Low DLCO in Idiopathic Pulmonary Arterial Hypertension—Clinical Correlates and Prognostic Significance

Introduction: Decreased diffusing capacity of the lung for carbon monoxide (DLCO) is observed in some idiopathic pulmonary arterial hypertension (IPAH) patients, but its clinical significance is uncertain. We aimed to assess clinical correlates and prognostic significance of low DLCO in IPAH patients. Material and methods: In the group of 65 IPAH patients the cut off value for low DLCO was set up based on histogram as <55% of predicted value. Demographic data, exercise capacity, lung function tests, hemodynamic parameters and survival of the patients were compared depending on DLCO value. Results: Low DLCO was found in 18% of the patients, and it was associated with male sex, older age, worse functional status and exercise capacity, and higher prevalence of coronary artery disease. Low DLCO carried a 4-fold increase of death risk in 5-year perspective. Conclusions: Low DLCO was a marker of worse functional capacity and increased risk of death in studied IPAH patients.

Pulmonary pathology in patients with ulcerative colitis treated with mesalazine--a challenging and complex diagnostic problem. Case series and literature review

Pulmonary involvement in the course of inflammatory bowel disease has been a subject of interest to clinicians for long time, but despite this, its epidemiology and potential pathomechanisms remain obscured. Equally unclear is the role of medications used for bowel disease treatment in lung disease development. We present three patients with ulcerative colitis, all treated with mesalazine, in whom unexplained lung disease developed. Due to different clinical and radiological presentation, different conditions were initially placed on the top of the differential list in each of them. The outcome was favourable in all patients despite differences in management. We compared our patients with similar cases from literature. We show the level of difficulty and complexity in the issue of lung disease in patients with inflammatory bowel disease.

[Community acquired pneumonia - treatment options according to the international recommendations]

Pneumonia remains one of the main reasons of heath care system utilization. Quick diagnosis and prompt treatment initiation determine favorable outcome. Empirical antibiotic treatment allows to achieve treatment success in most patients. Treatment recommendations are based on big epidemiological trials. Nevertheless, it is sometimes necessary to know the definite etiologic factor of pneumonia. In these cases microbiological diagnostics is useful, i.e. sputum microscopy and culture, blood culture, bronchial lavage culture, bacterial antigen tests in urine, molecular tests. Serological tests do not help much in everyday clinical practice. The most common microorganisms causing community acquired pneumonia (CAP) are: Streptococcus pneumoniae, atypical bacteria (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila), Haemophilus influenzae, influenza virus. Staphylococcus aureus and Pseudomonas aeruginosa rarely are etiologic factors of CAP. First line antibiotics in pneumonia treatment are beta - lactams. In case of allergy or intolerance of beta - lactams, new fluorochinolones should be used. Macrolides are useful if the atypical etiology is suspected. Duration of treatment in most cases should not exceed 7 days, sometimes it may be even shorter.

Tuberculosis in homeless persons in Poland

The fall in rates of tuberculosis (TB) in many countries has been accompanied by the concentration of cases in the social risk groups including homeless persons.

AIM

Comparison of TB features in homeless persons and in non-homeless patients.

METHODS

TB cases reported to National TB Register in Poland in whom information about the social status was available (the data about the social status were collected obligatorily in the years 2004-2013 only) were analysed. The results of DSTs were obtained from laboratory records and were available for the cases reported since 2010. Treatment outcome after 12 months was analysed for the cases registered between 2004-2012. The significance (Si) of the differences in proportions was assessed with chi-square test. P<0.05 was regarded as statistically significant. Test F was used to evaluate the significance of differences of the means of age. The multivariate logistic regression models were applied to find out the independently operating determinants of not achieving of success of treatment.

