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Bai Y, Li M, Chen S, Zhang Z, Huang X, Xia J, Zhan Q. Incidence, outcomes and risk factors of barotrauma in veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome. Respir Med 2023; 213:107248. [PMID: 37080477 DOI: 10.1016/j.rmed.2023.107248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Although acute respiratory distress syndrome (ARDS) patients are provided a lung rest strategy during extracorporeal membrane oxygenation (ECMO) treatment, the exact conditions of barotrauma is unclear. Therefore, we analyzed the epidemiology and risk factors for barotrauma in ARDS patients using ECMO in a single, large ECMO center in China. METHODS A retrospective analysis was performed on 127 patients with ARDS received veno-venous (VV) ECMO who met the Berlin definition. The epidemiology and risk factors for barotrauma during ECMO were analyzed. RESULTS Among 127 patients with ARDS treated with ECMO, barotrauma occurred in 24 (18.9%) during ECMO and 9 (7.1%) after ECMO decannulation, mainly in the late stage of ARDS (75%) and ≥8 days during ECMO (54.2%). Univariate and multivariate analyses showed that younger ARDS patients (OR = 0.953, 95%CI 0.923-0.983, p = 0.003) and those with pneumocystis jirovecii pneumonia (PJP) (OR = 3.15, 95%CI 1.070-9.271, p = 0.037), elevated body temperature after establishing ECMO (OR = 2.997, 95%CI 1.325-6.779, p = 0.008) and low platelet count after establishing ECMO (OR = 0.985, 95%CI 0.972-0.998, p = 0.02) had an increased risk of barotrauma during ECMO. There was no difference in ventilator parameters between patients with and without barotrauma. Barotrauma during ECMO was mainly related to the etiology of the disease and disease state. CONCLUSION There is a high incidence of barotrauma in ARDS patients during ECMO, even after ECMO decannulation. Young age, PJP, elevated body temperature and low platelet count after establishing ECMO are risk factors of barotrauma, and those patients should be closely monitored by imaging, especially in the late stage of ARDS.
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Affiliation(s)
- Yu Bai
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Shengsong Chen
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Zeyu Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Xu Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Jingen Xia
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
| | - Qingyuan Zhan
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
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2
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Choi JS, Kwak SH, Kim MC, Seol CH, Kim SR, Park BH, Lee EH, Yong SH, Leem AY, Kim SY, Lee SH, Chung K, Kim EY, Jung JY, Kang YA, Park MS, Kim YS, Lee SH. Clinical impact of pneumothorax in patients with Pneumocystis jirovecii pneumonia and respiratory failure in an HIV-negative cohort. BMC Pulm Med 2022; 22:7. [PMID: 34996422 PMCID: PMC8742377 DOI: 10.1186/s12890-021-01812-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PCP) with acute respiratory failure can result in development of pneumothorax during treatment. This study aimed to identify the incidence and related factors of pneumothorax in patients with PCP and acute respiratory failure and to analyze their prognosis. Methods We retrospectively reviewed the occurrence of pneumothorax, including clinical characteristics and results of other examinations, in 119 non-human immunodeficiency virus patients with PCP and respiratory failure requiring mechanical ventilator treatment in a medical intensive care unit (ICU) at a tertiary-care center between July 2016 and April 2019. Results During follow up duration, twenty-two patients (18.5%) developed pneumothorax during ventilator treatment, with 45 (37.8%) eventually requiring a tracheostomy due to weaning failure. Cytomegalovirus co-infection (odds ratio 13.9; p = 0.013) was related with occurrence of pneumothorax in multivariate analysis. And development of pneumothorax was not associated with need for tracheostomy and mortality. Furthermore, analysis of survivor after 28 days in ICU, patients without pneumothorax were significantly more successful in weaning from mechanical ventilator than the patients with pneumothorax (44% vs. 13.3%, p = 0.037). PCP patients without pneumothorax showed successful home discharges compared to those who without pneumothorax (p = 0.010). Conclusions The development of pneumothorax increased in PCP patient with cytomegalovirus co-infection, pneumothorax might have difficulty in and prolonged weaning from mechanical ventilators, which clinicians should be aware of when planning treatment for such patients.
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Affiliation(s)
- Ji Soo Choi
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Se Hyun Kwak
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Min Chul Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Chang Hwan Seol
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Sung Ryeol Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Byung Hoon Park
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Eun Hye Lee
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Seung Hyun Yong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sang Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyungsoo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Eun Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Su Hwan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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3
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Cho YM, Guevara S, Aronsohn J, Mumford JM, Shore-Lesserson L, Miyara SJ, Herrera M, Kirsch C, Metz CN, Zafeiropoulos S, Giannis D, McCann-Molmenti A, Hayashida K, Shinozaki K, Shoaib M, Choudhary RC, Aranalde GI, Becker LB, Molmenti EP, Kruer J, Hatoum A. Bilateral Spontaneous Pneumothorax in a COVID-19 and HIV-Positive Patient: A Case Report. Front Med (Lausanne) 2021; 8:698268. [PMID: 34977051 PMCID: PMC8716636 DOI: 10.3389/fmed.2021.698268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/24/2021] [Indexed: 01/08/2023] Open
Abstract
This case report describes a 60 year-old Black-American male with a past medical history of human immunodeficiency virus (HIV) infection and hyperthyroidism, who suffered a bilateral spontaneous pneumothorax (SP) in the setting of coronavirus disease 2019 (COVID-19) pneumonia. SP is a well-established complication in HIV-positive patients and only recently has been associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. While HIV and COVID-19 infections have been independently linked with increased risk of SP development, it is unknown if both infections interact in a synergistic fashion to exacerbate SP risk. According to the Centers for Disease Control and Prevention (CDC), patients living with HIV have a higher risk of developing severe COVID-19 infection and the mechanism remains to be elucidated. To the best of our knowledge, this is the first report of a HIV-positive patient, who in the setting of SARS-CoV-2 infection, developed bilateral apical spontaneous pneumothorax and was later found to have a left lower lobe tension pneumothorax. This case highlights the importance of considering SP on the differential diagnosis when HIV-positive patients suddenly develop respiratory distress in the setting of SARS-CoV-2 infection.
