Chest Tube Insertion in the Delayed Esophageal Perforation Phenomenon: A Tragic or Beneficial Outcome?

A 53-year-old woman with foreign body esophageal perforation, was first misdiagnosed as pulmonary thromboembolism. In referral hospital her chest computed tomography was reported as giant hiatal hernia or giant pulmonary abscess. She was treated for abscess, after several days, right hemithorax tube thoracostomy was performed. After that, she developed necrotizing fasciitis on the chest wall. After a 19-day delay, we found a 5-cm mid-thoracic esophageal tearing during thoracotomy and repaired it. After 2 years follow up the patient condition is good. This report describes a unique case of mid-thoracic foreign body esophageal perforation and rupture with a delay in diagnosis with a tragic course.

Elevated red blood cell distribution width predicts mortality in acute exacerbation of COPD.

Objective: Red blood cell distribution width (RDW) has been shown to predict clinical outcomes in many diseases. To our knowledge, the prognostic significance of RDW in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has not been reported so far. The aim of the present study is to investigate the relation of RDW to in-hospital mortality in patients with AECOPD. Methods: We retrospectively reviewed hospital records of inpatients with AECOPD in two referral teaching hospitals in two provinces of east Azerbaijan and west Azerbaijan, Iran. Associations between RDW and in-hospital death were analyzed with using correlation, logistic regression analysis, and receiver operating characteristic (ROC) curves is SPSS software. Results: We studied 330 patients, of whom 75 (22.7%) did not survive to hospital discharge. In univariate analysis higher RDW-SD values were associated with increased hospital mortality (30.2% vs. 15.8% p=0.002 odds ratio 2.31). Using the first quartile of RDW as reference, odds ratio (OR) mortality among patients in the highest RDW quartile was 5.34 (95%CI, 2.70-12.57;9=0.001). In multivariate analysis RDW-SD remained an independent risk factor for mortality after correction for age, thrombocytopenia, leukocyte count, mean corpuscular volume, anemia. In receiver-operating curve analysis the AUC for RDW was 0.663, which was more than that of hemoglobin, platelets. Conclusion: RDW on admission day proves to be a useful indicator to predict in-hospital death in AECOPD.

Approach to Patients with Severe Asthma: a Consensus Statement from the Respiratory Care Experts' Input Forum (RC-EIF), Iran.

Challenges in the assessment, diagnosis and management of severe, difficult-to-control asthma are increasingly regarded as clinical needs yet unmet. The assessments required to determine asthma severity, comorbidities and confounding factors, disease phenotypes and optimal treatment are among the controversial issues in the field. The respiratory care experts' input forum (RC-EIF), comprised of an Iranian panel of experts, reviewed the definition, appraised the available guidelines and provided a consensus for evaluation and treatment of severe asthma in adults. A systematic literature review followed by discussions during and after the forum, yielded the present consensus. The expert panel used the appraisal of guidelines for research and evaluation-II (AGREE-II) protocol to define an initial locally-adapted strategy for the management of severe asthma. Severe asthma is considered a heterogeneous condition with various phenotypes. Issues such as assessment of difficult-to-control asthma, phenotyping, the use of blood and sputum eosinophil count, exhaled nitric oxide to guide therapy, the position of anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty as well as the use of established, recently-developed and evolving treatment approaches were discussed and unanimously agreed upon in the panel. A systematic approach is required to ensure proper diagnosis, evaluate compliance, and to identify comorbidities and triggering factors in severe asthma. Phenotyping helps select optimized treatment. The treatment approach laid down by the Global Initiative for Asthma (GINA) needs to be followed, while the benefit of using biological therapies should be weighed against the cost and safety concerns.

Thrombocytopenia as a marker of outcome in patients with acute exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION: Thrombocytopenia (TP) is associated with poor outcome in patients who are critically ill with pneumonia, burns, and H1N1 influenza. To our knowledge, no similar study in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has been conducted to date. The aim of this study was to determine the impact of platelet count on the outcome of patients with AECOPD. MATERIAL AND METHODS: Patients admitted to our teaching hospital for AECOPD were divided into two cohorts, those with and without TP. The outcome of all patients was followed. RESULTS: Of the 200 patients with AECOPD, 55 (27.5%) had TP. Of these, 14 (25.5%) died in the hospital, whereas of the 145 non-TP patents, 11 (7.5%) died (p-value = 0.001). There was a significantly higher transfer rate to the ICU and mechanical ventilation in TP patients. The mean platelet count was significantly lower in patients who died than those who were discharged (161,672 vs. 203,005 cell/µL; p-value = 0.017). There was negative correlation between duration of hospitalization and platelet count. CONCLUSION: TP was associated with poor outcome in AECOPD. TP could be considered as a marker for the assessment of inflammation and prognosis in AECOPD patients based on its cost-effective features.

