients (32 females, 18 males; age range 24-79 years) with pleural thickening, fluid, plaques or calcification on previous CT scan were examined with FDG PET-CT. PET-CT imaging was obtained 1h after FDG injection. In 12 patients, delayed imaging from the thoracic region was performed 2h after injection. FDG uptake was evaluated visually and semiquantitively using standardized uptake value (SUV). FDG PET-CT findings were compared with histopathologic diagnosis. Results. Thirty-nine patients had increased FDG uptake in pleural lesions but PET-CT results were negative in 11 patients. When compared with histopathological results in FDG positive group, 34 patients had MPM, 5 had benign pathology; in FDG negative group 8 patients had benign pathology, 3 had MPM. Of patients with delayed imaging, 9 showed increased SUV but 3 had a decreased SUV on delayed images. Increased SUV group had 4 MPM, 5 benign pathology (3 chronic granulomatous inflammation, 2 benign asbestotic plaque). Decreased SUV group all had benign pathology (fibrosis, chronic inflammation, myofibrosis). Discussion. FDG PET-CT is a useful imaging modality in differential diagnosis of malignant and benign pleural lesions. Delayed imaging seems to be useful if there is a decrease in SUV suggesting a benign pathology but does not seem to contribute to the differential diagnosis if the SUV is increased(AU)

D-dimer levels in pleural effusions.

INTRODUCTION: D-dimer is a degradation product of cross-linked fibrin. We hypothesized that hemorrhagic pleural effusions would have greater D-dimer levels than non-hemorrhagic pleural effusions, and that persistently bloody effusions would be distinguishable from thoracentesis-induced bloody effusions by the D-dimer level. METHODS: Forty pleural effusions were studied. D-dimer levels (measured by ELISA), red blood cell (RBC) count, white blood cell (WBC) count, lactate dehydrogenase (LDH), and protein level was measured for each effusion. Ten effusions, five non-bloody, and five bloody were studied for each of the following disease states: parapneumonic effusion, congestive heart failure, post-coronary artery bypass grafting, and lung cancer. RESULTS: No significant difference of the D-dimer level was noted between bloody and non-bloody effusions of different disease states (P=0.286). There was no significant difference in the median D-dimer levels between all the bloody and all the non-bloody effusions (P=0.88). There was no significant difference (P=0.51) in D-dimer levels between five diseases groups when the bloody and non-bloody fluids were combined. The D-dimer levels did not correlate with the RBC count (r=0.11, P=0.48), WBC count (r=0.13, P=0.53), LDH (r=0.01, P=0.93), or protein levels (r=-0.01, P=0.93) in any of the groups. CONCLUSION: Measurement of pleural fluid D-dimer levels does not distinguish persistently bloody effusions from non-bloody effusions, and does not aid in narrowing the differential diagnosis of an effusion.

First report of pulmonary Nocardia otitidiscaviarum infection in an immunocompetent patient from Turkey.

Nocardiosis is a rare disease, and worldwide, respiratory and disseminated infections are most often due to Nocardia asteroides which is recognised increasingly as an opportunistic infection in patients with underlying chronic debilitating disease or immunodeficiency. However, infection with N. otitidiscaviarum and pulmonary nocardiosis in an immune-competent host remains very rare. We report a 65-year-old immune-competent male with pulmonary N. otitidiscaviarum infection in whom complete cure was provided with a 6 months of antibiotic combination including trimethoprim-sulfomethaxazol. This is the first report of pulmonary N. otitidiscaviarum infection in an immune-competent patient from Turkey.

Antibiotic resistance of bacterial ventilator-associated pneumonia in surgical intensive care units.

Ventilator-associated pneumonia (VAP) is the most common infection in intensive care units. It is caused by prolonged hospitalization and results in high mortality rates. This retrospective clinical study, of 140 patients in a surgical intensive care unit, aimed to identify the bacterial agents responsible for VAP infection, and determine antibiotic resistance rates in VAP. Antibiotic sensitivity was evaluated by culturing and testing tracheal aspirates from patients with clinical and radiological findings of VAP. The bacteria isolated most frequently were Pseudomonas aeruginosa (33.9%), Staphylococcus aureus (30.0%), Acinetobacter baumannii (26.1%), and Enterobacter species (4.3%). A. baumannii was more prevalent than in previous years. The results of antibiotic sensitivity testing suggested sulbactam/cefoperazone as the most appropriate drug for treating these patients. We suggest, however, that when staphylococcal pneumonia is suspected, a glycopeptide (vancomycin or teicoplanin) or combined trimethoprim-sulfamethoxazole is used as first-line therapy until sensitivity results are obtained. In conclusion, development of antibiotic policies for individual hospitals can reduce high antibiotic resistance rates due to VAP.

