Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis.

OBJECTIVE: We wanted to investigate the utility of performing fiberoptic bronchoscopy before bronchial artery embolization in patients with massive hemoptysis. MATERIALS AND METHODS: We retrospectively reviewed the cases of all patients with hemoptysis who had presented at either of two local hospitals, one county hospital and one community hospital, between 1988 and 2000 and who had undergone fiberoptic bronchoscopy before bronchial arteriography. All data were abstracted using a standardized coding form, and radiographs were independently reviewed by two of the authors. RESULTS: Twenty-nine patients meeting the inclusion criteria were identified; one patient was excluded because of missing radiographs. The remaining 28 patients consisted of 19 men and nine women, with an average age of 54.6 years (age range, 16-91 years). The clinically determined diagnoses of their symptoms were tuberculous bronchiectasis (n = 14; 50.0%); bronchogenic carcinoma (n = 4; 14.3%); active tuberculosis (n = 2; 7.1%); nontuberculous bronchiectasis (n = 2; 7.1%); active coccidioidomycosis, pancreaticobronchial fistula, arteriovenous malformation, and tetralogy of fallot (n =1 each; 3.6% each); and unknown cause (n = 2; 7.1%). The bleeding site determined through bronchoscopy was consistent with that determined through radiographs in 23 patients (82.1%); all had either unilateral disease (n = 15), bilateral disease with unilateral cavities (n = 5), or a preponderance of disease on one side (n = 3). Bronchoscopy was an essential tool in determining the bleeding site in only three patients (10.7%), all of whom had bronchiectasis without localizing features visible on chest radiographs. In the remaining two patients (7.1%), bronchoscopic findings were indeterminate, but radiographs were helpful. CONCLUSION: Fiberoptic bronchoscopy before bronchial artery embolization is unnecessary in patients with hemoptysis of known causation if the site of bleeding can be determined from radiographs and no bronchoscopic airways management is needed.

An unusual complication during central venous catheter placement.

A 31-year-old man with disseminated Coccidioides imitis infection required central catheter placement for access. The patient had an inferior vena cava (IVC) filter placed as a result of previous deep venous thrombosis of the left lower extremity. The guidewire could not be removed following placement of the right internal jugular catheter by the Seldinger technique. Fluoroscopic examination revealed entanglement of the J-tip guidewire in the apex of the IVC filter. The catheter was successfully removed by interventional radiologists using a snare tip catheter through the left femoral vein.

Pneumoparotid due to spirometry.

Pneumoparotid has been described in patients who generate increased intraoral pressures when playing wind instruments, while coughing, and when undergoing dental work. Some patients have intentionally created pneumoparotid to avoid duties at school or in the military, or to gain attention. We describe a patient who developed pneumoparotid during pulmonary function testing. The diagnosis of pneumoparotid depends on a suggestive clinical situation and glandular swelling with or without crepitus. Observation of aerated saliva per Stensen's duct or air in the parotid duct and/or gland by any imaging study is diagnostic if infection with a gas-forming organism can be reasonably excluded. No specific treatment is required, other than the avoidance of predisposing activities.

Airway coccidioidomycosis--report of cases and review.

Infection due to Coccidioides immitis usually begins in the lungs. Despite the initial pulmonary portal of entry, endotracheal and endobronchial coccidioidomycosis has rarely been described. Since the introduction of fiberoptic bronchoscopy and the AIDS epidemic, more C. immitis lesions of the large airways have been noted. We present data on 38 cases of coccidioidomycosis of the airways, including 6 cases detailed from our own experience and 32 from the literature. Direct infection of the airways (28 cases) is a more common mechanism of airways disease than is erosion into the airways from a lymph node (5 cases). Bronchoscopic findings vary and may show mucosal involvement or intrinsic obstruction. Endotracheal and endobronchial disease is not a self-limited disease and requires antifungal therapy. Disseminated disease in these patients is common. Coccidioidomycosis must be considered in the differential diagnosis of airway pathology.

The optimal number of pleural biopsy specimens for a diagnosis of tuberculous pleurisy.

