Sarcoidosis: the value of exercise testing.

STUDY OBJECTIVES: To evaluate exercise testing for the assessment of the extent of pulmonary disease in patients with sarcoidosis. DESIGN: Retrospective analysis of consecutive patients with sarcoidosis referred to the Pulmonary Physiology Laboratory between 1992 and 1997, who completed at least 6 min of progressive bicycle exercise. Resting and exercise pulmonary function measurements were compared to radiographic stage of disease. SETTING: Pulmonary Physiology Laboratory at Washington, DC, Veterans Affairs Medical Center. PATIENTS: Forty-eight outpatient veterans with biopsy specimen-proven sarcoidosis. RESULTS: Across all radiographic stages of sarcoidosis, total lung capacity, resting diffusing capacity, and exercise gas exchange measurements had a significant variance with radiographic stage. Across the early radiographic stage disease (stages 0 to 2), the change in alveolar-arterial oxygen pressure gradient between rest and exercise, normalized for oxygen uptake, was the most significant measurement in its variation with radiographic stage. CONCLUSIONS: Changes in gas exchange with exercise may be the most sensitive physiologic measurements to assess the extent of disease in early radiographic stages of sarcoidosis.

Giant lamellar bodies in a pulmonary MALT lymphoma: a case report with ultrastructural and immunohistochemical studies.

A 35-year-old, African-American man presented with a 7-year history of a persistent, enlarging pulmonary infiltrate in the right middle lobe associated with three episodes of right-sided pneumonia, recent 12-lb weight loss, and progressive shortness of breath. The nature of the right middle lobe infiltrate was unclear, but recurrent aspiration pneumonia and carcinoma of lung were important considerations. Exploratory thoracotomy with partial lobectomies revealed a low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT). Clusters of giant lamellar bodies were a unique finding in this lymphoma. Results of ultrastructural and immunohistochemical studies gave support to the views that these inclusions were derived from both products of cellular degeneration and surfactant. The pulmonary lymphoma subsequently spread to the gastric mucosa. The patient is alive with lymphoma 5 years after the initial diagnosis was made.

Interpretive algorithms for the symptom-limited exercise test: assessing dyspnea in Persian Gulf war veterans.

Interpretation of symptom-limited exercise testing requires analysis of a large body of simultaneously recorded cardiopulmonary data. Karlman Wasserman has recommended an algorithmic approach to interpretation (WA) that leads to a dichotomous choice between pulmonary and cardiovascular impairment. An alternative algorithm published by William Eschenbacher (EA) provides for concurrent assessment of cardiovascular and pulmonary exercise impairment. We analyzed a group of 29 individuals referred to the Pulmonary Physiology Laboratory at the Washington Veterans Affairs Medical Center for evaluation of dyspnea following service in the Persian Gulf War to assess the concordance of the two algorithms in determining the cause of dyspnea and exercise impairment in these individuals. They each performed a progressive, ramped, symptom-limited exercise test on a bike for a minimum of 6 min. Exercise measurements were analyzed by both interpretive algorithms. Concordance was found in 28% of tests. The greatest discordance occurred in identifying pulmonary limitation. Eleven had pulmonary limitation by EA; of these, WA found 1 to have pulmonary limitation, 5 to be normal, 4 indeterminate, and 1 musculoskeletal limitation. Of the 11 with pulmonary limitation by EA, but not by WA, 5 had abnormal resting pulmonary function measurements. Analysis of the differences between these two interpretive approaches is given. The EA algorithm may be more sensitive for detecting exercise impairment of pulmonary origin, but its specificity remains to be determined.

Disseminated blastomycosis and acquired immunodeficiency syndrome: a case report and ultrastructural study.

A 42-year-old, African-American man presented with a 2-month history of weight loss and fever for 2 weeks. Presumptive diagnoses of human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome were made on the basis of a CD4 lymphocyte count of 23 lymphocytes/mL. Chest x-ray revealed right paratracheal adenopathy and a miliary pattern. The etiology of the patient's pulmonary infection was not known, but tuberculosis was an important consideration. Over 5 days, the pulmonary infection progressed and was complicated by acute respiratory distress syndrome (ARDS), septic shock, and death, despite vigorous antibiotic and supportive therapy. Serologic tests for HIV infection were reported as positive after the patient's demise. The etiology of the patient's pulmonary infection, ARDS, and sepsis was not known until autopsy study revealed enumerable yeast-like cells of Blastomyces dermatitidis in the extensively consolidated lungs and in disseminated foci of infection in most other major organs. Diffuse alveolar damage was closely associated with the pulmonary blastomycosis. Electron microscopic study of the yeast-like cells of B. dermatitidis in the autopsy lung obtained and fixed 5 days after the patient's death revealed excellent preservation of viable organisms.

Herpetic bronchitis with a broncho-oesophageal fistula.