RESULTS

2,349 homeless persons (HP) and 72,989 other patients (OP) with TB were included. In the group of HP, there was a greater proportion of males in comparison with OP (90.5% vs. 66.3%) (Si). The mean age of HP was 49.8 years (SD±10.9); of OP-52.9 years (SD±17.5) (Si). 16.6% of HP and 10.4% of OP were previously treated for TB (Si). The previous treatment was adequate in 62.2% of HP and in 85.8% of OP (Si). Pulmonary TB was in 98.0%, extrapulmonary TB in 2.0% of HP and, respectively, in 92.5% and 7.5% of OP (Si). Pulmonary TB was confirmed by culture in 76.3% of HP and in 64.5% of OP (Si). Sputum smears were positive in 70.7% of HP and in 62.5% of OP (Si). Caseous pneumonia occurred in 2.7% of homeless subjects and in 1.1% of OP (Si); infiltrative TB in 95.5% of HP and in 97.5% of OP (Si). Resistance to isoniazid was observed in 2.9% of HP and in 3.1% of OP; to rifampicin in 0.0% of HP and in 0.2% of OP; to isoniazid and rifampicin in 0.4% of HP and in 0.8% of OP. These differences were not Si. Treatment success rate among HP was 44.1%; default rate 24.8%; 4.0% of HP died from tuberculosis; 3.2% died from other causes; 5.2% were transferred and their outcomes were unknown; 0.4% were still on treatment; 0.4% had treatment failure; in 17.9% of HP results of treatment were not available. Among other TB patients the rate of success was 66.8%; of default--8.8%; 1.9% died from TB; 3.1% died from other causes; 2.6% were transferred; 0.5% were still treated; 0.2% had treatment failure; in 16.1% the results were not reported. Differences between both groups were Si, except for the category "died from other causes", "still on treatment" and "treatment failure".

CONCLUSIONS

In the group of homeless persons with tuberculosis phenomena which indicate a delay in diagnosis of disease and in some cases the possibility of a recent infection and also unfavorable treatment outcomes occur in a greater proportion than among other patients. Targeted screening for TB and directly observed treatment could likely improve the epidemiological situation of tuberculosis in the population of homeless.

Ostre śródmiąższowe Zapalenie Płuc u Chorego na Reumatoidalne Zapalenie Stawów Leczonego Leflunomidem

Leflunomid (LEF), pochodna izoksazolowa, należy do leków przeciwreumatycznych modyfikujących przebieg choroby (DMARDs), które stanowią podstawę leczenia reumatoidalnego zapalenia stawów (RZS). J est lekiem skutecznym i bezpiecznym u chorych na RZS w sytuacji, gdy standardowe leczenie nie spowodowało znaczącej poprawy lub było źle tolerowane, ale może wywoływać śródmiąższową chorobę płuc. Czynnikami ryzyka wystąpienia śródmiąższowej choroby płuc wywołanej LEF są: stwierdzane wcześniej zmiany śródmiąższowe w płucach, palenie papierosów, niska masa ciała i stosowanie dawki nasycającej. W pracy przedstawiono przypadek 59-letniego chorego na RZS, z nikotynizmem w wywiadzie, leczonego w przeszłości metotreksatem (MTX), u którego wystąpiły duszność, kaszel i gorączka po około 2 miesiącach leczenia LEF. Z astosowano metyloprednizolon w pulsach, następnie prednizon i cyklofosfamid. Po okresie przejściowej poprawy doszło do narastania niewydolności oddechowej i zgonu.

Zmiany śródmiąższowe w Płucach u Chorych na Zapalenie Wielomięśniowe i Skórno-Mięśniowe—Prezentacja Trzech Przypadków