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Affiliation(s)
- Young Min Cho
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Judith Aronsohn
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - James M. Mumford
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Family Medicine, Glen Cove Hospital, Glen Cove, NY, United States
| | - Linda Shore-Lesserson
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Martin Herrera
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
| | - Claudia Kirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Christine N. Metz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Alexia McCann-Molmenti
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Muhammad Shoaib
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Gabriel I. Aranalde
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Lance B. Becker
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Ernesto P. Molmenti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- *Correspondence: Anthony Hatoum
| | - James Kruer
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
| | - Anthony Hatoum
- Department of Internal Medicine, Northeast Georgia Medical Center, Gainesville, GA, United States
- Ernesto P. Molmenti
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Laaribi I, Mimouni H, Bouayed Z, El Aidouni G, Berrichi S, Bahouh C, Bkiyar H, Housni B. Bilateral spontaneous pneumothorax in critically-ill COVID-19 infants: About two cases. Ann Med Surg (Lond) 2021; 73:103172. [PMID: 34904055 PMCID: PMC8648378 DOI: 10.1016/j.amsu.2021.103172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/05/2021] [Accepted: 12/05/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction COVID-19 is an emerging infection, it is the first large-scale pandemic of the 21st century. Several complications have been described during this infection but spontaneous pneumothorax remains an uncommon complication, even more so in infants. Clinical presentation We report two cases of a 9-month-old and 18-month-old males admitted to our department for the management of an acute respiratory distress due to a COVID-19 infection associated to a spontaneous pneumothorax successfully drained. While one patient had a favorable outcome, the other was readmitted to our department for the management of a septic shock secondary to a urinary tract infection with a deadly outcome. Discussion In this paragraph we describe known causes behind spontaneous pneumothorax, before detailing the different pathogenesis hypotheses linking pneumothorax to COVID-19, all while comparing data to the literature related to the adult population. Conclusion Spontaneous pneumothorax is a serious complication associated with severe COVID-19 that can occur in infants and must be considered in the event of a respiratory aggravation or a persistent hypoxia. The full scope of COVID-19's complications is widening with every related work reported in the literature. Spontaneous pneumothorax in infants infected with COVID-19 is an unprecedented complication. Multiple hypotheses were proposed to explain the occurrence of a spontaneous pneumothorax but none have been conclusively proven
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Affiliation(s)
- Ilyass Laaribi
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Hamza Mimouni
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Zakaria Bouayed
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Ghizlane El Aidouni
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Samia Berrichi
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Choukri Bahouh
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Houssam Bkiyar
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco.,Simulation Center, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Brahim Housni
- Anesthesia, Intensive Care and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco.,Simulation Center, Faculty of Medicine and Pharmacy, Oujda, Morocco
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5
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Kang DH, Kim SY, Kim YE, Koh HJ, Ahn YH. Case of cytomegalovirus pneumonia presented as pneumothorax in 4-month-old healthy infant. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Dong Hee Kang
- Department of Pediatrics, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Su Yeon Kim
- Department of Pediatrics, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Young Eun Kim
- Department of Pediatrics, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Hyo Jung Koh
- Department of Pediatrics, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Yeon Hwa Ahn
- Department of Pediatrics, Bundang Jesaeng Hospital, Seongnam, Korea
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6
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Zantah M, Dominguez Castillo E, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19 disease- incidence and clinical characteristics. Respir Res 2020; 21:236. [PMID: 32938445 PMCID: PMC7492794 DOI: 10.1186/s12931-020-01504-y] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/06/2020] [Indexed: 01/08/2023] Open
Abstract
Background Spontaneous pneumothorax is an uncommon complication of COVID-19 viral pneumonia. The exact incidence and risk factors are still unknown. Herein we review the incidence and outcomes of pneumothorax in over 3000 patients admitted to our institution for suspected COVID-19 pneumonia. Methods We performed a retrospective review of COVID-19 cases admitted to our hospital. Patients who were diagnosed with a spontaneous pneumothorax were identified to calculate the incidence of this event. Their clinical characteristics were thoroughly documented. Data regarding their clinical outcomes were gathered. Each case was presented as a brief synopsis. Results Three thousand three hundred sixty-eight patients were admitted to our institution between March 1st, 2020 and June 8th, 2020 for suspected COVID 19 pneumonia, 902 patients were nasopharyngeal swab positive. Six cases of COVID-19 patients who developed spontaneous pneumothorax were identified (0.66%). Their baseline imaging showed diffuse bilateral ground-glass opacities and consolidations, mostly in the posterior and peripheral lung regions. 4/6 cases were associated with mechanical ventilation. All patients required placement of a chest tube. In all cases, mortality (66.6%) was not directly related to the pneumothorax. Conclusion Spontaneous pneumothorax is a rare complication of COVID-19 viral pneumonia and may occur in the absence of mechanical ventilation. Clinicians should be vigilant about the diagnosis and treatment of this complication.
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Affiliation(s)
- Massa Zantah
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA.
| | - Eduardo Dominguez Castillo
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Ryan Townsend
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Fusun Dikengil
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
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7
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She WH, Chok KSH, Li IWS, Ma KW, Sin SL, Dai WC, Fung JYY, Lo CM. Pneumocystis jirovecii-related spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in a liver transplant recipient: a case report. BMC Infect Dis 2019; 19:66. [PMID: 30658592 PMCID: PMC6339407 DOI: 10.1186/s12879-019-3723-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 01/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a common opportunistic infection caused by Pneumocystis jirovecii. Its incidence at 2 years or more after liver transplant (LT) is < 0.1%. PCP-related spontaneous pneumothorax and/or pneumomediastinum is rare in patients without the human immunodeficiency virus, with an incidence of 0.4-4%. CASE PRESENTATION A 65-year-old woman who had split-graft deceased-donor LT for primary biliary cirrhosis developed fever, dyspnea and dry coughing at 25 months after transplant. Her immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone. PCP infection was confirmed by molecular detection of Pneumocystis jirovecii,in bronchoalveolar lavage. On day-10 trimethoprim-sulphamethoxazole, her chest X-ray showed subcutaneous emphysema bilaterally, right pneumothorax and pneumomediastinum. Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema. She was managed with 7-day right-sided chest drain and a 21-day course of trimethoprim-sulphamethoxazole before discharge. CONCLUSION Longer period of PCP prophylaxis should be considered in patients who have a higher risk compared to general LT patients. High index of clinical suspicion, prompt diagnosis and treatment with ongoing patient reassessment to detect and exclude rare, potentially fatal but treatable complications are essential, especially when clinical deterioration has developed.