Eosinopenia as a Marker of Outcome in Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

BACKGROUND: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause of hospitalization and mortality. Recent studies have shown the usefulness of eosinopenia in predicting the outcomes of patients admitted to the intensive care unit. This study examined the association of eosinopenia with the outcomes of patients with AECOPD. METHODS: This is a prospective study. Patients with AECOPD were divided into two cohorts: patients with eosinopenia and those without eosinopenia. Duration of hospitalization, need of mechanical ventilation, in-hospital mortality, rehospitalization, or death within 30 days after discharge were compared between the two cohorts. Eosinopenia was defined as eosinophil count of >40 cells/mm(3). RESULTS: Among 100 patients with AECOPD, 44 were eosinopenic and 56 were non-eosinopenic. Duration of hospitalization of patients with eosinopenia was 12.38 ± 9.85 days and that of patients without eosinopenia was 7.35 ± 5.68 days (p = 0.001). In all, 16 (36%) patients with eosinopenia and seven (12%) patients without eosinopenia needed mechanical ventilation (p = 0.005). In-hospital mortality rate among eosinopenic and noneosinopenic patients was 37.5% (12/44) and 7.6% (4/56), respectively (p = 0.006). Among 100 patients with AECOPD, 16 died in the hospital. Of these, 12 (27.27%) were eosinopenic and 4 (7.6%) were noneosinopenic (p = 0.006). The mean eosinophil count of patients who died in the hospital (n = 16) was 44.00 cells/ml whereas that of survivors (n = 84) was 107.41 cells/ml (p = 0.022). CONCLUSION: We conclude that a significant relationship exists between eosinopenia and outcomes of patients with AECOPD. Thus, eosinopenia can be a useful, easy-to-measure, and inexpensive biomarker for predicting the prognosis of patients with AECOPD.

Multi-vesicular pulmonary hydatid cyst, the potent underestimated factor in the formation of daughter cysts of pulmonary hydatid disease.

Pulmonary multi-vesicular hydatid disease (HD) with Echinococcus granulosus is rare. A 28-year-old woman presented to our center with cough and respiratory distress. Chest x-ray and computerized tomography scan revealed bilateral giant cysts with water-lily sign (ruptured hydatid cysts). The left cyst was in vicinity of heart. With thoracotomy cysts of both lungs were removed. Thousands of translucent, homogenized small daughter cysts were discovered from the left side cyst. Pathologic examinations revealed the ruptured hydatid cysts of both lungs with daughter cysts on the left lung cyst. To best of our knowledge probably this is the first report of multi-vesicular HD in lung. We suppose that the heart pulsation was effective in the formation of daughter cysts.

Prevalence of anemia and its impact on mortality in patients with acute exacerbation of chronic obstructive pulmonary disease in a developing country setting.

Chronic Obstructive Pulmonary Disease (COPD) is going to be the third most common cause of death worldwide. The natural course of COPD is interrupted by acute exacerbations (AECOPD) with an overall mortality rate of 10%. Anemia is a well-known independent predictor of mortality in several chronic diseases. Little is known about the impact of anemia on mortality in AECOPD. The aims of this study were to determine the prevalence of anemia in AECOPD patients and its impact on mortality in a developing country setting. We retrospectively studied 200 hospitalized patients with AECOPD (100 died in hospital and 100 survived) in Imam Khomeini teaching hospital, Urmia, Iran. Prevalence of anemia between deceased and surviving patients compared by using x-square test. Mean admission day Hb and Hct level were compared between the two groups by using Student t-test. Anemia was defined according to WHO criteria: Hb<13 g/dl in males; Hb<12 g/dl in females. The prevalence of anemia was significantly higher in patients who died in hospital compared to those who survived (72% vs. 49%, p=0.001 and OR=2.68). The mean ±SD Hb level was 11.5±2.7 g/dl among deceased patients vs. 13.0±2.0 g/dl among survivors (p value<0.001). The duration of hospitalization was significantly higher (p<0,001) in anemic patients (mean 13.28 days in anemic vs. 7.0 days in non-anemic patients). In bivariate correlation analysis, Hb was positively correlated with FEV1 (r=+0.210, p=0.011) and negatively with duration of hospitalization (r=-0.389, p=0.000). Anemia was common in AECOPD patients in this developing country setting and was significantly associated with in hospital mortality.

