High-resolution CT findings of parenchymal fibrosis correlate with prognosis in hypersensitivity pneumonitis.

BACKGROUND: Histopathologic evidence of fibrosis on surgical lung biopsy has been associated with reduced survival in patients with hypersensitivity pneumonitis (HP). Changes of pulmonary fibrosis detected on CT may also correlate with prognosis in patients with HP. METHODS: We identified 69 consecutive patients with HP diagnosed between January 1997 and December 2002 at Mayo Clinic, Rochester, MN. Patients were stratified into fibrotic and nonfibrotic groups based on the CT findings. Fibrosis was defined by the presence of irregular linear opacities, traction bronchiectasis, or honeycombing. MEASUREMENTS AND MAIN RESULTS: Of 69 patients, 26 were classified as fibrotic and 43 as nonfibrotic. Patients in the fibrotic group were older, had longer symptom duration, were more likely to have crackles on auscultation, more likely to be exposed to avian antigen, and had greater restrictive lung impairment (p<0.05 for all comparisons). There were 11 deaths in the fibrotic group and 1 death in the nonfibrotic group (p<0.0001). In the regression analysis, CT evidence of fibrosis, more severe pulmonary function abnormalities, and the presence of crackles on auscultation were predictive of reduced survival (p<0.05 for all). The presence as well as the extent of fibrosis on CT was associated with increased mortality. The age-adjusted hazard ratio for mortality in patients with fibrosis was 4.6 (95% confidence interval, 2.0 to 20.1; p<0.0001). CONCLUSION: CT findings of parenchymal fibrosis are associated with reduced survival in patients with HP and may serve as a useful prognostic indicator.

Role of surgical lung biopsy in separating chronic hypersensitivity pneumonia from usual interstitial pneumonia/idiopathic pulmonary fibrosis: analysis of 31 biopsies from 15 patients.

BACKGROUND: Lung biopsy has been proposed as a criterion for diagnosis of chronic hypersensitivity pneumonia (HP), especially in patients without proven antigen exposure. Histologic findings in some suspected HP patients overlap with usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP). We reviewed our experience to determine the specificity of histologic findings in surgical lung biopsies from patients with clinical diagnoses of HP. METHODS: Surgical lung biopsies from patients with chronic HP, idiopathic pulmonary fibrosis, and idiopathic NSIP were reviewed retrospectively without knowledge of the clinical diagnosis. Each specimen was assigned a histologic diagnosis, and selected histologic findings were tabulated. Clinical data were abstracted from medical records. RESULTS: Fifteen patients with clinical diagnoses of chronic HP underwent biopsy of one to three lobes. Ten showed features diagnostic of HP in all specimens. Two had discordant findings that included HP in one specimen and UIP or nonspecific changes in others. Biopsies from two showed only UIP, and one showed NSIP. Diagnostic features were present in all samples from 9 of the 11 patients with more than one biopsy site (81.8%). Three patients died of disease, including both patients from whom biopsies showed only UIP. CONCLUSIONS: Most patients with a clinical diagnosis of chronic HP have supportive histologic findings in surgical lung biopsies. A subset of HP patients has findings indistinguishable from UIP. Sampling from more than one lobe may be helpful in separating HP from idiopathic pulmonary fibrosis.

Profusion of fibroblast foci in patients with idiopathic pulmonary fibrosis does not predict outcome.

RATIONALE: The prognostic significance of fibroblast foci in surgical lung biopsies from patients with idiopathic pulmonary fibrosis (IPF) is unclear. OBJECTIVES: We assessed the relationship between profusion of fibroblast foci and survival in 43 patients with IPF seen at a tertiary referral medical center from 1996 to 2002. METHODS: Fibroblast foci in surgical lung biopsies were counted using a systematic morphometric point-counting technique. Patients with either clinical or pathologic evidence of accelerated disease were excluded from analysis. The association of fibroblast counts with survival was assessed using proportional hazards regression. RESULTS: The mean age (+/-SD) of the study population was 64+/-9 years; 26 (60%) patients were male. The mean (%+/-SD) profusion of fibroblastic foci was 0.6+/-0.7, expressed as a percentage of total points counted. Fibroblast foci counts did not differ markedly between upper, middle, and lower lobes. Median survival from the time of biopsy was 2.4 years; there were 25 (58%) deaths in the follow up period. There was no significant relationship between profusion of fibroblast foci and survival in the overall group (p=0.250). CONCLUSIONS: Higher prevalence of fibroblast foci assessed using a simple point-counting technique applied to surgical lung biopsies is not associated with survival in patients with clinically stable IPF.