STUDY OBJECTIVES: To determine the optimal number of pleural biopsy (PLBX) specimens for a diagnosis of tuberculous pleurisy. DESIGN: Retrospective review. SETTING: County hospital. METHODS: We reviewed all percutaneous needle biopsy specimens of the parietal pleura in 30 patients who had tuberculous pleurisy. Data are reported as mean+/-SEM and statistical comparisons are done with the Mann-Whitney test. We accepted p<0.05 as statistically significant. RESULTS: The number of biopsy specimens obtained from each patient ranged from 4 to 10 with 1 sample submitted for mycobacterial culture and the rest submitted for histologic study. Sixty percent of patients had pleural cultures positive for Mycobacterium tuberculosis and 80% had diagnostic histology. Overall pleural biopsy sensitivity (histology and culture) for tuberculous pleurisy was 87%. On average, 40.4%+/-4.7% of all PLBX specimens contained pleura. Diagnostic PLBX procedures compared to false-negative procedures produced more tissue specimens (7.1+/-0.3 vs 4.8+/-0.5, p=0.005) containing more pleural specimens (2.4+/-0.2 vs 0.8+/-0.5, p=0.01). If only PLBX procedures yielding more than six tissue specimens (n=18) or more than two pleural specimens (n=12) were analyzed, then the diagnostic sensitivity of PLBX for pleural tuberculosis was 100%. There seemed to be a direct relationship between the sensitivity of PLBX and the number of specimens submitted. CONCLUSIONS: The sensitivity of percutaneous needle biopsy for diagnosis of tuberculous pleurisy is highest when more than six specimens are obtained which, on average, contain more than two specimens of parietal pleura. There are no conclusive data indicating how many tissue specimens to submit for mycobacterial culture, but one specimen seems sufficient.

Pulmonary manifestations of strongyloidiasis.

Strongyloides stercoralis (SS) is endemic in tropical and subtropical areas worldwide and in the southeastern United States. The lifecycle of SS is both unique and complex. Human infection begins with the penetration of skin by filariform larvae that migrate hematogenously to the lungs. Larvae then ascend the airway, are swallowed, and mature in the gut. Unlike other nematodes, SS can autoinfect the same host and persist for decades. Categorization of infection includes acute, chronic-uncomplicated, and disseminated forms. Clinical manifestations depend on the particular organs involved. Fifteen to thirty percent of chronically infected people may be asymptomatic. On the other hand, SS may cause the adult respiratory distress syndrome, septic shock, and death. The diagnosis of SS infection is suspected in patients from endemic areas who have blood eosinophilia, and gastrointestinal or pulmonary symptoms. A definitive diagnosis is established by demonstration of SS larvae in stool, body fluids, or tissues. A presumptive diagnosis of SS infection can be achieved by serology. Thiabendazole is the mainstay of treatment, but repeat doses may be necessary if the parasite is not initially eradicated. The low incidence of disseminated SS in areas endemic for both SS and AIDS is surprising and unexplained.

Endovascular stenting of an aortopulmonary fistula presenting with hemoptysis. A case report.

We present a 45 year old man with massive hemoptysis due to an aortopulmonary fistula. Our patient had a history of a previous patent ductus arteriosus repair which was complicated by a previous aortopulmonary fistula. Computed tomography of the chest and aortography made the diagnosis of a recurrent aortopulmonary fistula. Because of the history of previous surgical aortic procedures, repair of the fistula was completed through a retroperitoneal aortotomy with intravascular insertion of an expandable stainless steel stent covered by a polyester graft. The patient has had no hemoptysis or computed tomographic evidence of fistula recurrence thirty eight months after the procedure.

Total lymphoid irradiation for refractory acute rejection in heart-lung and lung allografts.

