[Hypoxic eosinophilic pneumonia in two patients treated with ACE inhibitors]

Diffuse hypoxic pneumonia was found to be caused by angiotensin converting enzyme (ACE) inhibitors in two patients given enalapril and fosinopril for hypertension. Both patients developed sub-acute respiratory failure and lost weight. Imaging explorations showed multiple areas of alveolar consolidation, moderate pleural effusion and in one case linear opacities. In both cases, peripheral eosinophila was found and the bronchoalveolar lavage fluid contained lymphocytes. Progressive improvement was achieved after withdrawal of the ACE and corticosteroid therapy for three months. Subsequent x-rays and respiratory function tests returned to normal apart from persistently low CO diffusion in one patient. In view of other cases reported in the literature, ACE inhibitors should probably be included in the list of drugs capable of inducing pneumonia, notably eosinophilic pneumonia.

[Systemic scleroderma and cancers: 21 cases and review of the literature]

Twenty one cases of the association systemic scleroderma and cancer are reported. Neoplasic localisations were the following: pulmonary five cases; breast two cases; esophageal cancer one case; stomach one case; colon one case; uterus four cases; ovarian cancer one case; prostatic cancer one case; renal cancer one case; malignant hemopathies six cases. In the literature, more than three hundred cases of such an association have been reported since 1886, essentially lung cancers (more than 100). Recent epidemiological studies allow to conclude to a higher frequency of lung and breast cancers. We suggest that systemic scleroderma patients should be examined attentively and carefully for these risks.

Fatal ball-valve airway obstruction by an extensive blood clot during mechanical ventilation

A ball-valve airway obstruction by a blood clot cast of almost the whole bronchial tree occurred in a small-cell lung cancer patient, who had been on mechanical ventilation for 9 days. Chest radiographs revealed overinflated lungs. Attempts to remove the cast via fibreoptic bronchoscopy were unsuccessful and the patient died. A postmortem extraction of the clot was performed with a rigid tube. This case is rare because of absence of severe haemoptysis and lung volume reduction.

A 1-year comparison of turbuhaler vs pressurized metered-dose inhaler in asthmatic patients

An open, randomized, parallel-group study was conducted to investigate whether asthmatic patients, considered adequately treated with a corticosteroid and/or short-acting beta 2-agonist via pressurized metered-dose inhaler (pMDI), could be transferred to a corresponding nominal dose of budesonide and/or terbutaline via Turbuhaler, an inspiratory flow-driven multidose dry powder inhaler (Astra Draco; Lund, Sweden), without a decrease in the effect of treatment. One thousand four patients (555 women; mean age, 44 years; mean peak expiratory flow [PEF], 102% predicted normal value) were randomized and treated with either pMDI (current therapy) or Turbuhaler for 52 weeks. The variables studied were asthma-related events, morning PEF, and inhaler-induced clinical symptoms. Asthma-related events were defined in two ways: (1) sum of health-care contacts plus doublings or additions of steroids, and (2) number of 2 consecutive days with PEF less than 80% of baseline. Baseline was obtained from a 2-week run-in period while receiving previous therapy. No statistically significant difference was found in asthma-related events according to definition 1. According to definition 2, there was a statistically significant difference between the groups in favor of Turbuhaler (p = 0.008). The mean number of events was 1.7 with Turbuhaler and 2.2 with pMDI. The mean number of weeks per patient with a PEF less than 90% of baseline was 4.5 with Turbuhaler compared with 6.0 with pMDI (p = 0.002). The sum of inhaler-induced symptoms after 1 year of use was statistically significantly lower with Turbuhaler (0.40) than with pMDI (0.75) (p = 0.0001). In conclusion, budesonide and terbutaline in Turbuhaler offered a superior alternative to corticosteroids and bronchodilators delivered by pMDIs in the maintenance treatment of asthma.

Pleuropulmonary changes induced by ergoline drugs

Classic ergolines, such as bromocriptine, methysergide and ergotamine, can induce chronic pleuropneumonitis. We present the cases of eight patients who developed similar changes whilst on other ergolines. In this retrospective case study spanning 1985-1995, clinical data, radiological material, pulmonary function, bronchoalveolar lavage and histopathology were reviewed. Earlier literature on ergoline-induced pleuropulmonary changes was reviewed. Eight middle-aged to elderly individuals of both sexes developed pleuropulmonary changes during long-term therapy with regular dosages of nicergoline (n = 4), dihydroergocristine (n = 3), or dihydroergotamine (n = 1). Bibasilar pleural thickening with or without pleural effusion was present on chest radiographs and computed tomographic (CT) scans in six cases. Increased erythrocyte sedimentation rate was seen in most. Pure interstitial pneumonitis developed in two patients on dihydroergocristine and was reversible in each. Bronchoalveolar lavage was performed in four cases and was abnormal in all, but demonstrated no consistent pattern. Most patients exhibited lung restriction. The outcome was favourable showing slow improvement in all cases following discontinuation of the ergoline. Slight residual pleural thickening was seen in five out of the six cases with pleural involvement. Nicergoline and dihydroergotamine can induce a syndrome of chronic pleural thickening/effusion that slowly improves after drug withdrawal. Dihydroergocristine can induce reversible interstitial pneumonitis.