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Affiliation(s)
- Wong Hoi She
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Kenneth S H Chok
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China. .,State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Iris W S Li
- School of Public Health, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Ka Wing Ma
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Sui Ling Sin
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - James Y Y Fung
- State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.,Department of Medicine, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.,State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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8
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Bader S, Faul C, Raab S, Schwaiblmair M, Berghaus TM. Successful long-term treatment of persistent pulmonary air leak in pneumocystis jirovecii pneumonia by unidirectional endobronchial valves. Respir Med Case Rep 2018; 25:170-173. [PMID: 30181950 PMCID: PMC6121160 DOI: 10.1016/j.rmcr.2018.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 11/01/2022] Open
Abstract
Spontaneous pneumothorax is a rare complication of pneumocystis jirovecii pneumonia. We report a patient with pneumocystis jirovecii pneumonia and therapy-refractory, right-sided pneumothorax due to persistent air leak (PAL) despite prolonged chest tube placement and multiple pleurodesis attempts. Due to the patient's morbidity, we evaluated if the PAL can be sealed by unidirectional endobronchial valves (EBVs). After occlusion of the right upper lobe by a balloon catheter, the air leak flow-rate decreased from 800 ml/min to 250 ml/min. Zephyr EBVs (ZEBVs) were placed in the segmental right upper lobe bronchi and subsequently, a complete resolution of the pneumothorax was noted. During 30 months of follow-up, neither recurrence of pneumothorax nor any adverse events of EBV treatment were noted. We conclude that ZEBV placement might be an effective and well-tolerated treatment option for PAL secondary to pneumocystis jirovecii pneumonia with promising long-term results.
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Affiliation(s)
- Stefanie Bader
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Germany
| | - Christian Faul
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Germany
| | - Stephan Raab
- Department of Thoracic Surgery, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Germany
| | - Martin Schwaiblmair
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Germany
| | - Thomas M Berghaus
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Germany
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9
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Choi JW, Kim Y, Lee JH, Kim YS. Human Herpesvirus 8-Negative and Epstein-Barr Virus-Positive Effusion-Based Lymphoma in a Patient with Human Immunodeficiency Virus. J Pathol Transl Med 2015; 49:409-12. [PMID: 26081824 PMCID: PMC4579282 DOI: 10.4132/jptm.2015.06.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 11/17/2022] Open
Abstract
A 39-year-old man infected with human immunodeficiency virus (HIV) was admitted to our hospital because of sudden onset of chest pain. Chest radiography revealed pneumothorax of the right lung. Computed tomographic scans disclosed a 5.8-cm-sized emphysematous bulla in the right middle lobe of the lung. Histologically, the wedge-resected lung showed medium to large atypical cells within the bullous cavity of the Pneumocystis jirovecii pneumonia, without solid mass formation. These atypical cells were confirmed to be large B-cell lymphoma, Epstein-Barr virus–positive and human herpesvirus 8–negative. Therefore, this case was not diagnosed as primary effusion lymphoma, but effusion-based lymphoma arising in an emphysematous cavity of an HIV-infected patient. This type of effusion-based lymphoma has never been reported, and, although rare, it should be noted in order to clinically diagnose this lymphoma.
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Affiliation(s)
- Jung-Woo Choi
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Younghye Kim
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Ju-Han Lee
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Young-Sik Kim
- Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Mortensen KH, Babar JL, Balan A. Multidetector CT of pulmonary cavitation: filling in the holes. Clin Radiol 2015; 70:446-56. [PMID: 25623513 DOI: 10.1016/j.crad.2014.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 12/03/2014] [Accepted: 12/11/2014] [Indexed: 12/17/2022]
Abstract
Pulmonary cavitation causes significant morbidity and mortality. Early diagnosis of the presence and aetiology of a cavity is therefore crucial in order to avoid further demise in both the localized pulmonary and systemic disorders that may manifest with pulmonary cavity formation. Multidetector CT has become the principal diagnostic technique for detecting pulmonary cavitation and its complications. This review provides an overview of the aetiologies and their imaging findings using this technique. Combining a literature review with case illustration, a synopsis of the different imaging features and constellations is provided, which may suggest a particular cause and aid the differentiation from diseases with similar findings.
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Affiliation(s)
- K H Mortensen
- University Department of Radiology, Cambridge University, Cambridge, UK; Department of Radiology, Addenbrooke's Hospital, Cambridge, UK.
| | - J L Babar
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - A Balan
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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Park YK, Jung HC, Kim SY, Kim MY, Jo K, Kim SY, Kang B, Woo G, Choi HJ, Wie SH. Spontaneous Pneumomediastinum, Pneumopericardium, and Pneumothorax with Respiratory Failure in a Patient with AIDS and Pneumocystis jirovecii Pneumonia. Infect Chemother 2014; 46:204-8. [PMID: 25298911 PMCID: PMC4189138 DOI: 10.3947/ic.2014.46.3.204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 09/16/2013] [Accepted: 09/16/2013] [Indexed: 11/24/2022] Open
Abstract
Spontaneous pneumothorax occurs in up to 35% of patients with Pneumocystis jirovecii pneumonia. However, spontaneous pneumomediastinum and pneumopericardium are uncommon complications in patients infected with human immunodeficiency virus, with no reported incidence rates, even among patients with acquired immunodeficiency syndrome (AIDS) and P. jirovecii pneumonia. We report a case of spontaneous pneumomediastinum, pneumopericardium, and pneumothorax with respiratory failure during treatment of P. jirovecii pneumonia in a patient with AIDS; the P. jirovecii infection was confirmed by performing methenamine silver staining of bronchoalveolar lavage specimens. This case suggests that spontaneous pneumomediastinum and pneumopericardium should be considered in patients with AIDS and P. jirovecii pneumonia.
