Flexible bronchoscopy as a valuable tool in the evaluation of persistent wheezing in children

BACKGROUND

Persistent wheezing is a common problem in early childhood and leads to a diagnostic dilemma, excessive investigations, drug administration and additional cost.

OBJECTIVE

To determine the efficacy and the safety of FOB in children with persistent wheezing despite bronchodilator and inhaled steroid therapy.

METHODS

Patients with persistent wheezing that lasted at least 6 weeks and did not respond to bronchodilator and inhaled steroid therapy and to whom flexible bronchoscopy was performed were included to the study.

RESULTS

Between 1997 and 2009; 113 patients were enrolled to the study. Sixty-three percent of the children were male. Median age was 14 months at presentation and median duration of symptoms was 5 months. Bronchoscopy revealed pathological findings in 48% of the patients. Thirty-eight patients had malacia disorders, 14 had foreign body aspiration and two had external compression of airways which were later diagnosed as vascular ring. Major and minor complications were not seen in 92% of the patients while transient hypoxia was seen in 6%, stridor in 1% and tachycardia in 1% of the patients.

CONCLUSION

Flexible bronchoscopy provided rapid and definitive diagnosis for our patients with persistent wheezing without any major complications. This study is one of the largest studies concerning persistent wheezing. Early bronchoscopic evaluation can reduce cost by providing rapid and accurate diagnosis and preventing unnecessary investigations and drug administration. Flexible bronchoscopy is a safe procedure and should be considered in the evaluation of children with persistent wheezing.

Ectopic primary B cell lymphoma of the thyroid presenting as an anterior mediastinal mass. A case report

Ectopic thyroid tumours arising in the mediastinum without connection to the cervical thyroid gland are very rare. Follicular adenoma, papillary carcinoma and follicular carcinoma in the mediastinum has been reported, but primary ectopic thyroid B cell lymphoma has not been reported previously. We report mediastinal primary ectopic thyroid large B cell lymphoma in an 80-year-old man. Differential diagnosis from primary mediastinal large B cell lymphoma and clinicopathologic features are discussed.

Clinicopathologic features and prognostic significance of lung tumours with mixed histologic patterns

Lung tumours with a mixed histologic pattern are rare. We evaluated the clinicopathologic features and prognosis of lung tumours with mixed histology and compared them with the tumours which have single histology. The study group consisted of 39 patients with a mixed histologic pattern and a control group consisted of 41 patients with a single histology on the consecutive surgical specimens. In the study group three types of tumour were identified: adenosquamous carcinoma, combined neuro-endocrine tumours and biphasic tumours. The combined neuro-endocrine tumours were further divided into small cell carcinoma (SCLC)+non-neuro-endocrine carcinoma (NNEC), SCLC+large cell neuro-endocrine carcinoma (LCNEC) and LCNEC +NNEC. Clinicopathologic characteristics, stage and survival rates were evaluated retrospectively and compared with the tumours showing single histology. There was no significant difference in mean age, sex, smoking history, asbestos exposure and tumour size between the study and control groups (p > 0.05). Among adenosquamous carcinomas advanced stage (IIIa or IIIb) (p = 0.004), vascular invasion (p = 0.04) and parietal pleural involvement (p = 0.012) was significantly more evident than in the single histology group. Among combined neuro-endocrine tumours, advanced stages (p = 0.002) and vascular invasion (p = 0.003) were more evident than in the single histology group. Two- year survival rates were 60% for the single histology group, 39% for the adenosquamous group and 25% for the combined neuro-endocrine tumour group (p = 0.0002). Tumours with mixed histology are rarely seen in the lung. Among these tumours adenosquamous carcinoma and combined neuro-endocrine tumours present more aggressive clinico-pathologic behaviour than tumors with a single histology.

Giant resectable mediastinal carcinoid tumour--thymic origin or not?

Carcinoid tumours of the mediastinum are rare. We report a case of a giant mediastinal tumour in a 76-year-old man who had long-standing respiratory symptoms. The pathologic diagnosis was typical carcinoid tumour. Because of the enormous size of the tumour it was difficult to determine the site of origin. The patient has no sign of recurrence or metastasis 6 months after the operation.

Effect of occupation and smoking on respiratory symptoms in working children

OBJECTIVES

To compare the respiratory symptoms and the lung function of children who work in different occupational groups.