X chromosome inactivation in 30 girls with Rett syndrome: analysis using the probe

Rett syndrome (RS) is a neurologic disorder with an exclusive incidence in females. A nonrandom X-inactivation could provide insight into the understanding of this disease. We performed molecular analysis based on the differential methylation of the active and inactive X with probe M27 beta, taking into account the parental origin of the two Xs, in 30 control girls, 8 sisters, and 30 RS girls. In 27 control an 31 RS mothers, the inactivation status of the X transmitted to their daughters was also analyzed. The results showed a significantly increased frequency of partial paternal X inactivation (> 65%) in lymphocytes from 16/30 RS compared with 4/30 controls (P = 0.001). These results do not support the hypothesis of a monogenic X-linked mutation but should be taken into account when researching the etiology of this disease.

[Comparison of relative survival vs. classical survival. Apropos of primary bronchial cancer]

The aim of the study is to compare the usefulness of a recent relative survival model versus more classical methods for univariate and multivariate survival analysis, applied to a population of patients with surgically cured non small cell lung cancer, in determination of prognostic factors and appreciation of the exact role of age on survival. We studied 156 patients surgically treated between 1975 and 1988. Both univariate and multivariate analysis were performed, using the actuarial method and the Cox model for crude survival and the additive Hakulinen model (1985) for relative survival (total risk of death equal to natural risk of death in general population plus disease specific risk of death) which is an age-adjusted survival corrected for normal life expectancy. In addition, the loss in life expectancy was also calculated. Our 156 patients (including six females), whose age ranged from 30 to 78 (mean age 59) were almost all current or former smokers (97%) and 63% had clinical trouble. Squamous cell carcinoma was the most common histology (76%) before adenocarcinomas (20%). Pneumonectomy and lobectomy were equally performed. Post surgical TNM staging was stage I = 78 (50.3%), II = 23 (14.8%), IIIa = 44 (28.4%), IIIb = 10 (6.5%). By 31 December 1990, 116 patients had died, 24 were alive and 16 lost to follow-up. In univariate analysis, overall survival is (crude/relative): 1 year (75.8%/77.5%), 2 years (53.8%/56.0%), 5 years (28.7%/32.5%), 10 years (14.4%/18.9%). Univariate prognostic factors are histopathology, surgical procedure and post operative TNM staging. The overall loss in life expectancy is 71.4% (5.5 years of life expectancy vs 19.21). The loss is higher for the younger patients than for the older ones (73% for the 30-49 year old group--59.2% for the more than 70 year old group). In multivariate analysis, prognostic factors are: Cox model: post-surgical TNM staging, histopathology and age (RR = 2.18 [1.13-4.23] for patients over 65); Hakulinen model: TNM staging. In this model, age is no longer a significant prognostic factor. In conclusion, this study confirmed the poor prognosis of NSCLC, even if a curative surgical procedure has been possible, with a 5-year survival of 48% for stage I tumours but only 6% for stage III tumours. The most significant prognostic factor is the post-surgical TNM staging. The relative survival model of Hakulinen dismissed age as a significant prognostic factor.(ABSTRACT TRUNCATED AT 400 WORDS)

Piroxicam induced pulmonary infiltrates and eosinophilia

We describe 2 patients who developed pulmonary infiltrates while being treated with piroxicam. There was no satisfactory explanation other than drug induced lung disease for their illness. They had no exposure to pneumotoxic drugs or aerocontaminants. Microorganisms were not cultured in sputum or bronchoaveolar lavage. There was no underlying illness with possible lung involvement. Pulmonary infiltrates developed during piroxicam therapy, disappeared after drug withdrawal and recurred following rechallenge.

Minocycline pneumonitis and eosinophilia. A report on eight patients

We identified eight patients (six women and two men) who had pulmonary infiltrates during treatment with minocycline hydrochloride between 1989 and 1992 in French referral centers for drug-induced pulmonary diseases. Clinical files, chest roentgenograms, computed tomographic scans, pulmonary function, and bronchoalveolar lavage data were reviewed. Minocycline treatment was given for acne (n = 4), genital infection (n = 3), and Lyme disease (n = 1). The duration of treatment averaged 13 +/- 5 days (mean +/- SE); the total dose, 2060 +/- 540 mg. Patients presented with dyspnea (n = 8), fever (n = 7), dry cough (n = 5), hemoptysis (n = 1), chest pain (n = 2), fatigue (n = 3), and rash (n = 3). Chest roentgenograms showed bilateral infiltrates in all cases. Pulmonary function was measured in five patients; four had airflow obstruction and two had mild restriction. Blood gas tests demonstrated hypoxemia in seven patients (58 +/- 3 mmHg). Seven patients had blood eosinophilia (1.76 +/- 0.2 x 10(9)/L). Bronchoalveolar lavage (performed in seven patients) showed an increased proportion of eosinophils (0.30 +/- 0.07). The Cd4+/CD8+ ratio was determined in four cases and was low in three. Transbronchial lung biopsy, performed in two patients, showed interstitial pneumonitis in both patients, with marked infiltration by eosinophils in one patient. The outcome was favorable in all patients. Because of severe symptoms, steroid therapy was required in three patients. Rechallenge was not attempted. We conclude that minocycline can induce the syndrome of pulmonary infiltrates and eosinophilia, that presenting symptoms may be severe and may culminate in transient respiratory failure, and that the disease has a favorable prognosis.