A case of septicaemia, meningitis and pneumonia caused by Streptococcus bovis type II.

We present a case of septicaemia, pneumonia and meningitis due to Streptococcus bovis type-II in a patient who had undergone a total hip prosthesis under general anaesthesia three weeks earlier. This organism is an uncommon human pathogen that sometimes causes bacteraemia and endocarditis and is usually connected with colon pathology and dental procedures. In the reported case, there were no risk factors for S. bovis infection except for the hip operation. S. bovis type II sensitive to penicillin was isolated from all blood and pleural fluid cultures. The patient recovered and was discharged from hospital two weeks after presentation.

Churg-Strauss syndrome in an HCV seropositive patient.

Churg-Strauss syndrome was considered rare until leukotriene modifiers were introduced into medical practice in 1996. Since then, an increasing number of reports considering a possible relationship between leukotriene receptor antagonists and the Churg-Strauss syndrome have been published. Hepatitis C virus (HCV) is a blood-borne infection and a major health problem with an increasing prevalence worldwide. Previously, numerous reports suggested a relationship between HCV and certain autoimmune disorders such as cryoglobulinaemia and polyarteritis nodosa. We present a patient with HCV seropositive Churg-Strauss syndrome and a history of systemic corticosteroid and leukotriene receptor antagonist use, and discuss the possible risk factors in the aetiology of Churg-Strauss syndrome.

Epidemiological, clinical and laboratory features of brucellosis: a prospective evaluation of 120 adult patients.

This prospective study was carried out in the department of infectious diseases of Gaziantep University between January 1997 and December 1999 to evaluate the epidemiological, clinical and laboratory features of brucellosis in south-eastern Turkey. One hundred and twenty consecutive patients with active brucellosis were enrolled. The commonest way of transmission was ingestion of milk products from diseased animals. Brucella melitensis was isolated in the specimens of 31 (45.5%) of 68 patients. The commonest abnormalities on physical examination were fever (66.6%), hepatomegaly (63.3%) and splenomegaly (56.6%). Osteoarticular involvement was found in 34 patients (28.3%). Fifteen (12.5%) patients had ocular involvement. Hepatitis, orchiepididymitis, pulmonary involvement and meningitis were found in one (0.8%), four (6.8%), three (2.5%) and one (0.8) patient, respectively. The commonest haematological abnormalities were relative lymphomonocytosis (71.6%) and anaemia (36.6%). In conclusion, brucellosis continues to be a common health problem in communities where the consumption of unpasteurised dairy products is common. Since prevention is as important as early diagnosis in reducing the morbidity of brucellosis, we suggest that improving current health policies with additional educational programmes is essential.

Foreign body aspiration: clinical utility of flexible bronchoscopy.

Foreign body aspiration is a worldwide health problem which often results in life threatening complications. More than two thirds of foreign body aspirations occur among children younger than 3 years. Organic materials such as nuts, seeds, and bones are most commonly aspirated. There is a wide range of clinical presentation, and often there is not a reliable witness to supply the clinical history, especially in children. Maintaining a high index of suspicion is therefore necessary for the diagnosis. None of the imaging methods employed in such cases are diagnostic, and bronchoscopy is frequently necessary for the diagnosis as well as the treatment. In adults, removal of the foreign body can be attempted during diagnostic examination with a fibreoptic bronchoscope under local anaesthesia, which may help to avoid any further invasive procedures with more complications. When diagnosis is delayed, complications of a retained foreign body such as unresolving pneumonia, lung abscess, recurrent haemoptysis, and bronchiectasis may necessitate a surgical resection. However, some of the late complications may resolve completely after the retrieval of the foreign body, therefore, a preoperative flexible bronchoscopy should always be considered in suitable cases.

Comparison of non-invasive ventilation and standard medical therapy in acute hypercapnic respiratory failure: a randomised controlled study at a tertiary health centre in SE Turkey.

