A rare case of asthmatic patient with left Chilaiditi's syndrome.

The following case report aims to highlight the rarity of the case in question, in which there is left Chilaiditi syndrome in a patient with bronchial asthma. The patient is a 79-year-old woman who arrived in January 2023 at my facility for episodes of recurrent dyspnea, chest heaviness, wheezing, eructation, dysphagia, epigastric abdominal pain associated with frequent episodes of bronchitis. He performed simple spirometry which showed mixed mild-moderate ventilatory deficit with reduction of small airway volumes, reduced peak expiratory flow and negative broncho reversibility tests for asthma. At 3 months, the patient returned to my attention with a chest radiograph showing marked elevation of the left hemidiaphragm with deviation of the cardiac shadow to the right. He repeated the spirometry which resulted in a clear improvement compared to the previous control with an important variation of the peak respiratory flow during ICS/LABA, the objective finding previously found disappeared, this indicating the presence of an underlying bronchial asthma. The radiological picture was identified by me as Left Chilaiditi Syndrome, as the patient had gastrointestinal symptoms which accompanied the procession of respiratory symptoms. The diagnostic suspicion must be early in these pathologies and the proton pump inhibitors and new generation alginates with the presence of hyaluronic acid and melatonin must also be included in the treatment of the symptoms, which have an important action on gastroesophageal reflux disease (GERD) secondary to this herniation of the viscera into the thoracic cavity. The rarity is represented by the left localization of the diaphragmatic pathology.

Chest Examination 3.0 With Wireless Technology in a Clinical Case Based on Literature Review.

Physicians use auscultation as a standard method of thoracic examination: it is simple, reliable, non-invasive, and widely accepted. Artificial intelligence (AI) is the new frontier of thoracic examination as it makes it possible to integrate all available data (clinical, instrumental, laboratory, functional), allowing for objective assessments, precise diagnoses, and even the phenotypical characterization of lung diseases. Increasing the sensitivity and specificity of examinations helps provide tailored diagnostic and therapeutic indications, which also take into account the patient's clinical history and comorbidities. Several clinical studies, mainly conducted in children, have shown a good concordance between traditional and AI-assisted auscultation in detecting fibrotic diseases. On the other hand, the use of AI for the diagnosis of obstructive pulmonary disease is still debated as it gave inconsistent results when detecting certain types of lung noises, such as wet and dry crackles. Therefore, the application of AI in clinical practice needs further investigation. In particular, the pilot case report aims to address the use of this technology in restrictive lung disease, which in this specific case is pulmonary sarcoidosis. In the case we present, data integration allowed us to make the right diagnosis, avoid invasive procedures, and reduce the costs for the national health system; we show that integrating technologies can improve the diagnosis of restrictive lung disease. Randomized controlled trials will be needed to confirm the conclusions of this preliminary work.

Correlation between gastro-oesophageal reflux disease (GERD) lung volumes and exacerbation of bronchial asthma: Italian pilot observational retrospective study GERDAS.

Reflux asthma is an entity characterised by typical symptoms and in some cases is 'silent' and is more dangerous when associated with obesity and sleep apnoea syndrome. Its prevalence in the general population is high, as demonstrated by numerous studies listed below, and it is particularly a problem in the paediatric population; where, despite treatment by medical specialists, asthma symptoms are poorly controlled with a high risk of acute exacerbations. The aim of this clinical study is to show how the addition of a particular type of alginate (Deflux plus sachets) containing hyaluronic acid and melatonin at low doses administered over a prolonged period of six months, causes a reduction in vagal reflex stimulation of the oesophagus and pulmonary microaspiration reflexes by regulating lower oesophageal sphincter (LES) motility in asthmatic patients; improving the ACT score (asthma control test score). In the reported statistical analysis, ROC curves were performed for sensitivity and specificity for the analysed parameters, including the ACT score with statistically significant data p<0.0001. We conclude that the combination of conventional therapy for reflux asthma associated with alginates may improve the risk of acute asthma exacerbation and dynamic lung volumes.