METHODS

The study was performed among children attending vocational training centers. The participants were evaluated in six different occupation groups. Chronic cough, wheezing and shortness of breath were evaluated by questionnaire. The association of independent variables with the respiratory symptoms was investigated through both univariate and multivariate methods.

RESULTS

Among 642 children, 534 were males; the mean age was 17.7 +/- 1.0 years. Using an internal reference group, the odds ratios of chronic cough were significantly higher in the lathe (OR: 2.0, 95%CI: 1.07-3.74), coiffure (OR: 1.94. 95%CI: 1.01-3.70), and electricity-construction (OR: 2.63, 95%CI: 1.06-6.54) groups after adjustment for smoking, age, gender, and work characteristics. There were no significant differences in spirometric values between occupational groups in either smoking or non-smoking males. In non-smoking females, median values of FEV(1) (P: 0.046), PEF (P: 0.005) and FEF(25-75%) (P: 0.019) were lower in the textile compared to the coiffure group. There was no significant association between the total working time and spirometric values. There was no statistically significant relationship between the work-related factors and the smoking status.

CONCLUSIONS

The prevalence of chronic cough was higher in the lathe, coiffure, and electricity-construction groups and pulmonary function tests were lower in the non-smoking textile female group. Working children should be screened for respiratory symptoms and disease.

Cavernous hemangioma of the rib: a rare tumour

Hemangioma is exceedingly rare in the ribs. A case of rib hemangioma in a 54-year-old woman is presented. Chest roentgenogram and computed tomography revealed a mass in the left lateral costaphrenic sinus with bone destruction. She underwent resection of the 7th and 8th rib. The pathologic diagnosis was cavernous hemangioma. Hemangiomas of the rib are rare tumours but should be kept in mind in the differential diagnosis of rib tumours.

An unusual case of chylothorax complicating childhood tuberculosis

Endobronchial tuberculosis (EBTB) and chylothorax are rare clinical disorders. The concurrence of these two disorders as manifestations of childhood pulmonary tuberculosis has not been reported. We report a 4-month-old boy presenting with chylothorax as the initial presentation of tuberculosis that has been successfully treated with octreotide, antituberculosis drugs and steroid therapy.

Factors that correlate with sleep oxygenation in children with cystic fibrosis

OBJECTIVE

Cystic fibrosis (CF) patients may develop hypoxemia during sleep. Limited information is available on nocturnal oxygen saturation in CF children with less severe lung disease. The aim of this study was to investigate the degree of nocturnal oxygen desaturation and factors that correlate with nocturnal oxygenation in CF children with normal pulmonary function tests (PFTs) or mild to moderate lung disease.

METHOD

Awake resting and post-exercise SpO2 were measured by pulse oximetry. Each patient had overnight oximetry monitorization at home. Six minutes walk test (6MWT), Shwachman-Kulczycki (S-K), Brasfield and computed tomography (CT) scores, blood gas analysis and nutritional status of patients were evaluated.

RESULTS

Twenty-four patients with a median age of 9.5 years were included. Nocturnal mean SpO2 did not differ according to the severity of lung disease based on PFT. However, lowest SpO2 obtained was lower in children with both mild and moderate lung disease compared to normals (87.4% vs. 91.7%, respectively, p = 0.009). 95.8% of CF children with normal PFT or mild to moderate lung disease had desaturation events during sleep. Nocturnal mean SpO2 correlated with S-K (Spearman's rho = 0.64, p < 0.0001), Brasfield (Spearman's rho = 0.31, p = 0.007) and CT scores (Spearman's rho = -0.67, p < 0.0001) as well as PaO2 (Spearman's rho = 0.28, p = 0.021), SaO2 (Spearman's rho = 0.28, p = 0.023), z-score of weight (Spearman's rho = 0.23, p = 0.20) and height (Spearman's rho = 0.20, p = 0.30), there was no correlation with 6MWT.

CONCLUSIONS

In CF children with normal PFT or mild-to-moderate lung disease, nocturnal oxygenation may correlate with S-K, Brasfield and CT scores as well as PaO2, SaO2, z-score of weight and height.