Snoring as a risk factor for sexual dysfunction in community men.

INTRODUCTION: Severe obstructive sleep apnea has been associated with sexual dysfunction; however, it is unclear whether milder forms of sleep disturbances might also be associated with sexual problems. AIM: To evaluate the association between snoring and five measures of sexual dysfunction in a population-based sample of men. METHODS: A stratified random sample of men residing in Olmsted County, Minnesota completed a questionnaire containing questions from the Brief Male Sexual Function Inventory (BMSFI) and a sleep questionnaire. MAIN OUTCOME MEASURES: Levels of sexual drive (libido), erectile function, ejaculatory function, sexual problem assessment, and sexual satisfaction as assessed by the BMSFI. RESULTS: Of 827 men with a regular sexual partner, subjects were divided into categories of heavy (N = 95), moderate (N = 573), and none/mild (N = 159) snoring. Their median age was 64 years (range 51-90). The sexual satisfaction domain score was significantly lower in the heavy snoring group (P value = 0.01). The odds of low sexual satisfaction was 2.3 (95% CI 1.2, 4.1) among the heavy snorers compared with the none/mild snoring group. This association remained statistically significant after adjustment for smoking, medical comorbidities, and mental health status. However, there was no significant difference in ejaculatory function, erectile function, sexual drive, and sexual problem assessment across snoring categories. CONCLUSIONS: These data provide evidence of an association between snoring severity and reduced sexual satisfaction in a population of elderly community males. Snoring was not associated with biologic measures of sexual dysfunction.

Causes and presenting features in 85 consecutive patients with hypersensitivity pneumonitis.

OBJECTIVE: To assess the current spectrum of causes and clinical features associated with hypersensitivity pneumonitis (HP). PATIENTS AND METHODS: We studied consecutive patients with HP diagnosed at the Mayo Clinic in Rochester, Minn, from January 1, 1997, through December 31, 2002. Diagnostic criteria for HP included the following: (1) presence of respiratory symptoms, (2) radiologic evidence of diffuse lung disease, (3) known exposure or a positive serologic test result to an inciting antigen, and (4) no other identifiable cause for the lung disease. If there was no identifiable inciting antigen, 1 of the following 2 criteria was required: (1) lung biopsy specimen that demonstrated features of HP or (2) bronchoalveolar lavage lymphocytosis and high-resolution computed tomographic evidence of ground-glass opacities or centrilobular nodules bilaterally. RESULTS: The mean +/- SD age of the 85 study patients was 53 +/- 14 years; 53 patients (62%) were women. Only 2 patients (2%) were current smokers. Chronic (> or = 4 months) respiratory symptoms were present in 66 patients (78%). Histopathologic confirmation was obtained in 64 patients (75%). The cause was identified in 64 patients (75%), and the most common causes were avian antigens (34%) and Mycobacterium avium complex in hot tub water (21%). Farmer's lung disease accounted for 11% of cases, and an additional 9% were related to household mold exposure. The inciting antigen was not identifiable in 25% of patients. CONCLUSION: Most patients with HP seen at this tertiary care referral center in the Midwest region of the United States had chronic HP, and the most common causes were exposure to birds and exposure to hot tubs.

CT findings of granulomatous pneumonitis secondary to Mycobacterium avium-intracellulare inhalation: "hot tub lung".