Zapalenia wielomięśniowe (PM) i skórno-mięśniowe (DM) należą do układowych chorób tkanki łącznej charakteryzujących się osłabieniem siły mięśni proksymalnych oraz zajęciem różnych narządów wewnętrznych, w tym często płuc. Do zmian płucnych w przebiegu PM/DM należą: zapalenia naczyń z rozlanym krwawieniem pęcherzykowym oraz choroba śródmiąższowa płuc (ILD), która jest najczęstszą płucną manifestacją PM/DM, a jej występowanie znacznie pogarsza przebieg choroby i rokowanie. Patogeneza zmian śródmiąższowych w płucach nie jest dokładnie znana, wiadomo że dużą rolę w jej etiologii odgrywają mechanizmy autoimmunologiczne. Nie zaobserwowano związku między ciężkością choroby układowej tkanki łącznej a wystąpieniem zmian w płucach. Choroba śródmiąższowa płuc może się ujawnić w każdym momencie trwania choroby zapalnej mięśni, czasami wyprzedza jej objawy i rozpoznanie. Częstość wykrywania zmian śródmiąższowych w płucach zwiększa się wraz z czułością zastosowanych metod diagnostycznych — “złotym standardem” jest tomografia komputerowa płuc o wysokiej rozdzielczości. Lekiem pierwszego wyboru w leczeniu choroby śródmiąższowej płuc w przebiegu PM/DM są glikokortykosteroidy. W niniejszym artykule przedstawiono przypadki 3 mężczyzn w średnim wieku, chorych na PM/DM, z towarzyszącymi zmianami śródmiąższowymi w płucach, każdy o innym przebiegu klinicznym i obrazie zmian radiologicznych. U wszystkich chorych wykonano badania obrazowe (radiogram i tomografię komputerową klatki piersiowej) oraz czynnościowe układu oddechowego. U wszystkich pacjentów charakter zmian płucnych potwierdzono badaniem histologicznym. U dwóch chorych rozpoznano niespecyficzne śródmiąższowe zapalenie płuc, u jednego — organizujące się zapalenie płuc z odczynem sarkoidalnym w okolicznych węzłach chłonnych. Z powodu zaburzeń w badaniach czynnościowych płuc, wszyscy pacjenci leczeni byli prednizonem, u dwóch chorych dodatkowo wdrożono leczenie azatiopryną lub cyclofosfamidem z dobrym efektem.

Zaskakujące Rozpoznanie u Mężczyzny z Guzem ściany Klatki Piersiowej—Nie Wszyscy Chorują na Raka PłUca

Rak płuca jest najczęstszym nowotworem złośliwym u mężczyzn, który w stadium zaawansowanym może dawać przerzuty do tkanki podskórnej lub naciekać ścianę klatki piersiowej. Przedstawiono przypadek chorego, który został skierowany do kliniki z podejrzeniem raka płuca naciekającego boczną ścianę klatki piersiowej. Dodatkowo u pacjenta stwierdzono liczne przerzuty do kości płaskich (żeber, kręgów, czaszki). Szeroko zakrojona diagnostyka przyniosła zaskakujące rozpoznanie raka przewodowego piersi, nowotworu, który u mężczyzn występuje niezwykle rzadko i najczęściej prezentuje się jako dobrze odgraniczony guzek w okolicy brodawki sutkowej. Prezentowany przypadek pokazuje, jak istotną rolę odgrywa wnikliwa ocena mikroskopowa zmiany zlokalizowanej w ścianie klatki piersiowej.

Role of serum vascular endothelial growth factor D in discrimination of patients with polycystic lung diseases

INTRODUCTION

Polycystic lung diseases (PLDs) include numerous rare diseases including lymphangioleiomyomatosis (LAM), pulmonary Langerhans cell histiocytosis (PLCH), and lymphocytic interstitial pneumonia. In these cases, diagnosis is based on a histological examination of open lung biopsy samples; however, it is not always possible to perform this procedure. Serum markers characteristic for a given entity are still being sought.

OBJECTIVES

The aim of the study was to determine the usefulness of assessing serum vascular endothelial growth factor D (VEGF‑D) concentration in the differential diagnosis of LAM and other PLDs (OPLDs).

PATIENTS AND METHODS

Serum VEGF‑D levels were measured by an enzyme‑linked immunosorbent assay in 75 patients with PLDs including 29 women with LAM and 46 patients with OPLDs (28 women and 18 men).

RESULTS

Serum VEGF‑D levels were significantly higher in patients with LAM (median, 1557 pg/ml; interquartile range [IQR], 636-2593 pg/ml) than in all patients with OPLDs (median, 292 pg/ml; IQR, 233-405 pg/ml, P <0.0001) or than in women with OPLDs (median, 344 pg/ml; IQR, 243-452 pg/ml, P <0.0001). The serum VEGF‑D level exceeding 468 pg/ml identified LAM patients with the specificity of 90% and sensitivity of 87% (area under the curve of 0.908; 95% confidence interval, 0.820-0.996). In none of the patients with OPLDs serum VEGF‑D concentrations exceeded 800 pg/ml.