Invasive respiratory Aspergillosis is a treatable disease with early diagnosis and aggressive therapy

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Background: Invasive respiratory aspergillosis (IRA) is a fulminant infection in immunocompromised hosts. This study aims to evaluate the effectiveness of early screening of patients and the outcome of them during febrile neutropenia (FNP) episodes. Methods: Between 2003 and 2006, 212 FNP episodes were evaluated and the cases who are still febrile at their fifth FNP treatment were screened with computerized tomography (CT) of sinus, thorax and and other relevant sites. Results: Fungal infection rate was 15%, while IRA was detected in 22 patients. Thirteen of these patients were male. Fifteen patients had hematological malignancies, 6 had solid tumors and one patient had combined immunodeficiency and hemophagocytic lymphohistiocytosis. All patients had absolute neutrophil count of zero for 5 to 30 days (median 11.5 days). IRA cases were classified as definite (n:3), probable (n:7) and possible (n:12) according to European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group. Amphotericin B was administered emprically to all cases and continued as a single agent in 7 patients. Variable modifications with caspofungin, voriconazole or itraconazole were done in 11, 9 and 2 patients, respectively. At present, 7 patients are disease-free after completion of treatment, 6 patients are still on antifungal therapy, 4 patients were lost despite antifungal therapy and 5 patients died of underlying disease while in remission or with stabile disease for a median of 339 days (range: 13–1027 days). Therefore, our remission rate and overall survival rates are 83% and 60% respectively. Conclusions: Contrary to the previous reports, we suggest that IRA is a treatable disease with early diagnosis and aggressive antifungal therapy and it is worthwhile to screen FNP patients who are resistant to wide-spectrum antibiotics with CT for early intervention.

No significant financial relationships to disclose.

Late diagnosis of foreign body aspiration in children with chronic respiratory symptoms

BACKGROUND

Children with undiagnosed and retained foreign bodies (FBs) may present with persistent respiratory symptoms. Delayed diagnosis is an important problem in developing countries and several factors affect the delay.

OBJECTIVES

To investigate, the incidence of clinically unsuspected foreign body aspiration (FBA) in our flexible bronchoscopy procedures, the causes resulting in late diagnosis of FBA, and the incidence of the complications of FBA according to elapsed time between aspiration and diagnosis.

METHODS

We reviewed the records of all the patients who underwent flexible bronchoscopy between 1997 and 2004 in our clinic. Patients with FBA were identified and their medical records were reviewed.

RESULTS

During the study period, 654 children underwent flexible bronchoscopy; 32 cases (4.8%) of FBA were identified. Median age of patients was 29.5 months at presentation with a median symptomatic period of 3 months. None of the patients had a history of FBA. The most common misdiagnosis was bronchitis. Flexible bronchoscopy was performed to these patients within 1 week following presentation. In 87% of the patients (n=28), FBs were in organic nature. Patients were followed up for 21.0 months after removal of the FBs. Fifty-three percent (n=17) of the patients had a complete remission after bronchoscopic removal of the FBs. However, nine (28.8%) patients had chronic respiratory problems and six patients (18.8%) developed bronchiectasis.

CONCLUSIONS

Atypical or prolonged respiratory symptoms should alert the physician and clinical and radiological findings should be carefully evaluated for a possible FBA. Delay in diagnosis and treatment of FBA should be avoided to prevent complications.

Mucoid impaction: an unusual form of allergic bronchopulmonary aspergillosis in a patient with cystic fibrosis

We reported a child with cystic fibrosis (CF) who developed mucoid impaction related to allergic bronchopulmonary aspergillosis (ABPA). This is the first reported case of mucoid impaction related to ABPA in CF described to date in the literature. The case was successfully treated by corticosteroids and itraconazole therapy, but relapsed 6 months later. During exacerbation therapy, cataract formation complicated the corticosteroid treatment. We want to emphasize that 6-months therapy may be inadequate for the treatment of ABPA, and it is important to monitor for possible complications of corticosteroids therapy.