Serum CA-125 level in patients with chronic obstructive pulmonary disease with and without pulmonary hypertension.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive and debilitating disease and is going to be the 3rd most common cause of death worldwide. Pulmonary hypertension (PH) has severely bad influence on prognosis in COPD patients. Hence, early diagnosis of it is important for appropriate therapy. Echocardiography is used for this purpose, which requires cardiologist and expensive equipment which may not be available anywhere. CA-125, a biomarker of ovarian cancer, has shown to be associated with left ventricular failure. We aimed to show the relationship between CA-125 levels and PH in patients with COPD. METHODS: Ninety patients with stable COPD were enrolled into the study. Levels of CA-725 were measured from venous blood, and in the same day systolic pulmonary artery pressure (sPAP) was measured by transthoracic echocardiography. RESULTS: Of 90 Patients 57 had PH and 39 had not. Patients with PH had significantly higher CA- 125 levels compared with controls (mean 39.15 U/ mL vs. 24.22 U/mL, P < 0.04). Levels of CA-125 were correlated with sPAP (r=017, P=0.01). CONCLUSIONS: The CA-125 biomarker can be used to identify COPD patients with pulmonary hypertension. Since it is cheap and easily available it can help in centers with less access to echocardiography.

Delays in diagnosis and treatment of venous thromboembolism in a developing country setting.

INTRODUCTION: Rapid diagnosis and treatment of deep vein thrombosis and pulmonary thromboembolism reduce mortality and morbidity. The aim of this study is to investigate delays in treatment of deep vein thrombosis and pulmonary thromboembolism and related factor in a developing country. MATERIALS AND METHODS: We prospectively investigated 353 patients with diagnosis deep vein thrombosis and/or pulmonary thromboembolism in Urmia, Iran. We recorded dates of symptom onset, initial visit by a clinician, initiation of treatment, and confirmation of diagnosis. We also analyzed relation with some factors. RESULTS: The mean interval from symptoms onset to initiation of treatment was 4.70 days, 89% of this interval was between onset of symptoms to first medical evaluation (mean= 4.19 days). Mean time from onset of symptoms to confirmation of diagnosis was 6.29 days. Of 353 patients with venous thromboembolism 185 (52.4%) visited by a physician within two days of onset of symptoms and 168 (47.6%) patients after two days. Factors that was associated with earlier seeking with p value < 0.05 were pulmonary thromboembolism patients earlier than deep vein thrombosis, higher education, recent surgery, presence of cast, entire leg swelling. There was no association between age, gender, number of symptoms, and presence familial history of venous thromboembolism (all p value > 0.05). The delays time from first visit to final diagnosis was significantly shorter in patients with high probability score. CONCLUSION: Most patients with venous thromboembolism received anti-coagulation and diagnosis with delay. The main cause of delay is related to patient's delays. There is a need to improve people awareness about venous thromboembolism and to develop strategies to reduce delays.

Determination of safe margin in the surgical pathologic specimens of non-small cell carcinoma of the lung.

BACKGROUND AND AIM: Local recurrences of the tumor at the surgical margin are serious problems in pulmonary resections for lung cancer. The aim of this study is to determine the involved margins and safe distances of the resection sites from tumor for prevention of local recurrences. MATERIAL AND METHODS: In this prospective study, 66 patients operated for non-small cell lung carcinoma (NSCLC) from Jan 2006 to Sep 2008 were evaluated. After performing pulmonary resections, multiple biopsies were taken up from 5 mm (A), 10 mm (B), 15 mm (C), and 20 mm (D) distance from tumor. The specimens were studied histopathologically. RESULTS: From a total of66 patients with NSCLC admitted to our referral hospital, 25 (38%) had adenocarcinoma, 18 (27.3%) squamous cell carcinoma, 5 (7.5%) large cell carcinoma, 4 (6%) bronchoalveolar cell carcinoma, 4 (6%) adenoid cystic carcinoma, 3 (4.6%) malignant carcinoid tumor and 7 (10.6%) had metastasis. The most common symptoms were dyspnea and cough. Histopathologically tumor positive margins were found in 84.8% (A), 10.6% (B), 4.5% (C), and 0% (D). There was a significant statistically difference between tumor involvement at distances 5 mm (A) versus 10-20 mm (B-D) (P <0.001). CONCLUSION: A 20 mm distance from the gross tumor is considered as a safe surgical margin in any type of malignant pulmonary resections for prevention of local surgical recurrences if there was no pathologic examination before surgery.

