Outcome differences between recanalized malignant central airway obstruction from endoluminal disease versus extrinsic compression.

We compared the outcome of Nd:YAG laser therapy with stent placement for malignant central airway obstruction (CAO) at our center over a 10-year period. This is a retrospective review of patients undergoing Nd:YAG laser therapy or self-expanding metal stent (SEMS) placement for malignant CAO between November 2007 and October 2017. Seventy-two patients were recanalized for malignant CAO. The median (range) age was 63 (23-86) years, with 49 (68%) males. Patients underwent either laser therapy alone (N = 36), stent placement alone (N = 30), or both (N = 6). The wavelength of Nd:YAG laser used was 1064 nm, and median (range) laser energy used was 25 (15-35) W, in 377 (115-1107) pulses. Fifty-one (71%) patients died with median survival of 7.2 months. In subgroup analysis, 21 (58.3%) vs. 25 (83.3%), p = 0.03 patients died in the "laser resection" vs. "stent placement" group with longer median survival of 12.4 months in the former vs. 4.5 months, p = 0.0004 in the later. Esophageal cancer and left main bronchus involvement were significantly more common (10 (33.3%) vs. 0, p = 0.0001, and 16 (53.3%) vs. 8 (22.2%), p = 0.01), in the stent placement vs. laser resection group, respectively. Trachea or main bronchi involvement and respiratory failure on presentation requiring mechanical ventilation correlated with poorer survival. The immediate restoration of luminal patency, complication rate, and 30-day mortality was similar among the two groups. The median (range) energy used for laser therapy was 25 (15-35) W. Median of 377 pulses was used for the duration of 287.5 s. The results were compared using a Wilcoxon two-sample test, and Fischer exact test with p values considered indicative of a significant difference if less than 0.05. In patients requiring recanalization of malignant CAO, the extrinsic compression from esophageal cancer, trachea or main bronchi involvement, respiratory failure on presentation requiring mechanical ventilation, and stent placement correlated with poorer survival. Interventional pulmonology training program should emphasize on dedicated training in laser therapy as it is associated with improved survival.

Outcome of advanced lung cancer with central airway obstruction versus without central airway obstruction.

Patients with central airway obstruction (CAO) from advanced lung cancer present with significant morbidity and are assumed to have lower survival. Hence, they are offered only palliative support. We asked if patients who have advanced lung cancer with CAO (recanalised and treated) will behave similarly to those with advanced lung cancer without CAO. This study was a retrospective review of the medical records of the patients managed for advanced lung cancer during 2010 and 2015 at our institution. 85 patients were studied. Median survival and 1-, 2- and 5-year survival were 5.8 months, 30.3%, 11.7% and 2.3% versus 9.3 months, 35.7%, 9.6% and 4.7%, respectively, in the CAO and no CAO groups (p=0.30). More patients presented with respiratory failure (15 (35%) versus none; p=0.0001) and required assisted mechanical ventilation (10 (23.3%) versus none; p=0.001) in the CAO group compared with the no CAO group. Fewer patients received chemotherapy in the CAO group (11 (25.5%)) compared with the no CAO group (23 (54.7%); p=0.008). There was no difference in survival among patients with advanced lung cancer whether they presented with CAO or without CAO. Survival was similar to those without CAO in patients with recanalised CAO despite greater morbidity and lesser use of chemotherapy, strongly advocating bronchoscopic recanalisation of CAO. These findings dispel the nihilism associated with such cases.

Experience With the Use of Single-Use Disposable Bronchoscope in the ICU in a Tertiary Referral Center of Singapore.