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Affiliation(s)
- Yun Kyung Park
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hee Chan Jung
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Shin Young Kim
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Min Young Kim
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Kwanhoon Jo
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Se Young Kim
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Borami Kang
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Gihyeon Woo
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hyun Joo Choi
- Department of Pathology, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Seong-Heon Wie
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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12
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Etiology of spontaneous pneumothorax in 105 HIV-infected patients without highly active antiretroviral therapy. Eur J Radiol 2009; 71:264-8. [DOI: 10.1016/j.ejrad.2008.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 05/06/2008] [Indexed: 11/23/2022]
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13
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Nakamura H, Tateyama M, Tasato D, Haranaga S, Yara S, Higa F, Ohtsuki Y, Fujita J. Clinical utility of serum beta-D-glucan and KL-6 levels in Pneumocystis jirovecii pneumonia. Intern Med 2009; 48:195-202. [PMID: 19218768 DOI: 10.2169/internalmedicine.48.1680] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE New serum markers (1-->3) beta-D-glucan (beta-D-glucan) and KL-6 are reported to be useful for the clinical diagnosis of Pneumocystis jirovecii pneumonia (PCP). However, the utility of these markers in PCP with HIV infection (HIV PCP) and without HIV (non-HIV PCP) is unknown. This study was aimed to evaluate the utility of beta-D-glucan and KL-6 for the diagnosis of PCP in patients with HIV infection (HIV PCP) and non-HIV PCP. METHODS Retrospective study. PATIENTS We reviewed the medical records of consecutive 35 patients. The serum levels of beta-D-glucan and KL-6 in HIV PCP and non-HIV PCP were comparatively evaluated. We evaluated these markers in survivors and non survivors. RESULTS The detection rates of serum beta-D-glucan and KL-6 levels in non-HIV PCP were lower than those in HIV PCP (88% vs. 100%, 66% vs. 88%, respectively). The false positive rates of these markers in both groups were similar (12%, 37%, respectively). Oxygenation index, serum albumin, and mechanical ventilation were the variables which were significantly associated with poor outcome in the univariate analysis. CONCLUSION In conclusion, beta-D-glucan was a reliable diagnostic marker for PCP. However, the detection rate of beta-D-glucan and KL-6 in non-HIV PCP was lower than in HIV PCP. Neither beta-D-glucan nor KL-6 was associated with the outcome of PCP.
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Affiliation(s)
- Hideta Nakamura
- Department of Medicine and Prevention and Control of Infectious Diseases, Faculty of Medicine, University of the Ryukyus, Okinawa.
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Booth CM, Stewart TE. Severe acute respiratory syndrome and critical care medicine: the Toronto experience. Crit Care Med 2005; 33:S53-60. [PMID: 15640680 DOI: 10.1097/01.ccm.0000150954.88817.6] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 2003 global outbreak of severe acute respiratory syndrome (SARS) provided numerous challenges to the delivery of critical care. The Toronto critical care community has learned important lessons from SARS, which will help in preparation for future disease outbreaks. OBJECTIVES The objectives of this study were to review the epidemiology and clinical characteristics of the Toronto SARS outbreak, the challenges SARS provided to the delivery of critical care, and how we would like to be better organized for a similar challenge in the future. FINDINGS SARS manifests clinically as atypical pneumonia and ranges in severity from minor nonspecific symptoms to adult respiratory distress syndrome (ARDS). Approximately 20% of patients with SARS will become critically ill and require admission to the intensive care unit. ARDS develops in the majority of these patients. Mortality from ARDS in SARS is high, and outcome is associated with the presence of comorbid disease and the severity of illness at presentation. The influx of critically ill patients and the transmission of SARS to front line workers created a tremendous strain on Toronto's healthcare system. From a critical care perspective, the most important limitation in the response to SARS was the absence of a coordinated leadership and communication infrastructure. Other challenges encountered during SARS include the following: closure of intensive care unit beds and loss of staff through quarantine and illness, implementing novel infection control protocols, educating staff, conducting research to learn about SARS, system planning, and maintaining staff morale during this very difficult period. CONCLUSIONS Communication and leadership strategies were key components in the critical care response to SARS. Ideally, centers should have systems in place to allow for the rapid expansion and modification of critical care services in the event of a disease outbreak. Other critical care communities should consider their crisis response strategies in advance of similar events.
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Affiliation(s)
- Christopher M Booth
- Interdepartmental Division of Critical Care Medicine and the Department of Medicine, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Canada
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Amorim A, Sucena M, Fernandes G, Magalhães A. [Pleural disease and acquired immunodeficiency syndrome]. REVISTA PORTUGUESA DE PNEUMOLOGIA 2004; 10:217-25. [PMID: 15300311 DOI: 10.1016/s0873-2159(15)30574-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Respiratory infections are among the most common complications in patients infected with human immune deficiency virus (HIV) and can occur at all CD4 level. Pleural complications are uncommon but they have some distinctive aspects from HIV-negative patients. The PTX occurrence in HIV-positive patients was described for the first time in 1984. The total incidence of pneumothorax (PTX) in patients with acquired immune deficiency syndrome (AIDS) varies from 2.7% to 4.9%. The great majority occurs in patients with current or previous Pneumocystis carinii infection, who present subpleural pulmonary cavities with necrosis. The treatment of spontaneous PTX in patients with AIDS is difficult, with an increased tendency to bronchopleural fistula persistence. The use of tube thoracostomy, with or without pleural sclerose, can be insufficient to resolve PTX. Other therapeutic options are attachment of a Heimlich valve or surgical intervention. The prevalence and the etiology of pleural effusion (PE) among hospitalized patients with AIDS varies widely. One reason that can contribute to this variability is the difference on risk factors associated with HIV infection, in the studied population. Parapneumonic effusions, tuberculosis and Kaposi's sarcoma are the most common causes. Empyemas are a rare pleural complication. Although Pneumocystis carinii pneumonia is a common cause of pneumonias in AIDS patients, it is an unusual cause of pleural effusion. Other possible causes of pleural effusion are non-Hodgkin's lymphoma, namely body cavity-based lymphoma.