OBJECTIVE: The objective of our study was to describe the CT features of "hot tub lung" caused by exposure to Mycobacterium avium complex (MAC) organisms in contaminated water. MATERIALS AND METHODS: Chart review was performed to identify all patients with a histologic diagnosis of granulomatous pneumonitis and positive cultures for MAC between January 1, 1995, and July 1, 2004. Individuals identified who also had a hot tub were included in the study. Twelve patients, seven females and five males with an average age of 50 years (range, 13-66 years), who had a CT scan were identified. The CT images were reviewed by two thoracic radiologists who assessed the images for the presence of any parenchymal abnormalities, including nodules, areas of ground-glass attenuation, reticular opacities, and air trapping, on expiratory images. When nodules, reticular opacities, areas of ground-glass attenuation, or a combination of these findings was present, the reviewers visually determined the extent of involvement of the lungs using a scale of < 10%, 10-40%, or > 40%. They also recorded the distribution of the involvement both cephalocaudal and transaxial. Decisions were reached by consensus of the reviewers. RESULTS: Nodules were present in 10 (83%) of 12 patients. In eight (80%) of 10 patients, the nodules were diffuse with a centrilobular distribution. In the other two, the nodules were randomly distributed with an upper lung predominance. In five patients the nodules showed areas of ground-glass attenuation, whereas in the other five the nodules were solid. Areas of ground-glass attenuation were present in eight (75%) of 12 patients and were bilateral in all cases. The areas of ground-glass attenuation were diffuse in the cephalocaudal plane with a random distribution in the transaxial plane in seven (88%) of eight cases. In the remaining case, the areas of ground-glass attenuation had a lower lung predominance with a random distribution in the transaxial plane. Expiratory images showed evidence of air trapping in all seven cases for which these images were available. In one patient, air trapping was the only abnormality identified. CONCLUSION: The CT findings in patients with hot tub lung include areas of ground-glass attenuation, centrilobular nodules, and air trapping on expiratory images. These findings are similar to previously published findings of subacute hypersensitivity pneumonitis. Therefore, in cases in which CT findings suggest hypersensitivity pneumonitis, hot tub lung should also be a diagnostic consideration.

Complex sleep apnea syndrome: is it a unique clinical syndrome?

STUDY OBJECTIVES: Some patients with apparent obstructive sleep apnea hypopnea syndrome (OSAHS) have elimination of obstructive events but emergence of problematic central apneas or Cheyne-Stokes breathing pattern. Patients with this sleep-disordered breathing problem, which for the sake of study we call the "complex sleep apnea syndrome," are not well characterized. We sought to determine the prevalence of complex sleep apnea syndrome and hypothesized that the clinical characteristics of patients with complex sleep apnea syndrome would more nearly resemble those of patients with central sleep apnea syndrome (CSA) than with those of patients with OSAHS. DESIGN: Retrospective review SETTING: Sleep disorders center. PATIENTS OR PARTICIPANTS: Two hundred twenty-three adults consecutively referred over 1 month plus 20 consecutive patients diagnosed with CSA. INTERVENTIONS: NA. MEASUREMENTS AND RESULTS: Prevalence of complex sleep apnea syndrome, OSAHS, and CSA in the 1-month sample was 15%, 84%, and 0.4%, respectively. Patients with complex sleep apnea syndrome differed in gender from patients with OSAHS (81% vs 60% men, p < .05) but were otherwise similar in sleep and cardiovascular history. Patients with complex sleep apnea syndrome had fewer maintenance-insomnia complaints (32% vs 79%; p < .05) than patients with CSA but were otherwise not significantly different clinically. Diagnostic apnea-hypopnea index for patients with complex sleep apnea syndrome, OSAHS, and CSA was 32.3 +/- 26.8, 20.6 +/- 23.7, and 38.3 +/- 36.2, respectively (p = .005). Continuous positive airway pressure suppressed obstructive breathing, but residual apnea-hypopnea index, mostly from central apneas, remained high in patients with complex sleep apnea syndrome and CSA (21.7 +/- 18.6 in complex sleep apnea syndrome, 32.9 +/- 30.8 in CSA vs 2.14 +/- 3.14 in OSAHS; p < .001). CONCLUSIONS: Patients with complex sleep apnea syndrome are mostly similar to those with OSAHS until one applies continuous positive airway pressure. They are left with very disrupted breathing and sleep on continuous positive airway pressure. Clinical risk factors don't predict the emergence of complex sleep apnea syndrome, and best treatment is not known.

Hot tub lung: presenting features and clinical course of 21 patients.

