Cavitary lung masses in SLE patients: an unusual manifestation of CMV infection.

The typical radiographical findings of cytomegalovirus pneumonitis are bilateral interstitial infiltrates. In this study, the current authors describe two patients on corticosteroid treatment for systemic lupus erythematosus, complicated by histologically confirmed cytomegalovirus pneumonitis, presenting as cavitary masses. This rare presentation of cytomegalovirus pneumonitis broadens the differential diagnosis of cavitary lesions to include cytomegalovirus infection in immunocompromised individuals.

Sinoatrial block complicating legionnaire's disease.

A 59 year old woman presented with acute onset of fever, chills, diaphoresis, vague chest discomfort, and was found to be hypotensive and tachypnoeic. An electrocardiogram demonstrated sinoatrial block with a junctional rhythm between 50 and 80 beats/min. All cultures were negative and imaging studies unrevealing. Her urine tested positive for Legionella pneumophila antigen serotype 1 and she improved with antibiotic therapy.

Adult Still's disease and respiratory failure in a 74 year old woman.

A case of adult onset Still's disease in an elderly woman, that was associated with severe respiratory failure and multiorgan dysfunction, is reported. Histopathology was confirmed on open lung biopsy.

Possible levofloxacin-induced acute hepatocellular injury in a patient with chronic obstructive lung disease.

Levofloxacin is one of the most commonly prescribed antibiotics for both inpatient and outpatient care of respiratory tract infection. It is generally well tolerated, and it has an excellent safety profile. We report a case of severe acute liver toxicity that apparently complicated intravenous administration of levofloxacin, which resolved after discontinuation of the drug.

Intrathoracic desmoid tumor mimicking primary lung neoplasm.

Most reported thoracic desmoid tumors originate from the chest wall. However, intrathoracic desmoid tumors are rare. The pathogenesis of these tumors is unclear but antecedent trauma and operation have been implicated. Desmoid tumors can present either with pain or be incidentally detected on radiographic studies. We describe the case of a 60-year-old woman with an intrathoracic desmoid detected on a routine screening chest roentgenogram who underwent complete surgical resection of the tumor.

Asymptomatic expectoration of surgical staples complicating lung volume reduction surgery.

Lung volume reduction surgery (LVRS) has recently been introduced as a palliative treatment for patients with severe emphysema. The most common postoperative complication is persistent air leak requiring prolonged tube thoracostomy. We describe a unique case of a patient with severe emphysema who underwent LVRS and presented, about a year later, with the repeated expectoration of surgical staples.

Reexpansion pulmonary edema after VATS successfully treated with continuous positive airway pressure.

Reexpansion pulmonary edema is a well-described complication of treatment for pleural effusion and pneumothorax. It is very rarely described in association with anesthesia and video-assisted thoracoscopic surgery. The etiology is unclear but several mechanisms have been proposed. We report a case of reexpansion pulmonary edema after video-assisted thoracoscopic surgery treated successfully with continuous positive airway pressure.

Pulmonary arteriovenous malformations: a clinical review.

Pulmonary arteriovenous malformations (PAVMs) are a rare clinical entity. Most of them are associated with hereditary haemorrhagic telangiectasia. The usual clinical presentation is exertional dyspnoea and hypoxaemia. The initial test of choice for screening is the 100% oxygen method. A pulmonary angiogram is needed to define the anatomy and guide transcatheter embolisation (TCE). TCE has been shown to be effective and safe with a very low recanalisation rate and has largely replaced surgery for PAVMs. Computed tomography of the chest can be used for the follow up of asymptomatic PAVMs and TCE.

Yellow nail syndrome: resolution of yellow nails after successful treatment of breast cancer.

Yellow nail syndrome (YNS) is a rare entity of unknown cause in which congenitally hypoplastic lymphatics play a major role in the clinical manifestations of the disease. YNS has been associated with many malignancies and immune disorders. We report a case of new-onset YNS associated with breast cancer and dramatic improvement in the yellow nails with cancer treatment.

Development of a giant bulla after lung volume reduction surgery.

Lung volume reduction surgery (LVRS) is being evaluated in the treatment of emphysema. The proposed mechanisms of improvement are increased elastic recoil of the lung and improved mechanical efficiency of the muscles of respiration. We report a unique patient with emphysema who developed a giant bulla 3 years subsequent to LVRS. The patient underwent extensive evaluation, including measurements of lung mechanics. Bullectomy was performed, but it was unsuccessful. Although the mechanisms behind the development of giant bullous disease remain speculative, heterogeneous improvement in elastic recoil following LVRS may be one of the responsible mechanisms.

Development of pulmonary hypertension after lung volume reduction surgery.

This prospective, longitudinal study was designed to assess the hemodynamic changes occurring in patients who undergo lung volume reduction surgery (LVRS). Patients with emphysema treated with LVRS underwent hemodynamic evaluation before and after surgery. The study group consisted of nine patients with an average age of 64.4 yr. FEV1 rose significantly from 0.64 preoperatively to 0.99 L postoperatively. After surgery, pulmonary artery (PA) systolic pressure rose to 47.9 +/- 12.4 mm Hg, meeting criteria for development of pulmonary hypertension. In six patients, the elevation in PA pressure was attributed to an increase in the pulmonary vascular resistance, but for all nine patients the change was not statistically significant. The pulmonary artery occulsion pressure (PAOP) did not change postoperatively. There was no correlation of PAOP with global left ventricular ejection fraction. While preoperatively there was a negative correlation between symptoms (Mahler dyspnea index) and PA pressure, after surgery the change in PA pressures did not correlate with the change in symptoms (Mahler transitional dyspnea index). We concluded that development of pulmonary hypertension may occur after LVRS in patients whose symptomatic status improves and in whom this condition was not present preoperatively.