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Drake DF, Burnett DM. How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? a case report. Arch Phys Med Rehabil 2002; 83:1031-2. [PMID: 12098168 DOI: 10.1053/apmr.2002.33099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chest pain in a patient with acquired immune deficiency syndrome (AIDS) has a broad differential diagnosis including, but not limited to, coronary artery disease, gastroesophageal reflux, fungal esophagitis, and musculoskeletal pain. However, spontaneous pneumothorax must also be added to the list of possibilities. Spontaneous pneumothorax occurs 450 times more frequently in patients with AIDS versus the general population and is now the leading cause of nontraumatic pneumothorax in the urban population, to include both those with and without AIDS. Because many patients with human immunodeficiency virus (HIV) are young and typically devoid of comorbidity, the presentation of this pulmonary complication may be subtle. HIV-positive patients are receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for spontaneous pneumothorax to be an etiology of chest pain. We present a case exemplifying the need for rehabilitation professionals to maintain a broad-based approach when caring for patients with HIV and AIDS.
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Affiliation(s)
- David F Drake
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University's Medical College of Virginia Hospitals, Richmond, USA.
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17
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Abstract
Pneumothorax occurs in 1 to 2% of hospitalized patients with HIV and is associated with 34% mortality. Pneumocystis carinii pneumonia and chest radiographic evidence of cysts, pneumatoceles, or bullae are risk factors for spontaneous pneumothorax. Tube thoracostomy, pleurodesis, and surgical treatment are usually needed to manage spontaneous pneumothorax in AIDS. Pleural effusion is seen in 7 to 27% of hospitalized patients with HIV infection. Its three leading causes are parapneumonic effusions, tuberculosis, and Kaposi sarcoma. Pleural effusions occur in 15 to 89% of cases of pulmonary Kaposi sarcoma and in 68% of cases of thoracic non-Hodgkin lymphoma in patients with AIDS. Primary effusion lymphoma accounts for 1 to 2% of non-Hodgkin lymphomas. Kaposi sarcoma and primary effusion lymphoma are associated with human herpesvirus 8. The prognosis of patients with pleural Kaposi sarcoma and non-Hodgkin lymphoma in AIDS is poor, and the major goal of treatment is palliation.
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Affiliation(s)
- B Afessa
- Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Afessa B. Pleural effusion and pneumothorax in hospitalized patients with HIV infection: the Pulmonary Complications, ICU support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study. Chest 2000; 117:1031-7. [PMID: 10767235 DOI: 10.1378/chest.117.4.1031] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To describe the incidence, causes, and impact of pleural effusion and pneumothorax in hospitalized patients with HIV infection. DESIGN Prospective, observational. SETTING A university-affiliated medical center. METHODS During a 3-year period, 599 HIV-infected patients with a total of 1,225 consecutive hospital admissions were followed. A total of 1,097 hospital admissions were included. Patients' medical records, chest radiographs, and computerized laboratory values were reviewed. RESULTS Pleural effusions developed in 160 hospital admissions (14. 6%). The effusions were right sided (56%), left sided (29%), and bilateral (15%). Their sizes were small (65%), moderate (23%), large (9%), and massive (4%). The associated conditions were infectious: bacterial pneumonia (n = 50), pulmonary tuberculosis (n = 10), Pneumocystis carinii pneumonia (PCP; n = 5), and empyema (n = 2); and noninfectious: renal failure (n = 15), hypoalbuminemia (n = 12), malignancy (n = 9), pancreatitis (n = 7), hepatic cirrhosis (n = 5), congestive heart failure (n = 4), atelectasis (n = 3), pulmonary embolism (n = 3), trauma (n = 1), and surgery (n = 1). Pneumothorax developed in 13 hospital admissions (1.2%). The conditions associated with pneumothorax were iatrogenic (n = 4), bacterial pneumonia (n = 3), PCP (n = 2), positive pressure ventilation for PCP (n = 2), pulmonary Mycobacterium avium complex (n = 1), and trauma (n = 1). The in-hospital mortality of hospital admissions with pleural effusion was 10.0% compared to 5.4% of those without pleural effusion (p = 0.0407). The in-hospital mortality of hospital admissions with pneumothorax was 30.8% compared to 5.8% of those without pneumothorax (p = 0.0060). CONCLUSIONS Pleural effusions occur in 14.6% of hospital admissions in our patient population with HIV infection. Bacterial pneumonia is the condition most commonly associated with pleural effusion. Pneumothorax, seen in 1.2% of hospital admissions with HIV infection, is associated with poor outcome.
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Affiliation(s)
- B Afessa
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida Health Science Center, Jacksonville, FL, USA
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Affiliation(s)
- S A Sahn
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston 29425, USA.