CONCLUSIONS

An increased serum VEGF‑D level is a highly specific biomarker useful in a differential diagnosis of LAM and OPLDs.

Interstitial Pneumonia Connected with Rituximab Therapy—Case Report

Rituximab (RTX) is a monoclonal antibody against the CD20 antigen found on the surface of B cells. RTX causes cell lysis and is therefore used to treat lymphomas, leukaemias, transplant rejection and certain autoimmune disorders. Pulmonary adverse events associated with RTX have been reported in literature. We describe a patient with follicular lymphoma treated with R-CHOP scheme (rituximab, cyclophosphamide, doxorubicin, vincri- stine, prednisone) who had pulmonary symptoms during chemotherapy which were diagnosed as rituximab-induced interstitial pneumonia. Symptoms and radiological changes resolved with prednisone therapy.

Postępy w Pneumonologii w 2012 Roku

Rak płuca jest najczęstszym nowotworem zło- śliwym w większości uprzemysłowionych krajów świata [...]

[Interstitial pneumonia connected with rituximab therapy--case report]

Rituximab (RTX) is a monoclonal antibody against the CD20 antigen found on the surface of B cells. RTX causes cell lysis and is therefore used to treat lymphomas, leukaemias, transplant rejection and certain autoimmune disorders. Pulmonary adverse events associated with RTX have been reported in literature. We describe a patient with follicular lymphoma treated with R-CHOP scheme (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) who had pulmonary symptoms during chemotherapy which were diagnosed as rituximab-induced interstitial pneumonia. Symptoms and radiological changes resolved with prednisone therapy.

[Interstitial lung disease in patients with polymyositis and dermatomyositis--report of three cases]

Polymyositis (PM) and dermatomyositis (DM) are connective tissue diseases (CTD) characterized by proximal muscle weakness along with changes in various internal organs, with the lungs most frequently involved. Presentation of the disease in the lungs comprises diffuse alveolar haemorrhage due to vasculitis and interstitial lung disease (ILD), which is the most frequent manifestation of CTD in the lungs and worsens the outcome and prognosis. The mechanisms involved in the ILD are not fully known, but the role of autoimmune response is unquestioned. No relationship between the severity of CTD and the changes in the lungs was observed. ILD may present at any time in the course of CTD, sometimes before the signs and symptoms of myositis occur. The more accurate imaging methods are, the more frequently changes in the lungs are detected. High resolution computed tomography (HRCT) is a gold standard in ILD imaging. Treatment of PM/DM-related ILD relays on systemic glucocorticosteroids as the first choice drugs. We present three cases of PM/DM-related ILD in middle-aged men, with a different clinical and radiological presentation. In all cases, apart from imaging (plain X-ray and HRCT of the chest) and pulmonary function tests, histological evaluation of lung changes was performed. In two cases non-specific interstitial pneumonitis (NSIP) was diagnosed, and in the third--organizing pneumonia along with sarcoid changes in the lymph nodes. Because of decreased pulmonary function all patients were treated with systemic corticosteroids and two of them additionally with azathioprine or cyclophosphamide, and the outcome was good in all of them.

[A surprising diagnosis in a male with a tumour of the chest wall--not always lung cancer]

Lung cancer is the most frequent malignant tumour in men. Advanced disease may produce metastatic tumours in subcutaneous tissue and also infiltrate the chest wall. We present a history of a man referred to our department suspected of lung tumour infiltrating the chest wall. Additionally, bone metastatic disease was diagnosed (ribs, vertebral bodies and skull). Thanks to a wide diagnostic approach, ductal cancer of the breast was finally diagnosed, a neoplasm that is extremely rare in male patients, usually presenting as a definite nodule in the nipple area of the breast. This case shows the importance of careful histological evaluation of the chest wall tumour.

