Community-acquired pneumonia in patients requiring hospitalization

OBJECTIVE

This study aimed to investigate the microbial aetiology of community-acquired pneumonia (CAP) in patients requiring hospitalization.

METHODOLOGY

A prospective study of consecutive non-immunocompromised patients aged 12 years and above admitted with CAP from August 1997 to May 1999 was undertaken.

RESULTS

Of 127 patients hospitalized for CAP, an aetiological diagnosis was achieved in 53 cases (41.7%). Klebsiella pneumoniae was the most frequently isolated pathogen and caused 10.2% of all the cases, followed by Streptococcus pneumoniae (5.5%), Haemophilus influenzae (5.5%), Mycoplasma pneumoniae (3.9%) and Pseudomonas aeruginosa (3.9%). Gram-negative bacilli were significantly more frequently identified in patients aged 60 years or older and in patients with comorbid illnesses. Twelve of 13 patients who died from CAP had other comorbid illnesses compared to 63 of 114 patients who survived (P = 0.014). Three of eight bacteraemic patients died compared with 10 of 119 non-bacteraemic patients (P = 0.035).

CONCLUSIONS

The microbiology of CAP in patients requiring hospitalization in Malaysia appears to be different from that in Western countries. Gram-negative bacilli were more frequently isolated in older patients and in those with comorbidity. Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic.

Relationship between symptoms and objective measures of airway obstruction in asthmatic patients

The objective of this study was to determine the relationship between asthma symptoms and the degree of airway obstruction as measured by the forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) in a group of 64 asthmatic patients with clinically stable disease attending a university-based urban asthma clinic. Asthma symptoms did not correlate with the degree of airway obstruction as measured by prebronchodilator PEFR (total asthma symptom score vs PEFR: r = -0.214, p = 0.104, n = 59) and only correlated poorly with prebronchodilator FEV1 (total asthma symptom score vs FEV1: r = -0.256, p = 0.041, n = 64). These results lend support to the recommendation that airway obstruction should be measured objectively when assessing patients with chronic persistent asthma.

Awake respiratory function in patients with the obstructive sleep apnoea syndrome

INTRODUCTION

The flow-volume curves of patients with obstructive sleep apnoea (OSA) obtained during the awake state are frequently abnormal.

OBJECTIVE

To determine 1) the relationship between the awake respiratory function and the severity of sleep-disordered breathing in a group of Malaysian patients with the OSA syndrome and 2) the frequency of flow-volume curve abnormality in these patients.

MATERIALS AND METHODS

A retrospective analysis of the data from respiratory function tests during wakefulness and nocturnal polysomnography was performed on 48 patients with OSA. The severity of OSA was defined by the apnoea-hypopnoea index (AHI) and the lowest oxygen saturation during sleep (SpO2nadir).

RESULTS

AHI had a significant relationship with alveolar-arterial oxygen gradient (r = 0.34, p = 0.046) and SpO2nadir (r = -0.49, p < 0.001) but not with any anthropometric parameter or the other awake respiratory function variables measured. SpO2nadir had a significant relationship with body mass index (r = -0.54, p < 0.001), neck circumference (r = -0.39, p = 0.013), awake room air PaO2 (r = 0.61, p < 0.001), alveolar-arterial oxygen gradient (r = -0.41, p = 0.015) and baseline supine SpO2 (r = 0.53, p < 0.001). There was no correlation between SpO2nadir and any spirometric or static lung volume parameters. The maximum inspiratory and maximum expiratory flow-volume curves of 26 patients (54%) showed a ratio of forced expiratory flow to forced inspiratory flow at mid-vital capacity (FEF50/FIF50) greater than one. In addition, flow oscillations (the "sawtooth" sign) were noted in the inspiratory and/or expiratory flow-volume curves of 21 patients (44%), 9 of whom did not have an FEF50/FIF50 > 1. Altogether, the maximum flow-volume curves during wakefulness of 35 (73%) of the 48 patients showed variable upper airway obstruction and/or flow oscillations. However, the presence of these two upper airway abnormalities, either occurring alone or together did not have an effect on the severity of OSA as measured by the AHI or SpO2nadir.

CONCLUSIONS

Abnormalities of the flow-volume loop consistent with inspiratory flow limitation and/or upper airway instability during wakefulness are common in patients with the OSA syndrome. The degree of oxygen desaturation during sleep in these patients is related to their awake oxygenation status.

Lung cancer in patients younger than 40 years in a multiracial Asian country

OBJECTIVE

This study aimed to determine whether the clinicopathological features of lung cancer in patients younger than 40 years differ from that of older patients in an Asian country.

METHODOLOGY

We undertook a review of the clinicopathological data of all patients with confirmed primary lung cancer at the Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia, from October 1991 to September 1999.