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Azoulay E, Parrot A, Flahault A, Cesari D, Lecomte I, Roux P, Saidi F, Fartoukh M, Bernaudin JF, Cadranel J, Mayaud C. AIDS-related Pneumocystis carinii pneumonia in the era of adjunctive steroids: implication of BAL neutrophilia. Am J Respir Crit Care Med 1999; 160:493-9. [PMID: 10430719 DOI: 10.1164/ajrccm.160.2.9901019] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Factors predictive of mortality in patients with AIDS and Pneumocystis carinii pneumonia (PCP) were identified before the introduction of adjunctive steroids, but they have not been reevaluated since. Because PCP still occurs in AIDS, remaining fatal in some cases, we conducted a multivariate analysis of factors predicting mortality in patients with HIV-positive PCP managed from 1990 to 1995, i.e., after the consensus conference on the use of adjunctive steroids. The predictive value of clinical, laboratory, and bronchoalveolar lavage (BAL) data at admission and during the course of PCP was studied retrospectively using multivariate methods, in 144 patients with AIDS. Overall mortality was 21.5%. The univariate analysis identified seven factors predictive of 90-d mortality: Pa(O(2)) on room air < 60 mm Hg, lactate dehydrogenase > 1,000 IU, albuminemia < 30 g/L, BAL neutrophilia > 10%, nosocomial infection, pneumothorax, and a need for mechanical ventilation. Four of these factors were independently associated with 90-d mortality in the multivariate analysis; among them, two were evaluable at admission, namely, Pa(O(2)) < 60 mm Hg on room air and BAL neutrophilia > 10%, and two during hospitalization, namely, the development of pneumothorax and a need for mechanical ventilation. Moreover, BAL neutrophilia was correlated to occurrence of pneumothorax and a need for mechanical ventilation. In the era of adjunctive steroid use, AIDS-related PCP remains fairly common. Two independent factors evaluable at admission, Pa(O(2)) on room air and BAL neutrophilia, are predictive of death.
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Affiliation(s)
- E Azoulay
- Service de Pneumologie et Réanimation Respiratoire, Unité de Biostatistique, INSERM U444, France. Hôpital Tenon, Paris, France.
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Bédos JP, Dumoulin JL, Gachot B, Veber B, Wolff M, Régnier B, Chevret S. Pneumocystis carinii pneumonia requiring intensive care management: survival and prognostic study in 110 patients with human immunodeficiency virus. Crit Care Med 1999; 27:1109-15. [PMID: 10397214 DOI: 10.1097/00003246-199906000-00030] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To perform a descriptive study of patients with acute respiratory failure secondary to acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia and to identify variables that are predictive of death within 3 months. DESIGN Case series study. SETTING Infectious disease intensive care unit (ICU) in a university hospital. PATIENTS Detailed clinical, laboratory, and ventilatory data were collected prospectively within 48 hrs of admission and during the ICU stay in 110 consecutive human immunodeficiency virus-infected patients requiring ICU management with or without mechanical ventilation for P. carinii pneumonia-related acute respiratory failure. MEASUREMENTS AND MAIN RESULTS Continuous positive airway pressure was used initially in 66 (60%) patients. Among the 34 patients (31%) who required mechanical ventilation, including 12 at admission and 22 after failure of continuous positive airway pressure, 76% died. The 3-month mortality rate after ICU admission was estimated at 34.6% (95% confidence interval [CI], 25%-44%). The 1-yr survival rate was estimated at 47% (95% CI, 36%-58%). With successive multiple logistic regression models analyzing the relative prognostic importance of baseline clinical and laboratory tests variables, ventilation variables, and events in the ICU, only delayed mechanical ventilation after 3 days (odd ratio [OR], 6.7; 95% CI, 1.9-23.9), duration of mechanical ventilation of > or = 5 days (OR, 2.8; 95% CI, 1.1-6.9), nosocomial infection (OR, 5.2; 95% CI, 2.1-12.9), and pneumothorax (OR, 5; 95% CI, 1.7-14.7) were predictive of death within 3 months of ICU admission. Among patients with delayed mechanical ventilation on day 3 or later and with a pneumothorax associated or not associated with a nosocomial infection, the predicted probability of 3-month death was close to 100%. CONCLUSIONS Our data suggest that the most significant predictive factors of death were identifiable during the course of P. carinii pneumonia-related acute respiratory failure rather than at admission and can help in bedside decisions to withdraw intensive care support in such patients.
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Affiliation(s)
- J P Bédos
- Service de Réanimation des Maladies Infectieuses, Groupe Hospitalier Bichat-Claude Bernard, Paris, France
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Abstract
Given the multiple impairments in host defense that occur during HIV infection, patients with AIDS are at risk for a variety of pleural infections and neoplasms. Of infectious causes, bacterial parapneumonic effusions and empyemas and tuberculous pleurisy occur more frequently than effusions caused by P. carinii. In each case, therapy is directed at eradication of the causative organisms. In the setting of systemic Kaposi's sarcoma, pleural involvement is common, although diagnosis is difficult and therapeutic options are limited. Pleural effusions caused by non-Hodgkin's lymphoma often occur in the setting of pulmonary parenchymal disease and can be diagnosed cytologically. The recently described entity of primary effusion lymphoma occurs in the absence of solid-organ involvement. The development of a spontaneous pneumothorax in a HIV-infected individual should prompt a search for P. carinii infection. Although these pneumothoraces often recur and are difficult to manage, recent series suggest that surgical approaches to bronchopleural fistulas are reasonable in selected patients.
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Affiliation(s)
- J M Beck
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA
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Golpe Gómez R, Cifrián Martínez J, Fernández Rozas S, García Pérez M, Jiménez Gómez A, Mons Lera R. Neumotorax espontáneo asociado a la infección por el virus de la inmunodefíciencia humana (VIH). Arch Bronconeumol 1998. [DOI: 10.1016/s0300-2896(15)30450-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Despite advances in prophylaxis and the reduction of mortality and morbidity resulting from highly active antiretroviral therapy, neumocystis pneumonia remains a common problem in HIV-infected patients. There are many possible causes for the continued prevalence of this condition. This article examines the characteristics, and some of the complex causes of P. carinii pneumonia in AIDS patients.
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Affiliation(s)
- C F Decker
- Division of Infectious Diseases, National Naval Medical Center, Bethesda, Maryland, USA
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Bani-Sadr F, Dominique S, Gueit I, Peillon C, Humbert G. [Clinical and therapeutic aspects of spontaneous pneumothorax in human immunodeficiency virus infection: 9 cases]. Rev Med Interne 1997; 18:605-10. [PMID: 9365734 DOI: 10.1016/s0248-8663(97)82461-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Spontaneous pneumothorax in HIV infected patients are mostly due to a sub-pleural necrotizing pneumonitis most often related to Pneumocystis carinii pneumonia. From our experience of nine patients and a review of the literature, we describe the clinical characteristics and therapeutic management and confirm the frequent failure of simple chest tube drainage and the high morbidity and mortality rate despite treatment. An aggressive stepped-care management of thoracoscopic talc poudrage as initial therapy should be evaluated.