Pulmonary rehabilitation improves functional outcomes and quality of life in post-SARS-CoV-2 mild-to-moderate infection patients: a pilot study.

SARS-CoV-2 infection impairs functional outcomes and quality of life, even in its mild-to-moderate form. Therefore, it is appropriate to draw attention to the role played by respiratory rehabilitation and physiotherapists in the pulmonary rehabilitation process that post-SARS-CoV-2 patients must undergo. We enrolled 80 patients in a prospective case-control study; 40 cases (mild-to-moderate post-SARS-CoV-2 infection patients) and 38 control subjects (i.e., patients affected by other respiratory diseases) completed the same full pulmonary rehabilitation cycle. 6-minute walking distance, Borg category-ratio 10 scale, modified Medical Research Council (mMRC) dyspnea scale, European quality of life 5-dimensions-3-level (EuroQoL EQ-5D-3L) questionnaire, Barthel scale, arterial blood gas test, and peripheral oxygen saturation were compared for all patients before and after rehabilitation. All patients experienced significant improvements in all parameters analyzed, except for the arterial blood gas test. Results were similar for both groups; in particular, both groups experienced improvements in the mMRC scale, EuroQoL EQ-5D-3L questionnaire, Barthel scale, and 6-minute walking distance. Pulmonary rehabilitation appears to improve exercise tolerance, dyspnea, and quality of life in patients recovering from a mild-to-moderate SARS-CoV-2 infection. Further studies are needed on a larger sample size population to validate these results.

Research data communication strategy at the time of pandemics: a retrospective analysis of the Italian experience.

Coronavirus pandemic has radically changed the scientific world. During these difficult times, standard peer-review processes could be too long for the continuously evolving knowledge about this disease. We wanted to assess whether the use of other types of network could be a faster way to disseminate the knowledge about Coronavirus disease. We retrospectively analyzed the data flow among three distinct groups of networks during the first three months of the pandemic: PubMed, preprint repositories (biorXiv and arXiv) and social media in Italy (Facebook and Twitter). The results show a significant difference in the number of original research articles published by PubMed and preprint repositories. On social media, we observed an incredible number of physicians participating to the discussion, both on three distinct Italian-speaking Facebook groups and on Twitter. The standard scientific process of publishing articles (i.e., the peer-review process) remains the best way to get access to high-quality research. Nonetheless, this process may be too long during an emergency like a pandemic. The thoughtful use of other types of network, such as preprint repositories and social media, could be taken into consideration in order to improve the clinical management of COVID-19 patients.

A prospective evaluation of lung function at three and six months in patients with previous SARS-COV-2 pneumonia.

OBJECTIVE: This study investigated the consequences of Coronavirus Disease 2019 (COVID-19) pneumonia on lung function in the first 6 months after hospital discharge. METHODS: A prospective lung function assessment in SARS-CoV2 patients with COVID-19 pneumonia, hospitalized between March and April 2020, was conducted with spirometry measurements including lung volumes, mainly total lung capacity (TLC), lung diffusion capacity for carbon monoxide (DLCO) collected at 3 months after hospital discharge. Patients with restrictive ventilatory defect or impaired DLCO or both were re-evaluated at 6 months with global spirometry and chest HRCT scan. RESULTS: Among 40 consecutive patients, 19 (48%) had normal pulmonary functional tests (group A), and 21 (52%) showed residual lung function abnormalities at 3 months after hospital discharge (group B). In group B, 4 patients (19%) had only loss of lung volume as shown by TLC reduction (group 1), 13 patients (62%) had decreased both TLC and DLCO (group 2), and 4 patients (19%) had isolated reduction in DLCO (group 3). At 6-month follow-up in group 1, although all patients improved, only one normalized total lung capacity (TLC). In group 2, TLC and DLCO increased significantly (p < 0.01), but only 3 patients reached normal values. In group 3, DLCO improved for most patients, normalizing in 50% of them. At 6-months significant correlations between an internal-built chest HRCT scan severity score and TLC (r2 = 0.33; p < 0.01) and DLCO (r2 = 0.32; p < 0.01) were found. CONCLUSIONS: Nearly 50% of patients recovered in the post-critical phase. Most of those with abnormal pulmonary function tests at 3 months improved subsequently, but only another 29% (6 out of 21) reached normal values at 6 months. These results indicate that lung function spontaneous recovery is faster at first and occurs more slowly thereafter, leaving more than one third (15 out of 40) of patients with abnormal lung function tests at 6 months.