High sensitive C-reactive protein for prediction of adverse outcome in acute exacerbation of chronic obstructive pulmonary disease.

UNLABELLED: Hospitalization for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is associated with a high risk of mortality and complications. The goal of the study is to assess the clinical utility of serum high sensitive C-reactive protein (hs-CRP) at admission in predicting outcome in hospitalized patients with AECOPD. METHODS: Consecutive patients with AECOPD admitted to a public teaching hospital were studied prospectively. The adverse outcome defined occurrence of one or more of: (1) death in hospital or within 30 days after discharge, (2) transfer to the intensive care unit, or (3) intubation and mechanical ventilation. The correlation of hs-CRP with duration of hospitalization and FEV1% of predicted is also calculated. RESULTS: Of 60 patients, 22 had adverse outcome and 38 good outcomes. There were no significant differences between two group for mean age, gender, smoking status, and previous hospitalizations (p > 0.05). The adverse outcome rate was 56.5% in those with serum hs-CRP equal or more than 100 mg/ml versus 24.3% in patients with hs-CRP less 100 mg/ml (p = 0.01). CONCLUSIONS: Serum hs-CRP at admission is a predictor of outcome in AECOPD. Admission hs-CRP higher than 100 mg/ml was associated with near fourfold increased probability of adverse outcome.

Mini-mediastinotomy under local anesthesia for biopsy of anterior mediastinal masses with airway compression.

INTRODUCTION: Management strategies for anterior mediastinal masses (AMMs) depend strongly on the histopathological diagnosis. The manifestations of these masses sometimes are an emergency because of large airway or great vessel compression which make general anesthesia challenging and hazardous and many authors have emphasized the dangers of general anesthesia in such patients. METHODS: This prospective study carried on 23 patients with AMMs and large airway or vessel compression via mini-mediastinotomy under local anesthesia for taking histological biopsy. RESULTS: . A definite histolopathological diagnosis was made in all cases. Morbidity was seen in one patient with entering the pleural cavity, there was no mortality. Out of 23 patients, 9 patients had already undergone less invasive procedures without definite diagnosis. CONCLUSIONS: Mini-mediastinotomy under local anesthesia for diagnostic biopsy in AMMs with airway compression is safe, minimally invasive, effective, and is useful in therapeutic decision making for AMMs.

Efficacy and safety of iodopovidone pleurodesis through chest tube in spontaneous pneumothorax.

UNLABELLED: Pleurodesis is one of the best methods of controlling malignant pleural effusions and pneumothorax. Recently Iodopovidone (IP) which is cheap and easily available was used for pleurodesis and demonstrated low morbidity with good results similar to talcum powder. However, in those studies a wide range of pleural diseases were included, and heterogeneity makes it difficult to draw conclusions about spontaneous pneumothorax (SP). The aim of this study was to evaluate the efficacy and safety of IP pleurodesis in SP. METHODS: In 29 patients, we instilled 20 ml IP 10% diluted with 80 ml of normal saline through a chest tube, clamped for 4 h. Data on adverse events including chest pain, respiratory distress, allergic reactions, hypotension and failure of PD (the requirement for additional pleural procedures and recurrence) were collected. The follow-up period was 3 to 21 months. RESULTS: Complete response with no recurrence was obtained in 27 (93% percent) patients. One patient with bone marrow transplantation with cystic lung changes in lungs returned two months later with bilateral pneumothoraces. A case of Wegener's granulomatosis on corticosteroids and immunosuppressive therapy returned with SP on the same side four months later. Five (13%) patients experienced chest pain with visual scale measurment 1 to 5. No hypotension, allergic reaction, visual impairment were observed. CONCLUSIONS: Pleurodesis with IP was successful and was associated with only minor complication. It appears to be a good option for the pleurodesis in SP.

Aquatic leech as a rare cause of respiratory distress and hemoptysis.

