Updates on respiratory syncytial virus prophylaxis: the past, present and future.

PURPOSE OF REVIEW: Human respiratory syncytial virus (RSV) causes acute respiratory infection in individuals of all age groups. It is the most common pathogen identified in infants and young children with acute lower respiratory infection. Although most infants and young children experience mild, cold-like symptoms, some infants develop severe lower respiratory tract disease such as pneumonia and bronchiolitis that may result in an emergency department visit or hospitalization. RECENT FINDINGS: In the United States, hospitalization rates have risen during the last decades, and while premature infants with chronic lung disease and congenital heart disease are at increased risk for severe presentations, the majority of hospitalizations occur in previously healthy infants. Until recently, RSV prophylaxis was only available for former preterm infants and those with certain underlying medical conditions. SUMMARY: The need for preventive interventions against RSV is crucial. This paper will provide a review of the vaccine development, the spectrum of RSV prophylaxis, current challenges associated with the cost, insurance coverage and equitable distribution of targeted therapies.

Prenatal imaging and postnatal presentation, diagnosis and management of congenital lung malformations.

PURPOSE OF REVIEW: Congenital lung malformations (CLMs) vary in their clinical presentation and severity. Increases in prenatal diagnosis, observed regression of certain lesions, and prognostic uncertainty are driving an evolution in management. RECENT FINDINGS: There has been an increase in the early diagnosis of these malformations, a change that is attributable to the routine use of prenatal ultrasound. Although prenatal diagnosis of CLMs using ultrasound and MRI has increased, chest radiography and computed tomography still play important roles in diagnosis. The management of these lesions depends on the type of malformation and symptoms. The treatment of asymptomatic patients with lung malformations is controversial, because the prognosis of these lesions is largely unknown. Proponents of early intervention argue that the complications of CLM, which may include infection, pneumothorax, bleeding and malignant transformation, justify surgery. Advocates of conservative management note that some CLMs disappear postnatally, and that the long-term complication rate following surgery is unknown. There is a need to obtain natural history data regardless of the therapeutic recommendations. SUMMARY: This article reviews the prenatal radiographic features and postnatal clinical findings of various CLMs and the dilemmas regarding treatment.

Empyema in a woman with cystic fibrosis: a cautionary tale.

Cystic fibrosis (CF) is a disease which predisposes individuals to recurrent infective exacerbations of suppurative lung disease; however, empyema is a rare complication in these patients. Empyemas secondary to Staphylococcus aureus and Burkholderia cepacia have been described in patients with CF. We report the case of pleural empyema with mixed S. aureus and Pseudomonas aeruginosa infection in a 34-year-old woman with CF, which was managed with ultrasound-guided pigtail catheter insertion, fibrinolysis, and antibiotic therapy. Physicians should be aware of this unusual complication in CF patients, especially those receiving an immunosuppressive therapy.

Dyspnea in a patient with Raynaud's phenomenon: the uncovering of interstitial lung disease.

Interstitial lung disease (ILD) can develop in patients with connective tissue disease (CTD) in the context of progressive multiorgan involvement, but ILD can also be the predominant manifestation of active CTD. A high index of suspicion for CTD in patients presenting with pulmonary disease might facilitate timely, accurate diagnosis and management.

Pregnancy outcome in the setting of extremely low first trimester PAPP-A levels.

BACKGROUND: Serum pregnancy-associated plasma protein-A (PAPP-A) is part of first trimester Down syndrome screening. Low levels have been associated with adverse outcome as well as chromosomal abnormality. AIMS: To assess the incidence of adverse outcome when PAPP-A levels are at or below 0.2 multiples of the median (MoM). METHODS: Data on consecutive patients attending a first trimester screening program were collected. Those with PAPP-A levels < or = 0.2 MoM were divided into three groups: < or = 0.1 MoM; 0.11-0.15 MoM; and 0.16-0.2 MoM. RESULTS: Screening 44 535 patients resulted in 197 with PAPP-A levels < or = 0.2 MoM. The incidence of karyotypic abnormality increased with decreasing PAPP-A levels. In the absence of chromosome abnormality, pregnancy outcomes were defined as 'normal' in at least 30% and 'good' in at least 60%, with both percentages increasing as the PAPP-A level rose. The PAPP-A levels were significantly lower in the group with a poor outcome. The incidence of prematurity was similar in the three groups, but higher than the statewide average, while the incidence of extreme prematurity appeared to be related to reducing PAPP-A levels. The incidence of growth restriction in the three groups was similar, but was still double the incidence in the normal population. CONCLUSION: If the PAPP-A level is < or = 0.2 MoM and the karyotype is normal, there is an increased risk of adverse outcome. Even with PAPP-A below 0.1 MoM, a good outcome can be expected in 60% of cases. Careful morphological assessment is suggested and later monitoring of fetal growth and well-being.