Hyperimmune plasma infusion in an immunocompromised Covid-19 patient previously treated for follicular lymphoma.

Covid-19 in immunocompromised patients shows a prolonged course and may lead to a poor prognosis. Although data on hyperimmune plasma for treatment of Covid-19 suggest an improved outcome in immunocompetent patients, limited data are currently available in immunocompromised patients. We present the case of a 62-year-old Caucasian woman, who was previously treated with obinutuzumab and bendamustine for follicular lymphoma and showed a prolonged positive test for Covid-19. Since no improvement was observed with standard of care (including remdesivir), the possibility of hyperimmune plasma infusion was discussed. A first dose of hyperimmune plasma was administered, with subsequent onset of fever, increasing inflammatory indexes and worsening radiological findings. Three days later a second dose of plasma was administered. Within twelve hours cough and fever disappeared, and oxygen at rest was discontinued. The patient was discharged 5 days later, and nasopharyngeal swabs resulted negative 16 days after discharge.

Predictors of Worse Prognosis in Young and Middle-Aged Adults Hospitalized with COVID-19 Pneumonia: A Multi-Center Italian Study (COVID-UNDER50).

Obesity as well as metabolic and cardiovascular comorbidities are established, significant predictors of worse prognosis in the overall COVID-19 population, but limited information is available on their roles in young and middle-aged adults (aged ≤ 50 years). The main objectives of the present Italian multi-center study were to describe clinical characteristics and role of selected prognostic predictors in a large cohort of young and middle-aged hospitalized patients. Nine pulmonology units, across north and center of Italy, were involved in this retrospective study. Comorbidities were classified according to their known or potential association with COVID-19. A total of 263 subjects were included. The prevalence of obesity was 25.9%, mechanical ventilation (MV) was needed in 27.7%, and 28 in-hospital deaths occurred (10.6%). Obesity and older age were the only independent, significant predictors for MV. Comorbidities, such as hypertension, diabetes, asthma, and increased D-dimer levels were significantly associated with higher mortality risk, regardless of age, body mass index, and MV. Obesity in young and middle-aged adults is a strong predictor of a more complicated COVID-19, without, however, evidence of a significant effect on in-hospital mortality. Selected comorbidities, including hypertension, diabetes and asthma, significantly impact survival even in a younger population, suggesting the need for prompt recognition of these conditions.

Spontaneous synchronous bilateral hemothorax as the only finding in primary pleural angiosarcoma: a case report and a literature review.

Angiosarcoma is a rare malignancy of vascular origin, mostly originating from skin, soft tissues, and breast, but rarely also from the pleura. We present the case of a 55-year-old man who referred to our hospital for a spontaneous bilateral hemothorax. The CT angiography did not show any source of active bleeding; plus, no pleural or lung masses were observable. Cytological and microbiological analyses made on a sample of pleural fluid resulted negative. Despite numerous blood transfusions and thoracenteses, the patient deceased from hemorrhagic shock ten days later and the diagnosis of primary pleural epithelioid angiosarcoma was obtained only by autopsy. Additionally, we present a review of the literature about primary pleural angiosarcomas.

Respiratory function, autonomic dysfunction, and systemic inflammation are closely linked in patients with COPD and tidal flow limitation: An exploratory study.