BACKGROUND: Flexible bronchoscopy is performed frequently in intensive care units (ICUs) for various indications using the reusable conventional bronchoscope (CB). Recently, "single-use disposable bronchoscope" (SB) was introduced into the health care industry. The purpose of this study was to compare the utility of SB with CB in ICU. METHODS: A retrospective review of medical records of patients undergoing flexible bronchoscopy in the ICUs in the year 2015. RESULTS: Ninety-three patients undergoing flexible bronchoscopy in the ICU were studied. Eighty-three bronchoscopies were performed using SB in 71 patients, and 24 using CB in 22 patients. The most common indications for using the SB were percutaneous tracheostomy [n=37 (44.6%)] in neuro-ICU, followed by collecting specimens for microbiological evaluation [n=20 (24.1%)] in the medical ICU. Airway inspection [8 (9.6%)], bronchial toilet [8 (9.6%)], hemoptysis [5 (6%)], and intubation [3 (3.6%)] were other indications for which SB was used. Microbiological yield of SB was 70% (14/20) versus 70% (7/10) for CB (P=1.0). The median interval between identification of the need-to-start of the procedure was shorter with SB (10 min) versus CB (66 min, P=0.01), whereas the cost was similar, SGD450 versus SGD472, respectively. In addition, less (3 personnel) were needed to perform bronchoscopy with SB versus 5 with CB with additional resource sparing effect in terms of nursing personnel having to wheel the CB equipment to ICU. CONCLUSIONS: SB is equivalent in performance to CB in ICU. In addition, the SB may confer clinical, economic, and logistical advantages over the CB.

Our Clinical Experience of Self-Expanding Metal Stent for Malignant Central Airway Obstruction.

BACKGROUND: We studied the safety, effectiveness, and limitations of airway stenting using self-expanding metal stent (SEMS) in patients with malignant central airway obstruction (CAO). METHODS: A retrospective review of records of patients undergoing SEMS placement for malignant CAO during year 2013 - 2014 was done. RESULTS: Sixteen patients (11 males and five females) underwent SEMS placement for malignant CAO. Median (range) age was 66 (54 - 78) years. No perioperative or immediate postoperative complications were seen except acute myocardial infarction (AMI) in one patient. Three patients were transferred to intensive care unit (ICU) for closer monitoring after the procedure and were discharged the next day. All four patients with lung atelectasis on presentation experienced complete re-expansion of the lung post-stenting. The dyspnea was substantially relieved in 14 (87.5%) patients. Two of the three patients who had been intubated were weaned off from the ventilator following stent insertion. Stent patency was maintained until death in all patients except one. Median survival from the date of diagnosis and the date of stent placement in lung cancer, esophageal cancer, and thyroid cancer were 140 (21 - 564) and 85 (15 - 361), 288 (80 - 419) and 61 (60 - 171), and 129 (71 - 187) and 67 (16 - 118) days, respectively. This survival was similar to reported expected survival associated with the underlying malignancy. During follow-up, granulation tissue (n = 1), mucostasis (n = 1), and tumor ingrowth (n = 2) were the most frequently encountered complications. CONCLUSION: SEMSs are safe and effective in reversing respiratory failure caused by malignant CAO, averting premature death, allowing application of cancer targeted therapy, and restoring impending shortened survival to expected life expectancy associated with the underlying malignancy.

Significance of coexistent granulomatous inflammation and lung cancer.

AIMS: Coexistence of lung cancer and granulomatous inflammation in the same patient confuses clinicians. We aimed to document the prevalence, clinicopathological features, treatment outcomes and prognosis in patients with coexisting granulomatous inflammation undergoing curative lung resection for lung cancer, in a tuberculosis (TB)-endemic country. METHODS: An observational cohort study of patients with lung cancer undergoing curative resection between 2012 and 2015 in a tertiary centre in Singapore. RESULTS: One hundred and twenty-seven patients underwent lung resection for cancer, out of which 19 (14.9%) had coexistent granulomatous inflammation in the resected specimen. Median age was 68 years and 58.2% were males. Overall median (range) survival was 451 (22-2452) days. Eighteen (14%) patients died at median duration of 271 days after surgery. The postsurgery median survival for those alive was 494 (29-2452) days in the whole group. Subgroup analysis did not reveal any differences in age, gender, location of cancer, radiological features, type of cancer, chemotherapy, history of TB or survival in patients with or without coexistent granulomatous inflammation. CONCLUSIONS: Incidental detection of granulomatous inflammation in patients undergoing lung resection for cancer, even in a TB-endemic country, may not require any intervention. Such findings may be due to either mycobacterial infection in the past or 'sarcoid reaction' to cancer. Although all patients should have their resected specimen sent for acid-fast bacilli culture and followed up until the culture results are reported, the initiation of the management of such patients as per existing lung cancer management guidelines does not affect their outcome adversely.

Diagnostic performance of convex probe EBUS-TBNA in patients with mediastinal and coexistent endobronchial or peripheral lesions.