RESULTS

Of the 580 patients with lung cancer, 36 (6.2%; 23 males, 13 females) were 21-39 years old at diagnosis. The percentage of people who had never smoked was higher among the younger patients (58.3% vs 19.1%, P < 0.001). Although adenocarcinoma was the most common cell type in both groups, its incidence was higher in the younger patients (24/36 (66.7%) vs 228/544 (41.9%), P = 0.007). The mean World Health Organization performance status at presentation was worse in the younger patients (2.4 vs 2, P = 0.007). In the case of non-small cell lung cancer, all the younger patients presented with either stage IIIb or metastatic disease compared to 77.2% of the older patients (P < 0.001).

CONCLUSIONS

Younger lung cancer patients were more likely than older patients to have never smoked, to have adenocarcinoma, and to present with poorer performance status and with more advanced-stage non-small cell lung cancer.

Intravenous followed by oral ofloxacin in the treatment of community acquired lower respiratory tract infections in adults requiring hospitalisation

Forty patients were treated with ofloxacin for community acquired lower respiratory tract infections. Eighteen pathogens were isolated in sputum; Streptococcus pneumoniae (4) and Haemophilus influenzae (4) were the most common, followed by Klebsiella pneumoniae (3), Klebsiella spp. (2), Staphylococcus anreus (2), Pseudomonas spp. (2), and Pseudomonas aeruginosa (1). Ofloxacin 200 mg every 12 hours was administered for an average of 3.7 days intravenously followed by 5.4 days orally. Response to therapy was judged to be cure in 38 (95%; 95% C.I., 85%-95%) patients, failure in one (2.5%) and "indeterminate" in one (2.5%).

Localised nodular pulmonary amyloidosis in a patient with sicca syndrome

A 52 year old Chinese woman with a 25 year history of sicca syndrome (primary Sjogrens syndrome) was investigated for 3 episodes of haemoptysis. Clinical examination was unremarkable except for the presence of dry eyes and xerostomia. Computed tomography of the chest revealed a lobulated mass in the posterior basal segment of the left lower lobe. Histopathological examination of this resected nodule confirmed the diagnosis of nodular amyloidosis. The normal radiolabelled serum amyloid P component scintigraphy and the absence of monoclonal plasma cell dyscrasia in the bone marrow strongly support the diagnosis of localised nodular pulmonary AL amyloidosis in this patient. Nodular pulmonary amyloidosis can be associated with sicca syndrome and often simulates bronchogenic carcinoma, bronchiectasis or pulmonary tuberculosis.

Acceptance of the Accuhaler, a multi-dose powder inhaler, among asthmatic patients: a comparison with the pressurized metered-dose inhaler

This study aimed to evaluate dry powder inhaler naive asthmatic patients' perception and preference of the Accuhaler, a multidose dry powder inhaler and the pressurized metered dose inhaler (pMDI). After the first instruction, 66.7% of 48 patients enrolled in the study could demonstrate the correct use of the Accuhaler. When the patients were asked to compare the pMDI and the Accuhaler after using the Accuhaler to administer salmeterol for 4 weeks, the Accuhaler scored significantly better than the pMDI for the following features: knowing how many doses are left, presence of an attached cover, taste, instruction for use, attractiveness, ease of use, ease of holding, shape, and comfortable mouthpiece. The pMDI scored better to the Accuhaler in terms of size. More patients preferred the Accuhaler than the pMDI; the presence of a dose counter and perceived ease of use were the main reasons cited for their preference for the Accuhaler.

Pulmonary siderosis in an arc welder

An asymptomatic subject with radiographic changes due to welders' siderosis is described. This condition has not been well recognized and described in our community. Siderosis of the lung is generally considered to be a benign condition not associated with respiratory symptoms. However, recent reports have associated welding with various disorders of pulmonary function as well as lung cancer. There is a need for future epidemiological studies to better define the risk of long term welding.

Differences in pleural fluid characteristics, white cell count and biochemistry of tuberculous and malignant pleural effusions

Tuberculosis and malignancy are two common causes of exudative pleural effusions. In this retrospective study of 52 patients with tuberculous pleural effusions and 32 patients with malignant effusions, the median age of patients with malignant effusions (68.5 years) was older than that of patients with tuberculous effusions (34.5 years) (p < 0.001). Both types of effusion occurred more frequently on the right side and there was no difference between them in terms of right-sided dominance. A higher percentage of patients with malignant pleural effusions (44%) presented with large effusions than patients with tuberculous effusions (12%) (x2 = 11.33, p = 0.001). A higher proportion of patients with tuberculous effusion had lymphocyte predominant effusions and tuberculous effusions had higher lymphocyte percentage, lower red cell count, and higher protein content. However, there was considerable overlap of these characteristics of both types of effusions.