RATIONALE: The study aimed to investigate the interplay among respiratory function, autonomic dysfunction, and systemic inflammation in COPD patients. METHODS: In 19 COPD patients, functional respiratory parameters, heart rate variability (HRV), and plasma high-sensitivity-C-reactive-protein (hs-CRP) were assessed. Forced oscillation technique (FOT) was used to detect the absence (NFL) or presence (FL) of resting tidal expiratory flow limitation. Subsequently, patients underwent an incremental shuttle walking test (ISWT). Twenty healthy subjects were also shown as controls. RESULTS: FEV1, DLCO, and lung volumes displayed significant correlations with LH/FH ratio (0.56 < r2<0.27,p < 0.01). A significant relationship was found between LH/FH ratio with IC/TLC ratio% (r2 = 0.29,p < 0.05) and hs-CRP (r2 = 0.26,p < 0.05). Patients with FL had greater hs-CRP plasma levels (p < 0.05), lower IC/TLC% (p < 0.05), and higher LH/FH ratio (p<0.001). CONCLUSIONS: Worse airflow obstruction was associated with a higher LH/HF ratio, directly related, to hs-CRP and indices of dynamic hyperinflation. The presence of resting tidal FL with dynamic pulmonary hyperinflation is a strong driver of systemic inflammation and autonomic dysfunction.

"Elasto-lung point": A new tool for the sonographic confirmation of pneumothorax.

INTRODUCTION: Standard ultrasound gives the operator a dynamic morphology of the investigated anatomy, whereas ultrasound elastography (USE) provides quantitative and qualitative information about the elastic properties of the tissues. OBJECTIVES: We designed a single-arm prospective study in order to investigate the feasibility of USE in the diagnosis of pneumothorax if a lung point sign is present. METHODS: Thirty patients were enrolled in this protocol, from January 2017 to December 2018 at the Pneumology Department of the Azienda Socio-Sanitaria Territoriale Spedali Civili (Brescia, Italy). Patients who were suspected of having pneumothorax were previously evaluated with standard ultrasonography, and then, in the presence of lung point, we performed strain elastography. All patients were evaluated in supine and sitting positions with a linear probe (7.5 MHz). USE enhanced the air-tissue interface dividing the normal parenchyma from the air column of pneumothorax with a sharp line. We called this sign "elasto-lung point." RESULTS AND CONCLUSION: The "elasto-lung point" was able to confirm the diagnosis of pneumothorax in every investigated patient. USE is a simple, reproducible and inexpensive technique that can contribute to the diagnosis of pneumothorax, such as the classic "stratosphere" or "Bar Code" sign in M-mode. No false negative cases were observed.

Immune reconstitution inflammatory syndrome in tuberculous pleurisy and ulcerative colitis: a case report.

We present the case of a 46-year-old Caucasian male, affected by ulcerative colitis, who developed tuberculous pleurisy during immunosuppressive therapy; despite proper therapy, worsening of the radiological findings was observed. The case was discussed among an online group of Italian physicians and diagnosis of immune reconstitution inflammatory syndrome (IRIS) tuberculosis was established. Therapy was continued and full recovery was obtained. IRIS is a syndrome initially described during opportunistic infections in HIV infected after being placed in anti-retroviral therapy. It reveals itself through a wide variety of manifestations, including fever, lymphadenopathies, worsening of lung infiltrates, pleural or pericardial effusion, central nervous system involvement. Few data are available regarding the best therapeutic options. IRIS is an insidious and potentially serious complication of opportunistic infections in immunocompromised patients. The always wider diffusion of immunosuppressive therapies increases the number of patients at risk, therefore physicians need to be aware of the issue.

Doenças que mudaram a história

Doenças têm o poder de alterar o andamento do processo histórico? A resposta é positiva para o autor deste livro, um médico infectologista. Uma vez por mês, oito médicos se reúnem para jantar e conversar. Além da profissão, eles compartilham a paixão pela História, em particular pelo estudo de doenças que influenciaram no desencadeamento e na evolução de acontecimentos históricos. O tema dos encontros: de que modo doenças como varíola, tifo, escorbuto, cólera alteraram o destino de povos e nações?