ADMA, proteinuria, and insulin resistance in non-diabetic stage I chronic kidney disease

The rationale of this study is based on the fact that, both proteinuria and elevated asymmetric dimethyl arginine (ADMA) levels have been linked to the progression of vascular disease. Currently, there is not enough knowledge about any association between the levels of proteinuria and ADMA levels. Seventy-eight non-diabetic patients (42 men, 36 women, mean age of 26.1+/-5.2 years) with proteinuria having normal glomerular filtration rate were enrolled along with 38 healthy subjects (20 men, 18 women, mean age of 26.9+/-5.9 years). Proteinuria was below 3.5 g/day in 40 patients and above 3.5 g/day in 38 patients. Both groups had similar age, gender, and body mass index distributions. Serum ADMA, symmetric dimethyl arginine (SDMA), immunoreactive insulin, and high sensitivity C reactive protein (hsCRP) levels were measured. Insulin resistance was determined by homeostasis model assessment (HOMA). Serum ADMA, SDMA, insulin, hsCRP levels, and HOMA indexes were significantly higher in patients than in healthy control subjects. The above parameters were higher in the nephrotic range proteinuria group when compared to patients having protein levels below 3.5 g/day. There were significant correlations between the levels of proteinuria and the above parameters. According to the regression analysis, levels of proteinuria and hsCRP were significant determinants of serum ADMA levels. Our results indicate that, independent of other risk factors, ADMA is directly associated with proteinuria. Further studies are recommended to find out whether elevated ADMA levels are implicated in the high cardiovascular risk of proteinuric nephropathies.

The diagnostic values of serum, pleural fluid and urine neopterin measurements in tuberculous pleurisy

SETTING

Pulmonary department of a medical academy in Ankara, Turkey.

OBJECTIVE

Neopterin is a marker of cell-mediated immunity, and it has been demonstrated that neopterin levels of various body fluids could be elevated in tuberculosis. We aimed to investigate diagnostic values of serum, pleural fluid and urine neopterin measurements in tuberculous pleurisy (TP).

DESIGN

Serum, pleural fluid and urine neopterin levels were measured in 34 patients with TP and in 29 patients with pleural effusion of non-tuberculous origin as controls.

RESULTS

Neopterin levels in serum, pleural fluid and urine (38.28 +/- 14.18 nmol/l, 38.97 +/- 14.18 nmol/l and 759.15 +/- 622.74 micromol/mol, respectively) were significantly higher in patients with TP than those with non-tuberculous pleural effusion (22.57 +/- 6.02 nmol/l, 21.88 +/- 6.90 nmol/l and 343.10 +/- 233.65 micromol/mol, respectively). Pleural fluid neopterin > or =30 mol/l gave the best diagnostic yield, with 85% sensitivity, 93% specificity, 94% positive predictive value, 84% negative predictive value and 89% diagnostic accuracy, although it is not superior to pleural fluid adenosine deaminase determination.

CONCLUSION

We have suggested that elevated serum, pleural fluid and urinary neopterin levels in TP with respect to pleural effusions of non-tuberculous origin may reflect activation of cell-mediated immunity and that pleural fluid neopterin measurement may be of value in the differential diagnosis of TP.

Low parathormone levels and hypercalcaemia in patients with pulmonary tuberculosis: relation to radiological extent of disease and tuberculin skin test

AIM

We hypothesised that serum calcium (Ca) and parathormone (PTH) levels correlate with radiological extent and that there may also be a relationship between the tuberculin skin test (TST), serum Ca and PTH levels in patients with pulmonary tuberculosis (PTB).

MATERIALS AND METHODS

Forty-four patients with active PTB and 33 healthy subjects were enrolled in the study. Serum Ca, PTH, magnesium and phosphate levels were measured in patients and controls and compared. Correlations were also investigated for TST values, erythrocyte sedimentation rate (ESR), the degree of radiological involvement, serum PTH and corrected Ca levels.

RESULTS

There was a significant difference between the two groups for mean serum PTH and corrected Ca levels. Significant correlations were detected between radiological extent of disease and serum PTH levels, between TST values and serum PTH levels and between ESR and serum PTH levels. We suggest that abnormal Ca metabolism in PTB patients is related to the radiological extent of disease. Factors determining the radiological extent of disease, predominantly the patient's immune status, may have an important role in modulating Ca metabolism in PTB patients.

The effect of individualized diet challenges consisting of allergenic foods on TNF- and IL-1 levels in patients with rheumatoid arthritis

OBJECTIVE

To investigate the effect of individualized diet challenges consisting of allergenic foods, defined by the skin prick test (SPT), on tumour necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) levels in patients with rheumatoid arthritis (RA).