Causes of pleural exudates in a region with a high incidence of tuberculosis

OBJECTIVE

To define the causes of exudative pleural effusions in our region.

METHODOLOGY

A retrospective study was performed on consecutive patients with exudative pleural effusion seen in our hospital during a 4-year period.

RESULTS

Of 186 patients with a mean age (+/- SD) of 51.2 (+/- 19.2) years with exudative pleural effusions, 131 (70.4%) were males and 55 (29.6%) were females. The most frequent cause of exudative pleural effusions was tuberculosis (44.1%), followed by malignancy (29.6%). The majority (94.5%) of malignant pleural effusions were due to lung cancer. Apart from a patient with bilateral pleural effusions due to cryptococcosis, patients with tuberculous pleural effusion (mean age (+/- SD), 39.7 (+/- 17.5)) were significantly younger than the rest (P < 0.05). Tuberculous effusions were most frequent in the first five decades (60/82, 73.2%) and were the most common type of pleural effusion, accounting for 60 (69.8%) of 86 cases, in this age range. Malignant effusions were more frequent among the older age groups, 74.5% (41/55) of patients with malignant effusions being older than 50 years. Most types of pleural effusions showed a preference for the right side. Of the 44 cases of large effusions, 28 (63.6%) were caused by malignancy.

CONCLUSIONS

In our region with a high incidence of tuberculosis, the most frequent cause of pleural exudates is tuberculosis followed by malignancy, particularly lung cancer.

Tuberculous pleurisy as a manifestation of primary and reactivation disease in a region with a high prevalence of tuberculosis

SETTING

A teaching hospital in Malaysia.

OBJECTIVE

To review the demographic and clinical features of patients with pleural tuberculosis (TB).

DESIGN

Retrospective chart and chest radiograph review.

RESULTS

The chest radiograph of 54 (61.4%) of a total of 88 patients with pleural TB did not show any lung infiltrate (considered a manifestation of primary TB), while that of 32 (36.3%) patients showed infiltrates in the upper lobes or superior segment of the lower lobes, or the presence of parenchymal scarring in the upper lobes (typical of reactivation TB). Additionally, the chest radiograph of two (2.3%) patients showed miliary mottling (also classified as having primary TB). The mean age of patients with primary versus reactivation tuberculous pleurisy was 36.3 (+/-14.8) years and 44.6 (+/-19.3) years, respectively (P = 0.041). The median duration of symptoms before presentation was 14 days and 60 days in patients with primary and reactivation disease, respectively (P = 0.001).

CONCLUSION

In Malaysia, where the prevalence of TB is high, tuberculous pleurisy is more commonly a manifestation of primary rather than reactivation disease. Patients with primary TB pleurisy are younger and have a shorter duration of symptoms than those with reactivation TB pleurisy.

Giant cell arteritis presenting as chronic cough and prolonged fever

A 62-year-old man presented with a 3-month history of chronic non-productive cough and unexplained fever. Further questioning revealed that he had headaches and myalgia. Bilateral thickened temporal arteries were noted on physical examination. The erythrocyte sedimentation rate was 96 mm in 1 h. A biopsy specimen of the left temporal artery showed inflammatory changes consistent with the diagnosis of giant cell arteritis. Commencement of prednisolone resulted in rapid and dramatic resolution of his symptoms. Physicians should be aware of respiratory symptoms in patients with giant cell arteritis in order to avoid delay in diagnosis and therapy of this condition.

Massive pleural effusions in cryptococcal meningitis

Cryptococcal infection uncommonly presents with pulmonary manifestations and even more rarely so as massive bilateral effusions. Pleural involvement is usually associated with underlying pulmonary parenchymal lesions and is unusual while on antifungal therapy. We report a patient with cryptococcal meningitis who, while on intravenous 5-flucytosine and amphotericin B, developed life-threatening bilateral massive pleural effusions with evidence of spontaneous resolution, consistent with prior hypothesis of antigenic stimulation as the cause of pleural involvement.

Attitudes and knowledge of newly diagnosed tuberculosis patients regarding the disease, and factors affecting treatment compliance

SETTING

An urban university teaching hospital.

OBJECTIVES

To determine patients' attitudes to tuberculosis and their knowledge of the disease, and factors associated with treatment compliance.

DESIGN

All adult patients commenced on treatment for tuberculosis from September 1994 to February 1996 were interviewed on initiation of treatment. To assess patient compliance with treatment, hospital clinical records were reviewed retrospectively.