Tracheobronchitis and oesophagitis due to herpes simplex virus (HSV) are rare. Tracheo-oesophageal fistula due to HSV oesophagitis has been described in the immunocompromised host. A case is reported of a broncho-oesophageal fistula which developed secondary to herpetic bronchitis in an apparently immunocompetent patient.

Pathogenesis and therapy of pulmonary emphysema.

Emphysema is characterized by permanent enlargement of the respiratory air spaces distal to the terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis. We present a review of this disease, discussing its classification, pathology, and therapy.

Acute miliary tuberculosis of the skin in acquired immunodeficiency syndrome.

In human immunodeficiency virus-infected persons the clinical and radiographic appearance of pulmonary tuberculosis is frequently atypical, and extrapulmonary involvement is more frequent. We describe what we believe is the first case of a human immunodeficiency virus-infected person with acute miliary tuberculosis of the skin.

Multicentric endobronchial granular cell myoblastoma.

Granular cell myoblastoma (GCM) is a rare benign neoplasm involving the tracheobronchial tree. It is believed to arise from the Schwann cell. Four cases of tracheobronchial GCM, all of which were multicentric, are presented and a conservative therapeutic approach is suggested.

Disseminated Mycobacterium fortuitum successfully treated with combination therapy including ciprofloxacin.

We report a case of disseminated Mycobacterium fortuitum in a 76-yr-old male with no identifiable predisposing factors except chronic interstitial lung disease. Recurrent, progressive pulmonary symptoms and radiographic findings were followed by the development of multiple, culture-positive peripheral lesions. The patient responded rapidly and completely to combination therapy consisting primarily of ciprofloxacin, minocycline, and surgical drainage. Our experience supports the cautious use and further study of fluorinated quinolones for M. fortuitum infections caused by susceptible isolates.

Clinical role of bronchoalveolar lavage in adults with pulmonary disease.

BAL remains a powerful investigative tool. In a short span of 20 yr, it has helped tremendously in understanding some of the aspects of the pathogenesis of diseases involving the lower respiratory tract. To realize its full potential in the diagnosis and management of diseases involving the lower respiratory tract, there is a great need for standardization of the technical aspects of BAL as well as processing and analysis of the BAL cellular- and fluid-phase components. Despite these hurdles, BAL has been found to be diagnostic in several infectious and noninfectious diseases involving the lower respiratory tract, and it provides valuable information that may be helpful in characterizing the prognosis and response to therapy in certain interstitial diseases of the lung. It is expected that with future research, in particular long-term prospective epidemiologic and clinical studies in pneumoconioses and in other interstitial lung disease, BAL will prove more valuable in the diagnosis and management of such disease.

Pseudotumor of left kidney due to sarcoidosis.

Presence of granulomas in the kidney have been reported in up to 40 percent of patients with sarcoidosis. However, granulomatous infiltration producing renal enlargement with distortion of the normal renal contour, and mimicking renal "pseudotumor" is exceedingly rare and is the subject of this case report. Radiographic, scintigraphic, and histologic findings are presented.

Metastatic pulmonary calcification in sarcoidosis.

A patient with sarcoidosis with elevated 1,25-dihydroxy vitamin D levels, hypercalcemia, nephrolithiasis, and moderate azotemia is presented because of development of metastatic pulmonary calcification which was diagnosed by radioisotope scanning and tissue biopsy.

Extrapulmonary localization of gallium in sarcoidosis.

This paper describes the spectrum of extrapulmonary localization of gallium in patients with sarcoidosis. The usefulness of Ga-67 scintiscans in detecting clinically occult lesions, in directing clinicians to accessible sites for biopsy, and in following the course of extrapulmonary sites of involvement with therapy is emphasized.

Endoscopic removal of a bronchial lipoma with the Neodymium-YAG laser.

A 56-year-old man presented with right middle and lower lobe pneumonia with empyema. Bronchoscopy and endobronchial biopsy revealed a lipoma in the bronchus intermedius. Removal of the lipoma was achieved with the Neodymium-Yttrium-Aluminum-Garnet (Nd:YAG) laser through a fiberoptic bronchoscope. The present case represents the first report of endobronchial lipoma with the Nd:YAG laser in the United States.

Assessment of activity in chronic sarcoidosis: usefulness of serum angiotensin converting enzyme and gallium scan.

Gallium scan and serum angiotensin converting enzyme (SACE) activity were performed in 39 patients, who were not receiving corticosteroids and had histologically proven chronic sarcoidosis of at least 2 years duration. Results of these investigations were compared with clinical assessment of disease activity. In patients with radiographic evidence of pulmonary parenchymal disease, the positive and negative predictive values for gallium scan and/or SACE were 96 and 100% respectively; however, in patients with no radiographic evidence of parenchymal disease the positive and negative predictive values were 50 and 100%, respectively. These findings suggest that SACE and gallium scan are useful in assessing the activity and hence the need for therapy in patients with chronic sarcoidosis with radiographic evidence of parenchymal disease.