This study was designed in a tertiary health centre in south-eastern Turkey to compare the effectiveness of non-invasive ventilation (NIV) plus standard medical therapy (ST) to ST alone, in acute hypercapnic respiratory failure (AHRF) due to chronic obstructive pulmonary disease (COPD) exacerbation. Thirty-four consecutive patients were randomly assigned to receive either NIV plus ST or ST alone. NIV was applied with a simple non-invasive ventilator through a full face mask in the general ward. Initial settings for inspiratory and expiratory positive airway pressures were 9 cm HO2, and 3 cm HO2, respectively. We observed statistically significant improvements in the first hour of NIV regarding respiratory rate (p<0.001), pH (p<0.05), PaO2 (p<0.05), and PaCO2 (p<0.001). PaO2 (p<0.05) showed significant improvement only in the first hour of ST. The intubation rate and duration of hospitalisation in the NIV group were significantly shorter than those in the ST group (p<0.05). We conclude that NIV provides adjunctive therapeutic benefits compared with ST alone, and should be the choice of first step treatment in the AHRF due to COPD exacerbation in the appropriate setting and in selected patients.

Intrapleural urokinase in the management of parapneumonic empyema: a randomised controlled trial.

We compared the effectiveness of intrapleural urokinase versus normal saline via a thoracostomy tube in the treatment of parapneumonic empyema in a randomised controlled study. Forty-nine patients with parapneumonic empyema were randomly assigned to receive either intrapleural urokinase or normal saline treatment. The daily volume instilled through a chest tube was 100 ml in both groups. Urokinase (100,000 IU/day) was diluted in normal saline before instillation. The mean duration for defervescence was shorter (7 +/- 3 vs 13 +/- 5 days, p<0.01) and the mean volume of drained fluid during the five-day treatment period was significantly greater in the urokinase group (1.8 +/- 1.5 vs 0.8 +/- 0.8 litres, p<0.001) than in the control group. The subsequent decortication rate was 60% and 29.1%, respectively (p<0.001). The duration of hospitalisation was also shorter in the urokinase group (14 +/- 4 vs 21 +/- 4 days, p<0.001) than in the saline group. We conclude that intrapleural instillation of urokinase in the management of parapneumonic empyema provides a better outcome and reduces the need for decortication.

Drug-resistant tuberculosis at the University Hospital in Gaziantep, South-eastern Turkey.

We aimed to determine the present status of drug resistance of Mycobacterium tuberculosis at the Gaziantep University Hospital in south-east Turkey. Data for 1995 to 1999 were retrospectively evaluated with respect to smear-positive cases, first positive culture for Mycobacterium tuberculosis for each patient and drug-susceptibility tests for the major antituberculous drugs. Cultures were done using the Bactec 460 TB method. A total of 106 (40.2%) strains were resistant to at least one drug. Single drug resistance was observed in 47 strains (17.8%) and resistance to two or three drugs was found in 28 and 29 strains (10.6 and 11.0%), respectively. Two strains (0.8%) were resistant to all four drugs. While multidrug resistance was observed in 52 (19.7%) strains, resistance to isoniazid + rifampin was observed in 20 (7.6%) strains. This retrospective study showed that combined drug resistance of M. tuberculosis is highly prevalent in southeastern Turkey. Possible reasons for the failure of current control policies were considered.

Comparison of a single dose of aerosol salbutamol and fenoterol/ipratropium on bronchial asthmatic patients.

A combination dose aerosol of fenoterol hydrobromide (200 micrograms) and ipratropium bromide (80 micrograms) was compared with aerosolized salbutamol (200 micrograms) in 10 stable asthmatic patients. With both treatments a statistically significant improvement was noticed in both FEV1 and PEF measurements starting after 15 minutes and continuing until 330 to 360 minutes. No statistically significant differences in one second Forced Vital Capacity (FEV1) and Peak Expiratory Flow (PEF) was noted between the two treatments. No side effect was noticed. As a result, it was concluded that in bronchial asthmatic patients, the bronchodilator effects of the combination of a beta-2 agonist with anticholinergic drugs was as effective and lasted as long as salbutamol. This combination, in order to prevent cardiovascular complications, could be selected as a suitable treatment for those patients who need high doses of beta-2 agonist drugs.