Persistent or recurrent acute allograft rejection (AR) refractory to high-dose steroid therapy can adversely affect long-term outcomes of heart-lung (HLT), bilateral-lung (BLT), and single-lung (SLT) transplantations. The use of total lymphoid irradiation (TLI) for the management of refractory acute AR in six transplant recipients (two men, four women; mean age, 29.8 +/- 3.8 years) is detailed. There are two HLT (primary pulmonary hypertension [PPH], cystic fibrosis [CF]), 1 BLT (pulmonary hypertension postventricular septal defect repair), and 3 SLT (sarcoid, PPH, congenital heart disease with atrial septal defect) recipients. Refractory AR is defined as persistent rejection unresponsive to high-dose steroid therapy in all cases. The BLT and SLT recipients had at least two moderate and one mild AR events per patient. The HLT recipients had at least two moderate acute heart and one severe and one mild asynchronous acute lung rejection events per patient. A total of 800 cGy of total lymphoid irradiation (TLI) was administered over a 5-week period. Mild and transient leukopenia was the only observed side effect. The patient with PPH received TLI 313 days after HLT for recurrent AR at another institution and died of ARDS 4 weeks after completing TLI. The patient with CF received TLI 707 days after HLT and died 457 days after TLI of severe obliterative bronchiolitis (OB) with multiorgan failure. The patient with BLT received TLI 176 days after transplant and died 372 days after TLI of respiratory failure related to severe rejection. One patient with SLT received TLI 78 days after transplant and died 679 days after TLI of severe acute AR. The two remaining patients with SLTs have been free from acute AR for more than 4 years. The patient with sarcoidosis received TLI 37 days after SLT following a clinical rejection event and two severe acute AR events. He is alive with normal lung function 5 years later. The patient with PPH received TLI 108 days after SLT following three moderate acute AR events and is alive with stable OB 4 years later. These limited preliminary results suggest that TLI has merit for the treatment of intractable acute AR following HLT and lung transplantation.

Complications of long arm-catheters: a randomized trial of central vs peripheral tip location.

BACKGROUND: This two-part study initially evaluated complications associated with catheters inserted via upper extremity veins. The second prospective phase compared thrombotic risk of peripheral catheter tips vs a central vein terminus. METHODS: Patients from public institutions with infectious diseases were observed throughout their inpatient and outpatient use of IV catheters. Seventy-two and 39 patients enrolled in phase 1 and phase 2, respectively. Phase 1 consisted of prospective observations and analysis of complications and associated risk factors. Phase 2 randomized patients to a catheter tip location in the superior vena cava or the axillosubclavian-innominate vein and compared the incidence of thrombosis, phlebitis, and infection. RESULTS: In phase 1, there was an increased risk of thrombosis with peripheral tip localization (61% vs 16%, p < .05). Phase 2 confirmed increased thrombosis with tips in the axillosubclavian-innominate vein compared with the superior vena cava (60% vs 21%, p < .05) with an improved survival for central tip catheters (p < .02). Catheters associated with thrombosis were more likely to become infected (r = 0.48, p < .02). CONCLUSIONS: The experience supports use of the long arm catheter as an effective device for parenteral therapy. A novel method for placing these catheters makes most patients candidates for this approach. Placing a long arm-catheter's tip in the central venous circulation reduces the risk of thrombosis. A high incidence of tip misdirection indicates a need for radiographic confirmation before use.

A modified Abrams needle biopsy technique.

STUDY OBJECTIVE: To compare the diagnostic sensitivity of a modified Abrams needle pleural biopsy technique (A1) with the standard Abrams (A2) and Cope needle biopsy methods. The modified Abrams pleural biopsy technique consisted of suctioning each tissue sample into a syringe without removing the needle completely from the chest until the completion of the entire procedure. Both the standard Abrams and Cope needle techniques required needle removal from the chest after each pleural biopsy. DESIGN: Retrospective chart analysis. SETTING: Community teaching hospital affiliated with Stanford University. PATIENTS: Forty-seven patients (30 men and 17 women) with a mean age 44.5 years (range, 19 to 81 years) who were referred to a pulmonary consultation service for pleural biopsy. INTERVENTIONS: Two of us (C. M. K. and F. T. K.) used the modified Abrams technique and two of us (W. A. J. and A. C. C.) used the standard Abrams technique. The Cope needle was used as originally described. MEASUREMENTS: We recorded the type of pleural biopsy needle and technique used in each patient. Biopsy specimen diameter and number of tissue samples obtained, final diagnoses, and complications were recorded. RESULTS: The diagnostic sensitivity for tuberculous pleurisy was 82% for the modified Abrams method, 71% for the standard Abrams method, and 88% for the standard Cope technique (p > or = 0.3). There was no difference in size of tissue sample obtained (A1 vs A2), number of biopsies, or complications among the three methods of pleural biopsy. CONCLUSIONS: The modified method of Abrams needle biopsy demonstrates a diagnostic sensitivity for pleural tuberculosis (82%) that is equivalent to that for the standard Abrams or Cope methods.