BACKGROUND: Hot tub lung is an emerging lung disorder associated with exposure to Mycobacterium avium complex organisms contaminating hot tub water. OBJECTIVES: To define the clinical characteristics and outcome of patients with hot tub lung. METHODS: Retrospective review of 21 patients diagnosed with hot tub lung at a tertiary medical center over a 7-year period. RESULTS: The mean (+/-sd) age at presentation was 46 (+/- 15) years; 9 patients were men (43%). All patients described ongoing exposure to hot tubs. The most common referral diagnoses were sarcoidosis, bronchitis, and asthma. Dyspnea and cough were present in all patients, hypoxemia was noted in 10 patients (48%). High-resolution computed tomography of the chest had been performed in 20 patients and demonstrated diffuse centrilobular nodules and/or ground-glass opacities in all patients. M. avium complex was isolated from the hot tub water, respiratory secretions and/or lung tissue in all patients. Bronchoscopic or surgical lung biopsy was obtained in 18 patients and demonstrated bronchiolocentric granulomatous inflammation. With avoidance of exposure, clinical and radiologic improvement was observed in all patients. Additionally, 13 patients (62%) received corticosteroid therapy, 1 (5%) antimycobacterial therapy, 2 (10%) received both, and 5 patients (24%) received no pharmacologic therapy. CONCLUSIONS: Hot tub lung likely represents hypersensitivity pneumonitis due to inhalational exposure to M. avium complex. Antimycobacterial therapy does not appear to be required in the management of this disease. Although corticosteroids may be helpful in the treatment of severely affected patients, others can be managed by avoidance of additional exposure alone.

Cough-induced rib fractures.

OBJECTIVES: To define the demographic, clinical, and radiological features of patients with cough-induced rib fractures and to assess potential risk factors. PATIENTS AND METHODS: For this retrospective, single-center study, we identified all cases of cough-induced rib fractures diagnosed at the Mayo Clinic in Rochester, Minn, over a 9-year period between January 1, 1996, and January 31, 2005. Bone densitometry data from patients' medical records were analyzed, and T scores were used to classify patients into bone density categories. RESULTS: The mean +/- SD age of the 54 study patients at presentation was 55+/-17 years, and 42 patients (78%) were female. Patients presented with chest wall pain after onset of cough. Rib fracture was associated with chronic cough (> or =3 weeks' duration) in 85% of patients. Rib fractures were documented by chest radiography, rib radiography, computed tomography, or bone scan. Chest radiography had been performed in 52 patients and revealed rib fracture in 30 (58%). There were 112 fractured ribs in 54 patients. One half of patients had more than one fractured rib. Right-sided rib fractures alone were present in 17 patients (26 fractured ribs), left-sided in 23 patients (35 fractured ribs), and bilateral in 14 patients (51 fractured ribs). The most commonly fractured rib on both sides was rib 6. The fractures were most common at the lateral aspect of the rib cage. Bone densitometry was done in 26 patients and revealed osteopenia or osteoporosis in 17 (65%). CONCLUSIONS: Cough-induced rib fractures occur primarily in women with chronic cough. Middle ribs along the lateral aspect of the rib cage are affected most commonly. Although reduced bone density is likely a risk factor, cough-induced rib fractures can occur in the presence of normal bone density.

Accuracy of the triglyceride to high-density lipoprotein cholesterol ratio for prediction of the low-density lipoprotein phenotype B.

This study examined the accuracy of a triglyceride/high-density lipoprotein (HDL) cholesterol ratio of 3.8 for the prediction of low-density lipoprotein (LDL) phenotype B. The ratio of 3.8 was based on Adult Treatment Panel recommendations for normal fasting triglycerides (<150 mg/dl) and HDL cholesterol (>40 mg/dl). Fasting blood samples were obtained from 658 patients. LDL phenotype analysis was performed by nuclear magnetic resonance spectroscopy. A triglyceride/HDL cholesterol ratio of 3.8 divided the distribution of LDL phenotypes with 79% (95% confidence interval [CI] 74 to 83) of phenotype B greater than and 81% (95% CI 77 to 85) of phenotype A less than the ratio of 3.8. The ratio was reliable for identifying LDL phenotype B in men and women.

Dual coronary emboli in peripartum cardiomyopathy.

Coronary emboli are rare but devastating events. We present the case of a 31-year-old woman with peripartum cardiomyopathy and mural thrombus. She was admitted with an acute, non-ST elevation myocardial infarction. Two emboli were seen on the coronary angiogram: one in the left anterior descending coronary artery and a second in the left circumflex artery. Each embolus resolved after local infusion of eptifibatide at the time of angiography. There has been 1 report in the English-language medical literature of a similar coronary embolic event in the setting of peripartum cardiomyopathy; however, in that case, only 1 embolus was found. Our case further documents embolic coronary occlusion as a consequence of peripartum cardiomyopathy.