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Affiliation(s)
- F Bani-Sadr
- Service des maladies infectieuses et tropicales, hôpital Charles-Nicolle, Rouen, France
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Flum DR, Steinberg SD, Bernik TR, Bonfils-Roberts E, Kramer MD, Adams PX, Wallack MK. Thoracoscopy in acquired immunodeficiency syndrome. J Thorac Cardiovasc Surg 1997; 114:361-6. [PMID: 9305188 DOI: 10.1016/s0022-5223(97)70181-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The role of thoracic surgery in patients with acquired immunodeficiency syndrome (AIDS) continues to evolve. This review seeks to evaluate the outcome, morbidity, and mortality associated with video-assisted thoracoscopic surgery for empyema and pneumothorax in patients with AIDS. METHODS A retrospective review was conducted of patients with AIDS in whom video-assisted thoracoscopic surgery was performed for empyema (group 1) or intractable pneumothorax (group 2). RESULTS Twenty patients with AIDS (95% male, mean age 37.4 years, mean CD4 count 76 cells/ml3) underwent thoracoscopy. Surgery was performed for empyema (group 1) in 11 (55%) and intractable pneumothorax (group 2) in nine (45%). Three patients (15%) died within 30 days of the operation. At mean follow-up (29 months), overall survival was 55%. For those who survived the hospitalization and died within the follow-up period (35.3%), mean survival time was 8.2 months (range 1 month to 27 months). In group 1, surgical procedures were performed after 8 days of chest tube drainage and included pleural debridement and mechanical pleurodesis (n = 11) along with lung biopsy (n = 6). Survivals at 30 days and 29 months' follow-up were 90.9% and 45.4%, respectively. In group 2, significantly depressed CD4 counts (average 33.2 cells/ml3) were noted along with a more prolonged preoperative hospitalization (18.5 days) with 14.2 days spent with a chest tube before the operation. In this group, operative procedures included mechanical pleurodesis and talc poudrage (n = 9), bleb resection (n = 7), and lung biopsy (n = 1). Two deaths (22%) occurred within 30 days of the operation and survival at 29 months' follow-up was 66%. CONCLUSION Video-assisted thoracoscopic surgery performed in patients with AIDS for the treatment of empyema and intractable pneumothorax is effective, can be performed with little operative morbidity and mortality, and is associated with acceptable long-term survival. Video-assisted thoracoscopic surgery is best performed soon after the diagnosis of intractable pneumothorax or empyema has been established.
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Affiliation(s)
- D R Flum
- St. Vincent's Hospital and Medical Center, New York Medical College, N.Y., USA
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INTERVENTIONAL PROCEDURES IN THE AIDS PATIENT. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00456-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Scott AM, Myers GA, Harms BA. Pneumocystis carinii pneumonia postrestorative proctocolectomy for ulcerative colitis: a role for perioperative prophylaxis in the cyclosporine era? Report of a case and review of the literature. Dis Colon Rectum 1997; 40:973-6. [PMID: 9269817 DOI: 10.1007/bf02051208] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Medical management of severe ulcerative colitis has used cyclosporine with increasing frequency as an adjuvant to systemic steroids and mercaptopurine. However, the effects of combined management with cyclosporine and prednisone may lead to significant immune compromise and adversely affect operative morbidity in the event urgent surgery is required. METHODS A case is reported of a 43-year-old white male who presented with severe ulcerative colitis. The patient had been initially treated with prednisone and cyclosporine for six weeks before surgical intervention. The intractability of his ulcerative colitis caused the patient to present to surgery, where he underwent restorative proctocolectomy. RESULTS On initial presentation, the patient manifested systemic signs of severe ulcerative colitis with hypoalbuminemia, anemia, and weight loss, despite continuous prednisone and cyclosporine management. Before surgical intervention, a chest x-ray and the patient's respiratory status were normal. A total abdominal colectomy with ileal pouch reconstruction and temporary loop ileostomy were performed without incident. On the fifth postoperative day, the patient developed respiratory failure, which was subsequently diagnosed as Pneumocystis carinii pneumonia. Although ventilator support and both aggressive medical and surgical management eventually resulted in successful outcome, significant perioperative morbidity occurred. CONCLUSIONS In the era of aggressive medical management for ulcerative colitis with both steroids and cyclosporine, the complications of immunosuppression may be significant, including opportunistic pneumonia. Prophylaxis against P. carinii pneumonia with sulfa antibiotics should be considered, especially in patients for whom proctocolectomy is a potential end point.
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Affiliation(s)
- A M Scott
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison 53792, USA
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Abstract
Since approximately 40% to 65% of patients with AIDS will develop pulmonary disease, HIV-seropositive patients represent a large cohort of immunosuppressed individuals with the potential to progress to respiratory failure requiring mechanical ventilation and admission to the intensive care unit. This article reviews the cause, pathophysiology, diagnostic approach, and management of acute respiratory failure requiring mechanical ventilation in HIV-seropositive patients. Prognostic factors and survival rates for episodes of respiratory failure are also discussed. In addition, an overview of acute respiratory failure in pediatric AIDS patients is presented.
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Affiliation(s)
- M J Cowan
- Department of Critical Care Medicine, National Institutes of Health, Bethesda, Maryland, USA
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31
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Abstract
Improved understanding of Pneumocystis carinii, in particular the widespread use of chemoprophylaxis, has resulted in a declining incidence of infection in patients infected with HIV since the late 1980s. Despite these advances, P. carinii pneumonia continues to represent an important cause of pulmonary disease in HIV-seropositive individuals who do not receive chemoprophylaxis or when breakthrough episodes occur. This article reviews the history, biology, clinical manifestations, prognostic markers, therapy, and chemoprophylaxis of P. carinii pneumonia in HIV-seropositive patients.