Tuberculous otitis media.

Tuberculous otitis media (TOM) is a rare cause of chronic suppurative infection of the middle ear and mastoid. The increasing incidence of tuberculosis in the United States may be associated with more cases of TOM than recognized previously. Patients typically have a chronic tympanic membrane perforation and ear drainage associated with progressive and profound hearing loss. The correct diagnosis starts with consideration of the disease in a patient with a chronic middle ear infection that is unresponsive to routine therapy. TOM should be strongly considered in patients with known or suspected tuberculosis and a chronic ear infection; however, the lack of evidence of tuberculosis elsewhere does not exclude the possibility of TOM. Appropriate evaluation for TOM includes a chest film, purified protein derivative (PPD) skin testing, and smears or cultures of otic secretions for mycobacteria. Operative biopsy may be required. Facial nerve paralysis is highly suggestive of TOM. Medical therapy with antituberculous drugs is usually effective, and surgery is rarely needed.

The prevalence and response to therapy of Strongyloides stercoralis in patients with asthma from endemic areas.

STUDY OBJECTIVE: To evaluate the prevalence and response to therapy of Strongyloides stercoralis infection in immigrant patients with asthma from areas endemic for Strongyloides. DESIGN AND INTERVENTIONS: In all patients, we performed a complete history and physical examination, complete blood cell counts (CBC), S stercoralis serologic tests, spirometry, and evaluated three stool samples for ova and parasites. Patients treated for S stercoralis infection had follow-up CBC, spirometry, serologic tests, and at least three additional stool examinations to confirm eradication of the parasite. SETTING: Ambulatory and hospitalized patients who were referred to the respiratory medicine clinic of a general hospital for the evaluation and treatment of asthma. PATIENTS: Forty-five asthmatic adults, representing 12 endemic countries, ranging in age from 20 to 76 years, were prospectively evaluated. RESULTS: Six of 45 patients were infected with S stercoralis, which yielded a prevalence of 13 percent. The patients with asthma and S stercoralis infection had higher blood eosinophil counts (p = 0.006) and were younger (p = 0.006) compared with patients with only asthma. There was no difference in the duration of asthma, spirometry, or steroid use between the two groups. Patients with S stercoralis and asthma tended to be more recent immigrants (p = 0.05). Five of the six patients with S stercoralis agreed to be treated with thiabendazole but only four returned for follow-up evaluation. All four patients had eradication of S stercoralis infection confirmed by negative stool examinations and a decline in S stercoralis serology (160 +/- 25 percent vs 13 +/- 13 percent, p = 0.03). All four patients had a decline in total blood eosinophil counts (2,476 +/- 832 cells per cubic millimeter vs 551 +/- 138 cells per cubic millimeter, p = 0.03) without a clinical improvement in asthma. CONCLUSIONS: Our data suggest that patients with asthma from areas endemic for S stercoralis, who have elevated peripheral blood eosinophil counts, should be screened for S stercoralis infection. Successful eradication of S stercoralis, however, may not result in a clinical improvement of asthma.

Controlled utilization of induced sputum analysis in the diagnosis of Pneumocystis carinii pneumonia.

We investigated the outcome and potential cost savings of a system designed to limit physician access to induced sputum analysis (ISA) for the diagnosis of Pneumocystis carinii pneumonia (PCP). Four respiratory medicine physicians screened all requests for ISA to determine the pretest likelihood of PCP. Twenty-two of 102 requests for ISA over a 1-year period were denied due to a low clinical suspicion for PCP. Seven individuals had a definitive alternative diagnosis confirmed and the remaining 15 were empirically treated for a presumptive diagnosis. All individuals were followed for at least 60 days or until death. None of the 22 individuals developed PCP during the follow-up period. We estimate that this approach saved $27,474, avoided exposure of health care workers to Mycobacterium tuberculosis, and was educational for the referring physicians.