To compare the performance of convex probe endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) with conventional endobronchial biopsy (EBB) or transbronchial lung biopsy (TBLB) in patients with mediastinal, and coexisting endobronchial or peripheral lesions.Retrospective review of records of patients undergoing diagnostic EBUS-TBNA and conventional bronchoscopy in 2014.A total of 74 patients had mediastinal, and coexisting endobronchial or peripheral lesions. The detection rate of EBUS-TBNA for mediastinal lesion >1 cm in short axis, EBB for visible exophytic type of endobronchial lesion, and TBLB for peripheral lesion with bronchus sign were 71%, 75%, and 86%, respectively. In contrast, the detection rate of EBUS-TBNA for mediastinal lesion ≤1 cm in short axis, EBB for mucosal hyperemia type of endobronchial lesion, and TBLB for peripheral lesion without bronchus sign were 25%, 63%, and 38%, and improved to 63%, 88%, and 62% respectively by adding EBB or TBLB to EBUS-TBNA, and EBUS-TBNA to EBB or TBLB. Postprocedure bleeding was significantly more common in patients undergoing EBB and TBLB 8 (40%) versus convex probe EBUS-TBNA 2 patients (2.7%, P = 0.0004).EBUS-TBNA is a safer single diagnostic technique compared with EBB or TBLB in patients with mediastinal lesion of >1 cm in size, and coexisting exophytic type of endobronchial lesion, or peripheral lesion with bronchus sign. However, it requires combining with EBB or TBLB and vice versa to optimize yield when mediastinal lesion is ≤1 cm in size, and coexisting endobronchial and peripheral lesions lack exophytic nature, and bronchus sign, respectively.

Pleural LDH as a prognostic marker in adenocarcinoma lung with malignant pleural effusion.

To study the performance of serum and pleural lactate dehydrogenase (LDH) level in predicting survival in patients with adenocarcinoma lung presenting with malignant pleural effusions (MPE) at initial diagnosis.Retrospective cohort study of the patient hospitalized for adenocarcinoma lung with MPE in year 2012.Univariate analyses showed lower pleural fluid LDH 667 (313-967) versus 971 (214-3800), P = 0.04, female gender 9 (100%) versus 27 (41.5%), P = 0.009, never smoking status 9 (100%) versus 36 (55.3%), P = 0.009, and epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy 8 (89%) versus 26 (40%), P = 0.009 to correlate with survival of more than 1.7 year versus less than 1.7 year. In multivariate analysis, low pleural fluid LDH and female gender maintained significance. The pleural LDH level of ≤1500 and >1500 U/L discriminated significantly (P = 0.009) between survival.High pleural LDH (>1500 IU/L) predicts shorter survival (less than a year) in patients with adenocarcinoma lung presenting with MPE at the time of initial diagnosis. This marker may be clinically applied for selecting therapeutic modality directed at prevention of reaccumulation of MPE. Patients with low pleural LDH may be considered suitable for measures that provide more sustained effect on prevention of reaccumulation such as chemical pleurodesis or tunneled pleural catheter.

Evaluation of pulmonary nodules in Asian population.

BACKGROUND: American College of Chest Physicians (ACCP) provides guidelines to manage pulmonary nodules. Pulmonary nodules however can be malignant or benign. Similar incidence of tuberculosis (TB) and lung cancer in Asian countries raises concern over the relevance of suggested guidelines in Asian population. There is little data on the pattern of clinical practice in the management of pulmonary nodules in Asian country (Singapore). Our study describes the current pattern of clinical practice in this area highlighting the variation in practice and discussing the potential reasons. METHODS: Retrospective review of the medical records of patients diagnosed with lung cancer in 2010. RESULTS: Sixty nodules were identified in 32 patients. Nodules were detected incidentally on routine imaging in 7 (21.9%) patients. TB contact tracing and pre-employment screening were common ways by which nodules were detected incidentally. Over one third (37.5%) were non-smokers. Majority of nodules were located in the upper lobes of right and left lung followed by right lower lobe (RLL). Only few patients 8 (25%) had positron emission tomography (PET) scan for staging purposes. There were no difference in survival between patients who presented with single, 747 (range, 25-1,840) days vs. multiple nodules 928 (range, 30-2,572) days, P=0.26. In a retrospective analysis of malignancy risk with the probability calculator, 62.5% patients were at low-moderate risk whilst 32.5% were at high risk. CONCLUSIONS: The clinical practice of managing pulmonary nodules in Asian population differs from ACCP guidelines. None of the patient had pre-test probability calculated, and few had PET scan. This is because upper lobe predominance of lung cancer is identical to TB, non-smoking history does not have any weight in discounting malignancy risk where many of the Asian lung cancer patients are non-smokers, and the local endemicity of TB and its confounding effect on radiological findings of CT scan and PET scan.