RESULTS

A total of 135 patients with a mean age (+/-SD) of 41.9 (+/-17.4) years (range 15-84 years) were interviewed. The patients had limited understanding and knowledge about tuberculosis. There was a negative correlation between patient age and tuberculosis knowledge score (r = -0.18, P = 0.038). Patients with tertiary education had better knowledge than the others. Of 118 patients who were followed-up in our chest clinic, 80 (67.8%) completed the prescribed treatment. Compliance with treatment and follow-up was not affected by age, sex, ethnic group, educational level, occupation, extent of knowledge, tuberculosis symptoms, hospitalisation for tuberculosis or duration of the prescribed treatment regimen. There was a trend toward poorer compliance among patients who equated disappearance of tuberculosis symptoms with cure of the disease.

CONCLUSIONS

Malaysian patients with newly diagnosed tuberculosis attending a university teaching hospital had misconceptions and limited knowledge about the disease and its treatment. Educational background was an important determinant of a patient's level of knowledge about tuberculosis. Compliance was not affected by patient characteristics. Adequate counselling and education of patients and close relatives on tuberculosis and the necessity for prolonged treatment may help to improve treatment compliance.

Hypercalcaemia in patients with newly diagnosed tuberculosis in Malaysia

SETTING

University Hospital, Kuala Lumpur, Malaysia.

OBJECTIVE

To determine the incidence of hypercalcaemia in Malaysian patients with newly diagnosed tuberculosis (TB) before the commencement of antituberculosis treatment.

DESIGN

A prospective study of consecutive patients with newly diagnosed bacteriologically and/or histologically proven tuberculosis in our institution from September 1994 to March 1996.

RESULTS

Of a total of 120 patients (67 males, 53 females), 68 had pulmonary TB, nine had pulmonary and pleural TB, 18 had pleural TB without chest radiograph evidence of lung involvement, 16 had various other forms of extra-pulmonary TB and nine had disseminated TB. The mean age of the patients was 44.3 (+/-18.0) years. The mean albumin-adjusted serum calcium concentration was 2.53 (+/-0.22) mmol/l. Hypercalcaemia was present in 27.5% of the patients, but only 12% of these patients showed symptoms of hypercalcaemia. The type of TB and, in the case of pulmonary TB, the radiographic extent of lung involvement, had no effect on the serum calcium level.

CONCLUSION

Hypercalcaemia is not uncommon among Malaysian patients with newly diagnosed TB, but it is rarely symptomatic.

Awareness of the ozone layer and acceptance of a new CFC-free metered dose inhaler among asthmatic patients

SETTING

University of Malaya Medical Centre, Kuala Lumpur, Malaysia.

OBJECTIVE

To assess the awareness of the ozone layer and the acceptance of the new non-chlorofluorocarbon (CFC) propellant hydrofluoroalkane 134a salbutamol pressurised metered dose inhaler (MDI) Airomir among asthmatic patients.

DESIGN

A total of 113 consecutive asthmatic patients aged 12 years and above from the out- and in-patient services of the hospital were interviewed using a questionnaire.

RESULTS

Sixty-five per cent of the patients were aware of the existence of the ozone layer, 23% that CFCs play a role in ozone depletion, and only 10% that current MDIs contained CFCs. All the patients felt that pressurised MDIs should be made CFC-free after they had considered the role of CFCs in the destruction of the ozone layer. Eighty-one per cent of 94 patients who preferred the Airomir inhaler over a multi-dose dry powder inhaler for administering bronchodilator medications were willing to switch to the new inhaler once it became available on the market.

CONCLUSION

Awareness of the damaging effect of CFCs on the ozone layer among asthmatic patients would encourage them to change to an ozone-friendly, CFC-free pressurised MDI.

Detection of Mycobacterium tuberculosis in bronchoalveolar lavage from patients with sputum smear-negative pulmonary tuberculosis using a polymerase chain reaction assay

The objective of this study was to evaluate the utility of a polymerase chain reaction (PCR) assay in detecting Mycobacterium tuberculosis in bronchoalveolar lavage (BAL) specimens of patients suspected of having active pulmonary tuberculosis (TB) but who were sputum smear-negative. Patients undergoing investigation for suspected pulmonary TB at the University Hospital, Kuala Lumpur, and who were sputum smear-negative underwent fibreoptic bronchoscopy and BAL. One portion of each lavage specimen was submitted for smear examination for acid-fast bacilli and mycobacterial culture and the other portion assayed by PCR for the presence of a 562-base pair DNA segment belonging to the insertion sequence IS986, unique to the M. tuberculosis complex. As controls, lavage specimens from patients with other lung lesions were also similarly tested. The PCR assay gave a positivity rate of 80.9% (55 of 68) compared with 8.8% of smear examination and 7.4% of culture for detecting M. tuberculosis in BAL specimens. The assay was positive in two of 45 BAL specimens from 35 control subjects. The PCR assay was more sensitive than smear and culture in detecting M. tuberculosis in BAL specimens of patients with sputum smear-negative pulmonary TB.