Postępy w Pneumonologii w 2012 Roku

Przewlekła obturacyjna choroba płuc (POChP) jest trzecią lub czwartą przyczyną zgonu na świecie po nowotworach, chorobach serca i naczyń oraz (w niektórych krajach) śmierci z przyczyn gwałtownych. Wszelkie aspekty choroby od jej patogenezy do paliatywnej opieki pod koniec życia są przedmiotem badań bardzo licznych zespołów naukowców [...]

Hiperkalcemia i Uszkodzenie Nerek w Przebiegu Sarkoidozy—Opis Przypadku

Zaburzenia gospodarki wapniowej w przebiegu sarkoidozy pod postacią hiperkalcemii lub/i hiperkalciurii mogą u niektórych chorych powodować uszkodzenie nerek. Zagrażająca życiu hiperkalcemia nie jest zjawiskiem częstym u chorych na sarkoidozę. Niewydolność nerek spowodowana ciężką hiperkalcemią zdarza się rzadko. W pracy zaprezentowano przypadek 53-letniego mężczyzny przyjętego do Kliniki Chorób Płuc z powodu objawów zespołu hiperkalcemicznego i niewydolności nerek, u którego rozpoznano sarkoidozę. Zastosowanie glikosteroidów systemowych spowodowało normalizację kalcemii oraz poprawę parametrów nerkowych. W artykule omówiono przyczyny hiperkalcemii u chorych na sarkoidozę, mechanizmy uszkodzenia nerek oraz postępowanie u tych chorych.

Impact of Social Risk Factors on Treatment Outcome in Patients with Culture Positive Pulmonary Tuberculosis (CPPTB)

Introduction: The aim of the study was to evaluate the impact of social risk factors on treatment outcome among culture- positive patients treated for active pulmonary tuberculosis in three separate districts—Warsaw, Gdansk and Siedlce—in years 1995 and 2000. Materials and methods: We retrospectively reviewed medical records of patients who were notified in 1995 and 2000 and were treated in hospitals and dispensaries. Alcohol abuse and homelessness were recognized as risk factors associated with tuberculosis and nonadherence to treatment. Treatment outcome was evaluated using treatment indicators defined by the World Health Organisation: cured, treatment completed, treatment defaulted, treatment failure and “other” results of treatment. Results: Seven hundred and eight patients with culture positive pulmonary tuberculosis were included (373 in 1995 and 335 in 2000). There were 85 patients with risk factors in 1995 and 101 patients in 2000. 80 of participants in 1995 and 69 in 2000 abused alcohol, 5 and 32 were classified as homeless, respectively. Among alcohol abusers treatment success rates according to the WHO definition (either bacteriologic cured or treatment completed) were 45.1% in 1995 and 53.6% in 2000. Among patients not abusing alcohol treatment success rates were 63.8% and 54.1%, respectively. The differences were statistically significant (p = 0.005 in 1995 and p = 0.0186 in 2000). In 1995 forty percent of homeless patients had succeeded treatment, while the rate of treatment success among non-homeless was 60%. Because of small number included in homeless group the difference was not statistically significant (p = 0.6532). In 2000 treatment success rate among homeless participants was 25% and among non-homeless—57.1%, which was highly statistically significant (p = 0.001). Conclusions: Alcohol abuse and homelessness were associated with bad treatment outcome among patients with pulmonary tuberculosis. Interventions to improve treatment adherence in patients considered to be at risk for default are necessary.

Interstitial Lung Disease in Patients with Primary Biliary Cirrhosis

Primary biliary cirrhosis (PBC) is a chronic autoimmune disorder of unknown etiology. The disease affects middle-aged women and is characterized by the destruction of the intralobular bile ducts that causes consequent cholestasis. AMA is a hallmark of PBC, composed mostly of IgG and IgM class. The M2 antibody is the most specific one, with sensitivity range of 54–98% depending on type of test used. PBC is often accompanied by other autoimmune diseases, such as Sjøgrens syndrome, thyroiditis, rheumatoid arthritis, dermatomyositis, polymyositis. Interstitial lung disease (ILD) has been reported in patients with primary biliary cirrhosis but its frequency and nature are poorly understood. We report pulmonary involvement in the course of PBC in 4 middle-aged women. Histopatological examination of lung specimens was available in three patients: two presented with sarcoid—like granulomas, one with lymphocytic interstitial pneumonia (LIP). In one patient the diagnosis of pulmonary fibrosis was based on clinical and radiological features. Because of abnormal pulmonary function tests (PFT) results all the patients were treated with prednisone, one, additionally with azathioprine. The treatment was successful in all of the patients.