Role of Bronchoscopy in Prompt Discharge From the Intensive Care Unit.

BACKGROUND: Intensive care unit (ICU) stays are 2.5 times more costly than other hospital stays, and 93.3% of ICU use is for respiratory disease with ventilator support. The aim of this study was to assess the role of bronchoscopy on discontinuation of mechanical ventilation, and prompt discharge from ICU in our institution. METHODS: Retrospective review of medical records of patients referred for bronchoscopic intervention for acute respiratory failure from malignant or benign central airway diseases requiring ICU admission. RESULTS: Twelve critically ill patients were studied. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube, and 3 (25%) had tracheostomy tube. Nine (75%) of 12 patients admitted to ICU could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention. Median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002). Radiologically, all 8 patients with lung atelectasis on presentation experienced complete reexpansion of the lung on the day after bronchoscopic intervention. CONCLUSION: The majority of patients in our cohort (75%) of benign and malignant etiology could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of mechanical ventilation and extubation after bronchoscopic intervention. We advocate early recognition and bronchoscopic intervention in suitable patients.

Timeliness of Diagnosing Lung Cancer: Number of Procedures and Time Needed to Establish Diagnosis: Being Right the First Time.

To study number of procedures and time to diagnose lung cancer and factors affecting the timeliness of clinching this diagnosis. Retrospective cohort study of lung cancer patients who consecutively underwent diagnostic bronchoscopy in 1 year (October 2013 to September 2014). Out of 101 patients diagnosed with lung cancer from bronchoscopy, average time interval between first abnormal computed tomogram (CT) scan-to-1st procedure, 1st procedure-to-diagnosis, and 1st abnormal CT scan-to-diagnosis was 16 ± 26, 11 ± 19, and 27 ± 33 days, respectively. These intervals were significantly longer in those requiring repeat procedures. Multivariate analysis revealed inconclusive 1st procedure to be the predictor of prolonged (>30 days) CT scan to diagnosis time (P = 0.04). Twenty-nine patients (28.7%) required repeat procedures (n = 63). Reasons behind repeating the procedures were inadequate procedure (n = 14), inaccessibility of lesion (n = 9), inappropriate procedure (n = 5), mutation analysis (n = 2), and others (n = 2). Fifty had visible endo-bronchial lesion, 20 had positive bronchus sign, and 83 had enlarged mediastinal/hilar lymph-nodes or central masses adjacent to the airways. Fewer procedures, and shorter procedure to diagnosis time, were observed in those undergoing convex probe endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) (P = 0.04). Most patients exhibit enlarged mediastinal lymph node or mass adjacent to the central airway accessible by convex probe EBUS-TBNA. Hence, combining it with conventional bronchoscopic techniques such as bronchoalveolar lavage, brush, and forceps biopsy increases detection rate, and reduces number of procedures and time to establish diagnosis. This may translate into cost and resource savings, timeliness of diagnosis, greater patient satisfaction, and conceivably better outcomes.

Subconjunctival haemorrhage from bronchoscopy: A case report.

Flexible bronchoscopy has been available for almost five decades. It has evolved as one of the most commonly used invasive diagnostic and therapeutic procedure in pulmonology, and its scope of applications is progressively expanding with the addition of new adjunct technologies such as endobronchial ultrasound, bronchial Thermoplasty, and navigational bronchoscopy. It is a safe procedure with complications ranging from fever, infiltrates, hypoxemia, bleeding, pneumothoraces and death, with most significant complications being bleeding and pneumothorax. We report a case of subconjuctival haemorrhage as an immediate complication of bronchoscopy. To our knowledge this is the first report documenting this rare complication.

Pharmacologic treatment of SARS: current knowledge and recommendations.