The lung in inflammatory bowel disease

Respiratory involvement in patients with inflammatory bowel disease (IBD) has been reported mainly since 1976. This form of involvement should clearly be separated from interstitial lung disease due to sulfasalazine or mesalamine, although the distinction may be difficult in some cases. We report the data of an ongoing Registry containing 33 cases (23 cases receiving no drug therapy) with ulcerative colitis or, less often, Crohn's disease, who developed varied bronchopulmonary problems. In several cases, the exact diagnosis and the relation of the bronchopulmonary disease to IBD had not been established for many years, thus delaying effective treatment with steroids. In most cases (28/33), respiratory involvement followed the onset of IBD (8 of these 28 cases were postcolectomy), and in the remainder, respiratory manifestations predated the IBD. Patterns of involvement included: 1) Airway inflammation, in the form of subglottic stenosis, chronic bronchitis, severe chronic bronchial suppuration, bronchiectasis, and chronic bronchiolitis. In cases with large airway involvement, endoscopy showed exuberant inflammatory tissue in the airways and narrowing of tracheal and/or bronchial lumen. Histologically, airways were heavily infiltrated by a dense aggregate of inflammatory cells, and there were mucosal ulcerations. 2) Varied patterns of interstitial lung disease, mainly bronchiolitis obliterans with organizing pneumonia, and pulmonary infiltrates and eosinophilia. (3) Miscellaneous other forms of involvement including striking neutrophilic necrotic parenchymal nodules (corresponding histologically to sterile aggregates of neutrophils), and serositis. Steroids were very effective in the majority of cases. Inhaled steroids were of durable benefit in patients with chronic bronchitis, but less often so in those with chronic bronchial suppuration, bronchiectasis, or chronic bronchiolitis. Steroids administered orally led to marked improvement in patients with interstitial lung disease and necrotic nodules, but lacked effectiveness in several patients with severe airway inflammation or chronic bronchiolitis. Intravenous steroids were required in the initial management of life-threatening complications such as asphyxiating subglottic stenosis or extensive interstitial lung disease. Bronchial lavages with methylprednisolone were effective in some patients with severe airway inflammation. Patients with IBD can develop varied inflammatory complications in the lung, and a sizable fraction of these complications is steroid-sensitive.

The lung in inflammatory bowel disease

Respiratory involvement in patients with inflammatory bowel disease (IBD) has been reported mainly since 1976. This form of involvement should clearly be separated from interstitial lung disease due to sulfasalazine or mesalamine, although the distinction may be difficult in some cases. We report the data of an ongoing Registry containing 33 cases (23 cases receiving no drug therapy) with ulcerative colitis or, less often, Crohn's disease, who developed varied bronchopulmonary problems. In several cases, the exact diagnosis and the relation of the bronchopulmonary disease to IBD had not been established for many years, thus delaying effective treatment with steroids. In most cases (28/33), respiratory involvement followed the onset of IBD (8 of these 28 cases were postcolectomy), and in the remainder, respiratory manifestations predated the IBD. Patterns of involvement included: 1) Airway inflammation, in the form of subglottic stenosis, chronic bronchitis, severe chronic bronchial suppuration, bronchiectasis, and chronic bronchiolitis. In cases with large airway involvement, endoscopy showed exuberant inflammatory tissue in the airways and narrowing of tracheal and/or bronchial lumen. Histologically, airways were heavily infiltrated by a dense aggregate of inflammatory cells, and there were mucosal ulcerations. 2) Varied patterns of interstitial lung disease, mainly bronchiolitis obliterans with organizing pneumonia, and pulmonary infiltrates and eosinophilia. (3) Miscellaneous other forms of involvement including striking neutrophilic necrotic parenchymal nodules (corresponding histologically to sterile aggregates of neutrophils), and serositis. Steroids were very effective in the majority of cases. Inhaled steroids were of durable benefit in patients with chronic bronchitis, but less often so in those with chronic bronchial suppuration, bronchiectasis, or chronic bronchiolitis. Steroids administered orally led to marked improvement in patients with interstitial lung disease and necrotic nodules, but lacked effectiveness in several patients with severe airway inflammation or chronic bronchiolitis. Intravenous steroids were required in the initial management of life-threatening complications such as asphyxiating subglottic stenosis or extensive interstitial lung disease. Bronchial lavages with methylprednisolone were effective in some patients with severe airway inflammation. Patients with IBD can develop varied inflammatory complications in the lung, and a sizable fraction of these complications is steroid-sensitive.