[Interstitial lung disease in patients with primary biliary cirrhosis]

Primary biliary cirrhosis (PBC) is a chronic autoimmune disorder of unknown etiology. The disease affects middle-aged women and is characterized by the destruction of the intralobular bile ducts that causes consequent cholestasis. AMA is a hallmark of PBC, composed mostly of IgG and IgM class. The M2 antibody is the most specific one, with sensitivity range of 54-98% depending on type of test used. PBC is often accompanied by other autoimmune diseases, such as Sjögrens syndrome, thyroiditis, rheumatoid arthritis, dermatomyositis, polymyositis. Interstitial lung disease (ILD) has been reported in patients with primary biliary cirrhosis but its frequency and nature are poorly understood. We report pulmonary involvement in the course of PBC in 4 middle-aged women. Histopatological examination of lung specimens was available in three patients: two presented with sarcoid - like granulomas, one with lymphocytic interstitial pneumonia (LIP). In one patient the diagnosis of pulmonary fibrosis was based on clinical and radiological features. Because of abnormal pulmonary function tests (PFT) results all the patients were treated with prednisone, one, additionally with azathioprine. The treatment was successful in all of the patients.

[Impact of social risk factors on treatment outcome in patients with culture positive pulmonary tuberculosis (CPPTB)]

INTRODUCTION

The aim of the study was to evaluate the impact of social risk factors on treatment outcome among culturepositive patients treated for active pulmonary tuberculosis in three separate districts - Warsaw, Gdansk and Siedlce - in years 1995 and 2000.

MATERIAL AND METHODS

We retrospectively reviewed medical records of patients who were notified in 1995 and 2000 and were treated in hospitals and dispensaries. Alcohol abuse and homelessness were recognized as risk factors associated with tuberculosis and nonadherence to treatment. Treatment outcome was evaluated using treatment indicators defined by the World Health Organisation: cured, treatment completed, treatment defaulted, treatment failure and other results of treatment.

RESULTS

Seven hundred and eight patients with culture positive pulmonary tuberculosis were included (373 in 1995 and 335 in 2000). There were 85 patients with risk factors in 1995 and 101 patients in 2000. 80 of participants in 1995 and 69 in 2000 abused alcohol, 5 and 32 were classified as homeless, respectively. Among alcohol abusers treatment success rates according to the WHO definition (either bacteriologic cured or treatment completed) were 45.1% in 1995 and 53.6% in 2000. Among patients not abusing alcohol treatment success rates were 63.8% and 54.1%, respectively. The differences were statistically significant (p = 0.005 in 1995 and p = 0.0186 in 2000). In 1995 forty percent of homeless patients had succeeded treatment, while the rate of treatment success among non-homeless was 60%. Because of small number included in homeless group the difference was not statistically significant (p = 0.6532). In 2000 treatment success rate among homeless participants was 25% and among non-homeless - 57.1%, which was highly statistically significant (p = 0.001).

CONCLUSION

Alcohol abuse and homelessness were associated with bad treatment outcome among patients with pulmonary tuberculosis. Interventions to improve treatment adherence in patients considered to be at risk for default are necessary.

Hypercalcemia and renal failure in the course of sarcoidosis--case report

Disturbances of calcium metabolism such as hypercalcemia or/and hypercalciuria in the course of sarcoidosis can be a cause of renal failure in some patients. Life threatening hypercalcemia in sarcoidosis patients is not very frequent. Severe hypercalcemia leading to renal insufficiency is a very rare condition. We present a case of 53-year old man who was admitted to Department of Lung Diseases because of hypercalcemic syndrome and renal failure, and in whom diagnosis of sarcoidosis was made. He was successfully treated with systemic corticosteroids. In this article we present physiological mechanism of hypercalcemia in sarcoidosis patients, mechanism of renal damage and management of these difficult problems.