This paper presents a 73 years old male with three weeks history of intermittent hemoptysis, dysphagia, dyspnea, stridor, and suffocations sensation. By means of fibrotic bronchoscopic examination, the cause was found to be a leech in the glottis. It was removed by injection of 4 ml lidocaine 2%. Infestation into the respiratory tract by a leech may become lethal because of hypoxia and death secondary to airway obstruction. A high index of suspicion of leech infestation sould be considered in patients presenting with hemoptysis, hoarseness and respiratory distress and a history of recent contact with fresh water streams.

Multiple bilateral traumatic pulmonary pseuodocysts in a 53 year-old male diagnosed retrospectively.

Traumatic pulmonary pseudocyst (TPPC) is a rare complication, which might be encountered after thoracic trauma. It is most often (75-100%) seen in children and young adults. A 53 year-old male presented with multiple bilateral pulmonary cysts after a motor vehicle accident. We evaluated the patient for abscess, tuberculosis, and Wegener's granulomatosis with negative results. Follow up chest X-rays showed spontaneous resolutions of pseudocysts with replacement with pneumatocelae. In patients with recent chest trauma, TPPC should be kept in mind to prevent unnecessary invasive tests.

Kimura's disease with eosinophilic panniculitis--treated with cyclosporine: a case report.

Kimura's disease is a rare, benign, slow growing chronic inflammatory swelling with a predilection for the head and neck region and almost always with peripheral blood eosinophilia and elevated serum IgE levels. Here, we report a 25-year-old male patient with asthma, Reynaud phenomenon, eosinophilic panniculitis, bilateral inguinal lymphadenopathy and peripheral blood eosinophilia.He responded initially to oral prednisolone with the subsidence of peripheral blood eosinophilia, asthma and the Reynaud phenomenon. But with tapering of prednisolone symptoms reappeared and hereby he was treated with cyclosporine. He has been symptom free for 6 months of follow up while taking cyclosporine 25 mg orally per day. Eosinophilia has resolved. This case shows that in addition to previously reported associations, Kimura disease may be associated with eosinophilic panniculitis and that cyclosporine could be effective in its treatment.

Endobronchial metastasis from oral fibrosarcoma 13 years after treatment of primary tumor.

Endobronchial metastasis (EBM) is uncommon and frequently is seen in renal, breast, and colorectal carcinomas. Other reported primary tumors include melanoma, sarcomas, and tumors of the uterine cervix, testis, ovary, prostate, thyroid, pancreas, and adrenal glands. With reviewing the literature, we were able to find only one report of EBM from fibrosarcoma (in Spanish). We described a 56-year-old woman with EBM of oral fibrosarcoma with local recurrence 13 years after treatment of primary tumor. We conclude that the possibility of central airway metastasis should be kept in mind if patients with a past history of malignancy present with symptoms consistent with bronchial tumors, even if there are 13 years interval. Of several mechanisms EBM, we assume direct aspiration and implantation of tumor cells to bronchus from oral cancer.

Superior vena cava syndrome in a man with situs inversus totalis and left main bronchus cancer.

Situs inversus (SI), is left to right inversion of internal organs. It may remain unrecognized until discovery during emergency surgery or investigation of symptoms. There are three reports of lung cancer with SI in Medline. However search in PubMed by 15 December 2008, there isn't any report of superior vena cava syndrome (SVCS) with any benign or malignant disease in patients with SI. We present the case of a 59 year old man with small cell carcinoma in left main bronchus presented with SVCS. Chest radiography and contrast enhanced CT scan confirmed SI with compression left side located superior vena cava with left lung small cell carcinoma. To our knowledge, here, we present the first case of SVCS with SI.

Multiple mediastinal hydatid cysts: a case report.

Hydatid cyst (HC) in mediastinum is very rare. To the best of our knowledge, a case with multiple HCs in mediastinum is not reported already. We herein report a case of multiple HCs of the mediastinum and liver in a - 50 year-old woman presented with chest pain, cough and dyspnea for about two years. She had been treated for tuberculosis for 20 years. Chest CT scan showed multiple cysts in posterior mediastinum and one cyst in left lobe of liver. Via right posterolateral thoracotomy, multiple cysts were excised in mediastinum. And then, hepatic left lobe cyst was removed trans-diaphragmatically. Histopathologic examination confirmed HCs. Despite its rarity, primary HCs should be considered in the differential diagnosis of mediastinal multiple cystic lesions in endemic regions.