The severe acute respiratory syndrome (SARS) pandemic caught the world by surprise in 2003 and spread rapidly within a relatively short period of time. Hence, randomised placebo-controlled clinical trials on the treatment of SARS were not possible. Our understanding was obtained from observational, cohort studies, case series and reports. Nevertheless, such information is useful in providing clinical management guidelines and directing future research in case SARS recurs. Early in the pandemic, a combination of ribavirin and corticosteroids was adopted as the standard treatment in Hong Kong, Canada and elsewhere because of the apparent good results of the first few patients. Subsequent reports showed that ribavirin was associated with a high rate of toxicity and lacked in vitro antiviral effect on SARS-coronavirus (SAR-CoV). The timing and dosage regimens of steroid in the treatment of SARS are controversial. Pulse methylprednisolone 250 to 500 mg/day for 3 to 6 days has been reported to have some efficacy in a subset of patients with "critical SARS", i.e., critically ill SARS patients with deteriorating radiographic consolidation, increasing oxygen requirement with PaO2 <10 kPa or SpO2 <90% on air, and respiratory distress (rate of 30/min). Prolonged therapy with high-dose steroids, in the absence of an effective antimicrobial agent, could predispose patients to complications such as disseminated fungal infection, and avascular necrosis. Kaletra (400 mg ritonavir and 100 mg lopinavir), a protease inhibitor used in the treatment of human immunodeficiency virus infection, may be considered for early treatment of SARS patients, preferably in a randomised double-blind placebo-controlled clinical trial setting. Interferon (IFN) is not recommended as standard therapy in SARS. However, there are enough data on in vitro activity of IFN preparations and a few clinical studies for these products to support a controlled trial if SARS recurs. Many other experimental treatments have been tried in an uncontrolled manner, and they should not be recommended as standard therapy.

SARS: how to manage future outbreaks?

Severe acute respiratory syndrome (SARS) was an unknown disease barely 3 years ago. After the World Health Organization declared the world SARS-free on 5 July 2003, there were episodic recurrences of SARS between September 2003 and May 2004, including 4 cases of laboratory-acquired SARS. SARS posed a mammoth challenge because of the impact of nosocomial transmission on healthcare manpower and facilities, and the resources needed for controlling and preventing further spread. Through worldwide scientific collaboration, the medical community has made much progress in unraveling its enigma, though much more needs to be discovered. This paper highlights how we can apply our knowledge of its epidemiology, mode of transmission, clinical course, ICU admission, complications, predictors of poor outcome, treatment and infection control to help us avert a catastrophic outbreak, and to manage our resources and patients. SARS preparedness and response planning must be flexible and dynamic so that appropriate measures can be implemented as an outbreak progresses. Even if SARS does not reemerge, the experience gained from such planning is valuable in preparing for threats of bioterrorism or a global avian influenza A (H5N1) virus pandemic.

SARS plague: duty of care or medical heroism?

Severe acute respiratory syndrome (SARS) is a new infectious disease that emerged in mid- November 2002 in Guangdong, southern China. The global pandemic began in late February 2003 in Hong Kong. By the time SARS was declared contained on 5 July 2003 by the World Health Organization (WHO), it had afflicted 8096 patients in 29 countries. No other disease had had such a phenomenal impact on healthcare workers (HCWs), who formed about 21% of SARS patients. In Vietnam, Canada and Singapore, HCWs accounted for 57%, 43% and 41% of SAR patients, respectively. At the beginning of the outbreak, there was practically no information on this disease, which did not even have a name until 16 March 2003, except that it was infectious and could result in potentially fatal respiratory failure. Indeed, HCWs had lost their lives to SARS. Understandably, some HCWs refused to look after SARS patients or even resigned. Initially, much negative publicity was given to such HCWs. It was a very trying time for HCWs as many were also ostracised by the society which they served. They were perceived to be a potential source of infection in the community because of their contact with SARS patients, whom they risked their lives looking after. Subsequently, as we learnt more about the disease and educated the public about the plight of the frontline HCWs, the public gave the frontline HCWs tremendous support and even honoured them as heroes. Being in the medical profession, caring for patients is one of our expected responsibilities. On the other hand, as public citizens, HCWs have the right to resign when they feel that their responsibility to their families should take priority over that to their patients. As a result of this scourge, each HCW learnt to decide if caring for patients is their chosen profession and vocation. Many chose to live up the Hippocratic oath.

Expanding ICU facilities in an epidemic: recommendations based on experience from the SARS epidemic in Hong Kong and Singapore.