An unusual case of left upper lobe pulmonary edema.

This is a report of an unusual case of left, predominantly upper lobe, pulmonary edema secondary to paravalvular mitral regurgitation (MR) complicating mitral valve replacement. Transesophageal echocardiography proved helpful in making the diagnosis of MR and suggesting the mechanism of the pulmonary edema.

Changes in pulmonary mechanics after lung volume reduction surgery.

Lung volume reduction surgery (LVRS) is a promising new treatment for emphysema and leads to increased flow rates. We investigated the mechanisms by which flow rates could increase and the correlates of lessened dyspnea in patients undergoing LVRS before and 3 months after LVRS in patients with severe emphysema. The following were done: routine pulmonary function testing, measurements of elastic recoil (Pel), tidal breathing patterns, inspiratory work of breathing (Winsp), construction of static recoil-maximum flow curves, and measurement of baseline and transitional dyspnea index (TDI). There were increases in forced vital capacity (FVC: 2.24 +/- 0.71 to 2.92 +/- 0.63 liters; p < 0.05), forced expired volume in 1 (FEV1: 0.64 +/- .16 to 1.03 +/- 0.28 liters; p < 0.01), and decreases in all divisions of lung volume, e.g. total lung capacity (TLC: 6.86 +/- 1.41 to 5.96 +/- 1.49 liters; p < 0.01). Maximum Pel increased (11.7 +/- 3.7 to 19.8 +/- 7.8 cmH2O; p < 0.02) as did the coefficient of retraction (CR = Pel/TLC: 1.8 +/- 0.7 to 3.6 +/- 3.6 +/- 2.2 cmH2O/liter). However, the individual responses in other parameters were markedly different among patients. There was no consistent trend in changes in the slope or position of the static recoil-maximum flow curve or Winsp. The only positive correlate of improved dyspnea (TDI = 3.22 +/- 2.22; p < 0.01) was improvement in CR, FEV1 being a weak negative correlate and change in lung volume not being a correlate at all. We conclude that there is a heterogeneous response of the airways to LVRS. Increased elastic recoil was the primary determinant of improved flow rates after LVRS and is the only positive correlate for improvement in dyspnea.

Primary pulmonary hypertension in a patient with CD8/T-cell large granulocyte leukemia: amelioration by cladribine therapy.

We report a case of primary pulmonary hypertension in an adult man with CD8/T-cell large granulocyte leukemia. Successful treatment of his leukemia with cladribine resulted in dramatic and sustained improvement of his pulmonary hypertension.

Chronic lithoptysis with multiple bilateral broncholiths.

A case of chronic lithoptysis with unusual features was undiagnosed for 20 years. The presence of multiple broncholiths in different segments of both lungs, not previously described, was confirmed endoscopically. Areas of unusual mucosal punctate calcifications, not appreciated on concurrent high-resolution CT scan, also are described.

The diagnosis, classification, and management of asthma according to severity.

UNLABELLED: This activity is designed for primary care and specialist physicians. GOAL: To provide prompt and appropriate treatment for asthma of all levels of severity resulting in improved level of activity and decreased need for urgent care and hospitalization with a possible reduction in the annual decline of lung function, degree of permanent airway damage, and mortality. OBJECTIVES: 1. To provide a framework on the basis of history, physical findings, and laboratory results for the diagnosis of asthma. 2. To improve the ability to classify asthma by degree of severity. 3. To describe an incremental therapeutic approach to asthma by degree of severity. 4. To provide a systematic approach with regard to periodic reevaluation of asthma severity and modification of the treatment plan.

Is hand washing really needed in an intensive care unit?

OBJECTIVES: To determine whether a rigorous antiseptic hand washing of bare hands with 4% chlorhexidine and alcohol reduced fingertip microbial colonization as compared with the use of boxed, clean, nonsterile latex gloves. In addition, to investigate if aseptic donning technique and/or a prior hand washing would reduce the level of glove contamination. DESIGN: Prospective, randomized, crossover design, with each subject serving as his/her own control. SETTING: University intensive care unit. SUBJECTS: Forty-three intensive care nurses. INTERVENTIONS: The fingertips of 20 nurses were cultured before and after a strict antiseptic hand washing and before and after the routine and aseptic donning of sterile gloves. Subsequently, the fingertips of 43 nurses were cultured before and after the casual donning of nonsterile gloves over unwashed hands and before and after a strict antiseptic hand washing. Fingertip cultures were plated directly on agar, incubated for 24 hrs, and counted and recorded as the number of colony-forming units (cfu) for each hand. Different colony types were then subcultured. MEASUREMENTS AND MAIN RESULTS: Hand washing with antiseptic reduced colonization from 84 to 2 cfu (p < .001). The proportion of cases with > or = 200 cfu/hand was reduced from 30% to 9%. Aseptic or casual donning of sterile gloves, with or without prior antiseptic hand washing, resulted in consistently low glove counts between 0 and 1.25 cfu. Nonsterile gloves casually donned over washed or unwashed bare hands diminished the bioburden to 2.17 and 1.34 cfu, respectively. No qualitative difference was found in the microorganisms recovered from gloved or bare hands. CONCLUSIONS: Antiseptic hand washing and the use of nonsterile gloves over unwashed hands confer similar reductions in the number of microorganisms. There is no additional benefit with the use of aseptic donning technique, prior antiseptic hand washing, or the use of individually packaged sterile gloves.