METHODS

Twenty patients with a positive SPT response for food extracts and 20 with a negative SPT response were enrolled. None of the patients had active disease. All patients were fasted for the most common allergenic foods for 12 days and then allocated to two groups according to SPT results. Food challenges were performed with allergenic foods in the prick-positive group (PPG) and with corn and rice in the prick-negative group (PNG) for a period of 12 days. Then, allergenic foods were excluded from the PPG patients' diet and corn and rice were removed from the PNG patients' diet. Clinical examinations were performed after fasting (baseline), at the end of the challenge phase and at the end of the re-elimination phase. Stiffness, pain, tender and swollen joint counts, health assessment questionnaire (HAQ), Ritchie's articular index, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum TNF-alpha and IL-1beta levels were measured.

RESULTS

TNF-alpha (P < 0.01), IL-1beta (P < 0.05), ESR (P < 0.05) and CRP (P = 0.001) levels and all of the clinical variables, except HAQ, were increased with food challenges in the PPG. These increases were also recorded after the re-elimination phase. In the PNG, no significant change was seen in any of the variables, except pain (P < 0.05). During the study, important differences were observed for most of the variables between the two groups. Thirteen (72%) patients in the PPG and three (18%) in the PNG experienced disease exacerbation with challenges. This aggravation continued after elimination.

CONCLUSIONS

Our results suggest that individualized dietary revisions may regulate TNF-alpha and IL-1beta levels in selected patients with RA.

Arachnoid cyst rupture with subdural hygroma: Case report and literature review

Arachnoid cyst rupture causing subdural hygroma is rare. Twenty-one cases have been previously reported in the literature. We report a case of a 9-year-old boy presenting signs and symptoms of increased intracranial pressure due to the rupture of a type III arachnoid cyst causing subdural hygroma. The clinical and radiological findings as well as the management of the patient are discussed in relation to the pertinent literature.

Multifocal intradiploic cavernous hemangioma of the skull associated with nasal osteoma

OBJECTIVE

To present a 42-year-old female patient with multifocal cavernous hemangioma of the skull associated with nasal osteoma.

DESIGN

A case report. INTERVENTION METHODS: X-rays, computerized tomography, magnetic resonance imaging, and histopathology were used to achieve the diagnosis of this rare entity. The multiple cavernous hemangiomas were resected en-bloc and a curettage biopsy was obtained from the nasal osteoma.

RESULTS

The patient healed well after the operation. No recurrences of the cavernous hemangiomas were observed after one-year follow-up.

CONCLUSION

Multifocal cavernous hemangiomas are rare benign lesions of the calvarium, arising from the intrinsic vasculature of the bone. Although they are benign, radiological findings are not always characteristic and their multiple presentation may easily make surgeons consider the other malignancies of the skull in the differential diagnosis. Histopathologic confirmation of the tumor is the definitive method for diagnosis. The treatment of choice is early en bloc resection of the tumour where it is possible.

Ogilvie's syndrome after cervical discectomy

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is characterized by abdominal distention and massive colonic dilatation without any mechanical cause of obstruction. Lumbar spine operations can be an etiologic factor. We had a case with Ogilvie's syndrome after cervical discectomy. We also treated successfully this case by parasympathetic agent, neostigmine.

Diabetes insipidus secondary to penetrating spinal cord trauma: case report and literature review

STUDY DESIGN

Case report.

OBJECTIVE

To present a case of central diabetes insipidus (CDI) that developed after a gunshot injury to the thorax and thoracic spinal cord and to discuss the disease process in light of the relevant literature.

SUMMARY OF BACKGROUND DATA

Antidiuretic hormone (ADH) abnormalities may develop after spinal trauma and/or surgery. Although there are published reports of inappropriate ADH syndrome arising in this clinical picture, CDI is rare.

METHODS

A 33-year-old woman with hemopneumothorax and a gunshot wound to her thoracic spine was treated with chest tube drainage. No surgery was performed for the spinal injury. The patient was paraplegic on admission and rapidly developed excessive urine output. Testing revealed that her serum ADH level was low, consistent with CDI. Desmopressin acetate nasal spray was the prescribed treatment.

RESULTS

The patient responded well to the desmopressin acetate spray.

CONCLUSIONS

CDI is a complicated hormonal disorder characterized by excessive urine output. It is typically linked to an abnormality in the hypothalamohypophyseal axis that markedly reduces ADH production. The most common inciting causes are craniocerebral trauma, brain tumor and/or surgery, and central nervous system infection. Although uncommon, CDI should be considered when a spinal trauma patient develops excessive urine output.