Epidemics have the potential to severely strain intensive care resources and may require an increase in intensive care capability. Few intensivists have direct experience of rapidly expanding intensive care services in response to an epidemic. This contribution presents the recommendations of an expert group from Hong Kong and Singapore who had direct experience of expanding intensive care services in response to the epidemic of severe acute respiratory syndrome. These recommendations cover training, infection control, staffing, communication and ethical issues. The issue of what equipment to purchase is not addressed. Early preparations should include fit testing of negative pressure respirators, training of reserve staff, sourcing of material for physical modifications to the ICU, development of infection control policies and training programmes, and discussion of triage and quarantine issues.

Potentially fatal paracetamol overdose and successful treatment with 3 days of intravenous N-acetylcysteine regime--a case report.

INTRODUCTION: Paracetamol overdose is the most common drug overdose worldwide. To our knowledge, the maximum number of paracetamol tablets ingested reported in the literature is 45 g. CLINICAL PICTURE: We describe a 21-year-old patient who acutely ingested 120 tablets, each 500 mg paracetamol (i.e., 60 g equivalent to 1200 mg/kg body weight) in a suicidal attempt. Our patient also drank 2 bottles of codeine-based cough syrup equivalent to 360 mg of codeine. At 6 hours post ingestion, her serum paracetamol level was 207 mg/L. The poor prognostic factors for paracetamol overdose in our patient included massive paracetamol ingestion (confirmed by blood levels), codeine co-ingestion and elevated serum amylase (189 U/L). TREATMENT: She was treated with a 3-day modified regimen of intravenous N-acetylcysteine. OUTCOME: The liver function tests and the prothrombin time remained normal over the second and third day of admission and the patient was discharged without complications on the fifth day. CONCLUSION: From this experience we feel that in very severe paracetamol poisoning, a modified regime of intravenous N- acetylcysteine for 3 days is safe and efficacious.

Analysis of deaths during the severe acute respiratory syndrome (SARS) epidemic in Singapore: challenges in determining a SARS diagnosis.

CONTEXT: An outbreak of severe acute respiratory syndrome (SARS), an infectious disease attributed to a novel coronavirus, occurred in Singapore during the first quarter of 2003 and led to 204 patients with diagnosed illnesses and 26 deaths by May 2, 2003. Twenty-one percent of these patients required admission to the medical intensive care unit. During this period, the Center for Forensic Medicine, Health Sciences Authority, Singapore, performed a total of 14 postmortem examinations for probable and suspected SARS. Of these, a total of 8 were later confirmed as SARS infections. OBJECTIVE: Our series documents the difficulties encountered at autopsy during the initial phases of the SARS epidemic, when the pattern of infection and definitive diagnostic laboratory criteria were yet to be established. DESIGN: Autopsies were performed by pathologists affiliated with the Center for Forensic Medicine, Health Sciences Authority, Singapore. Tissue was accessed and read at the Tan Tock Seng Hospital, Singapore, and at the Armed Forces Institute of Pathology, Washington, DC. Autopsy tissue was submitted to the Virology Department, Singapore General Hospital, for analysis, and in situ hybridization for the SARS coronavirus was carried out at the National Institute of Infectious Diseases, Tokyo, Japan. RESULTS: Thirteen of 14 patients showed features of diffuse alveolar damage. In 8 patients, no precipitating etiology was identified, and in all of these patients, we now have laboratory confirmation of coronavirus infection. Two of the 8 patients presented at autopsy as sudden unexpected deaths, while the remaining 6 patients had been hospitalized with varying lengths of stay in the intensive care unit. In 3 patients, including the 2 sudden unexpected deaths, in situ hybridization showed the presence of virally infected cells within the lung. In 4 of the 8 SARS patients, pulmonary thromboemboli were also recognized on gross examination, while one patient had marantic cardiac valvular vegetations. CONCLUSIONS: It is unfortunate that the term atypical pneumonia has been used in conjunction with SARS. Although nonspecific by itself, the term does not accurately reflect the underlying dangers of viral pneumonia, which may progress rapidly to acute respiratory distress syndrome. We observed that the clinical spectrum of disease as seen in our autopsy series included sudden deaths. This is a worrisome finding that illustrates that viral diseases will have a spectrum of clinical presentations and that the diagnoses made for such patients must incorporate laboratory as well as clinical data.