Herpes zoster ophthalmicus and varicella zoster virus vasculopathy.

Herpes zoster (HZ) corresponds to the reactivation of varicella zoster virus (VZV). Among adults, the ophthalmic division of the trigeminal nerve is one of the most common sites of involvement. Vasculopathy caused by HZ is associated with significant morbidity and mortality, affecting structures such as the brain, which can lead to stroke. In this review, we analyzed the epidemiological and clinical aspects of the vascular involvement of VZV, focusing on the peculiarities of its association with ocular HZ. A review of the available literature indicated that ocular involvement of HZ was a risk factor for vasculopathy after adjusting for age, sex, body mass index, smoking, indicators of metabolic syndrome, and vascular and heart diseases. Considering the severity of this complication, vascular disease mediated by VZV requires early diagnosis and aggressive treatment. Finally, the anti-HZ vaccine has been recommended as a prophylactic measure in the elderly, but it should be used with caution in immunocompromised individuals.

Herpes zoster ophthalmicus and varicella zoster virus vasculopathy / Herpes zoster ophthalmicus e vasculopatia por vírus varicella zoster

ABSTRACT Herpes zoster (HZ) corresponds to the reactivation of varicella zoster virus (VZV). Among adults, the ophthalmic division of the trigeminal nerve is one of the most common sites of involvement. Vasculopathy caused by HZ is associated with significant morbidity and mortality, affecting structures such as the brain, which can lead to stroke. In this review, we analyzed the epidemiological and clinical aspects of the vascular involvement of VZV, focusing on the peculiarities of its association with ocular HZ. A review of the available literature indicated that ocular involvement of HZ was a risk factor for vasculopathy after adjusting for age, sex, body mass index, smoking, indicators of metabolic syndrome, and vascular and heart diseases. Considering the severity of this complication, vascular disease mediated by VZV requires early diagnosis and aggressive treatment. Finally, the anti-HZ vaccine has been recommended as a prophylactic measure in the elderly, but it should be used with caution in immunocompromised individuals.

RESUMO Herpes zoster (HZ) corresponde à reativação do vírus varicela zoster (VVZ) e, entre os adultos, o envolvimento da divisão oftálmica do nervo trigêmeo é um dos locais mais comuns A vasculopatia associada ao HZ é uma complicação dotada de grande morbimortalidade e afeta diferentes estruturas, favorecendo, inclusive o acidente vascular cerebral. Nesta revisão analisamos aspectos epidemiológicos e clínicos da vasculopatia mediada pelo VZV, bem como as peculiaridades relacionadas com o HZ ocular. De acordo com dados disponíveis na literatura, o acometimento ocular pelo HZ mostrou ser um fator de risco para vasculopatia após se ajustar para idade, sexo, índice de massa corporal, tabagismo, indicadores da síndrome metabólica, doença vascular e cardiopatias. Em face da gravidade dessa complicação, a doença vascular mediada pelo VZV requer diagnóstico precoce e tratamento agressivo. A vacina anti-HZ tem sido recomendada profilaticamente em idosos, mas deve ser usada com cautela em indivíduos imunocomprometidos.

Histoplasmose do sistema Nervoso Central Como Única Manifestação da Doença em Pacientes Imunocompetentes

O artigo apresenta dois casos de histoplasmose em que o acometimento do sistema nervoso central foi a única manifestação clínica da doença. Revisão da literatura permitiu confirmar a raridade dessa forma de patologia, em particular em crianças, sendo o segundo caso aqui apresentado o de mais baixa idade na literatura nacional. São feitos comentários sobre a variedade das apresentações clínicas e os principais diagnósticos diferenciais da doença e são discutidos os resultados laboratoriais, tanto em relação às alteraçõesliquóricas quanto aos resultados sorológicos