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Affiliation(s)
- S J Levine
- Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, USA
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Abstract
Illicit drug users comprise a substantial and growing proportion of the HIV-infected population. Although they develop pulmonary complications common to all HIV transmission groups, they also have unique respiratory illnesses due to the direct effect of the illicit drugs on the lung. Bacterial infections, tuberculosis, and noninfectious complications all have a major effect on morbidity and mortality in this portion of the HIV-infected population.
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Affiliation(s)
- A E O'Donnell
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
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Asboe D, Fisher M, Nelson MR, Kaplan DK, al-Kattan K, Gazzard BG. Pneumothorax in AIDS: case reviews and proposed clinical management. Genitourin Med 1996; 72:258-60. [PMID: 8976829 PMCID: PMC1195673 DOI: 10.1136/sti.72.4.258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumothorax is a not uncommon complication of advanced HIV infection, and may prove difficult to manage in view of its recalcitrant and recurrent nature. In this group where immunosuppression and reduced life expectancy are a feature, standard protocols are often abandoned in favour of a more conservative approach. This is often unsuccessful. METHODS Patients attending the Department of Genitourinary Medicine, Chelsea and Westminster Hospital who sustained pneumothorax between 1988 and 1992 were identified retrospectively and their notes reviewed. RESULTS Fifteen patients were identified of whom three had post-procedural pneumothoraces. In the remaining 12 patients, 10 had previously had Pneumocystic carinii pneumonia (PCP), whilst all 12 had some evidence to suggest current PCP (seven proven, five presumptive). In those six patients with a single, unilateral pneumothorax, four were managed successfully with intercostal drainage alone (one patient died early, one required pleurectomy). In those with recurrent pneumothoraces or pneumothoraces that did not respond to prolonged intercostal drainage, failure of medical treatment was judged to have occurred and surgery was performed. Overall, conservative management failed in 7/11 patients. Conversely surgery resulted in resolution in 7/7 with recurrence seen in one individual. Median survival was similar in the two groups. CONCLUSIONS Pneumothorax in patients with AIDS is associated with a high rate of intercurrent PCP; a low threshold for treating this infection presumptively is indicated. Intercostal drainage was successful in patients with a single, unilateral pneumothorax. However, in patients with recurrent or bilateral pneumothorax extended periods on intercostal drainage were uniformly unsuccessful. Early surgical referral should be considered in this group.
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Affiliation(s)
- D Asboe
- Department of HIV/Genitourinary Medicine, Chelsea and Westminster Hospital, London, UK
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Solomon KS, Levin TL, Berdon WE, Romney B, Ruzal-Shapiro C, Bye MR. Pneumothorax as the presenting sign of Pneumocystis carinii infection in an HIV-positive child with prior lymphocytic interstitial pneumonitis. Pediatr Radiol 1996; 26:559-62. [PMID: 8753672 DOI: 10.1007/bf01372242] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
An HIV-positive child presented with a pneumothorax secondary to cavitary Pneumocystis carinii pneumonia (PCP). Lymphocytic interstitial pneumonitis had been evident on earlier radiographs but had resolved, concurrent with a decrease in her CD4 counts, before the radiographic changes of PCP became evident. As immune function declines in HIV-positive children, the chest radiograph may paradoxically clear. In such a setting, development of focal lung disease, including pneumothorax, may herald Pneumocystis carinii infection.
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Affiliation(s)
- K S Solomon
- Department of Radiology, Division of Pediatric Radiology, Babies & Children's Hospital of New York, Columbia-Presbyterian Medical Center, 3959 Broadway, BHN 3-318, New York, NY 10032, USA
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Metersky ML, Colt HG, Olson LK, Shanks TG. AIDS-related spontaneous pneumothorax. Risk factors and treatment. Chest 1995; 108:946-51. [PMID: 7555166 DOI: 10.1378/chest.108.4.946] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To define risk factors and optimum therapy for AIDS-related spontaneous pneumothorax (PTX). DESIGN Case-control study. SETTING Tertiary care center. PATIENTS Thirty-five patients with AIDS who developed spontaneous PTX between January 1, 1988 and December 31, 1991, of whom 27 (77.1%) did so in the setting of Pneumocystis carinii pneumonia (PCP). Forty-one patients who were diagnosed as having PCP and did not develop PTX served as the control group. RESULTS Using logistic regression, a history of cigarette smoking, aerosolized pentamidine treatment, and the observation of pneumatoceles by chest radiography were associated with an increased risk of PTX. Although not associated with an increased risk of occurrence of PTX, the use of systemic corticosteroids for PCP treatment was associated with a longer requirement for chest tube drainage. Although chest tube drainage alone was often successful, chemical and surgical pleurodesis was often effective in treating prolonged air leaks and was associated with a lower incidence of recurrent PTX, although this difference did not achieve statistical significance (p = 0.07). CONCLUSIONS Patients at high risk of developing AIDS-related spontaneous PTX can be identified. Systemic corticosteroids may increase the risk of morbidity from AIDS-related PTX. Chemical and surgical pleurodesis may be of value in short-term treatment and in reducing the risk of recurrence.
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Affiliation(s)
- M L Metersky
- Pulmonary Division, University of Connecticut Health Center, Farmington, USA
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Abstract
The incidence of pneumothorax in HIV-infected children has not been reported. In adults with AIDS, pneumothorax has been described exclusively in association with Pneumocystis carinii pneumonia (PCP). We report the cases of three children with AIDS, one with lymphoid interstitial pneumonitis (LIP) without evidence of PCP and two with PCP, all of whom developed spontaneous pneumothorax (SP). On presentation, none of the children had any risk factors for the development of pneumothorax, but all had radiographic evidence of subpleural cystic lesions and bilateral pleural adhesions. None of the patients responded to conservative medical management, which included chest tube thoracostomy and chemical pleurodesis. Two patients underwent pleurectomy that resulted in resolution of the pneumothorax. Both patients with PCP who developed pneumothorax died, but the patient with LIP and SP has had no recurrences of any serious respiratory problems 3 years after pleurectomy and excision of the intrathoracic cysts.
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Affiliation(s)
- S A Schroeder
- Department of Pediatrics, New York Medical College, Valhalla, USA
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37
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Mitchell DM, Miller RF. AIDS and the lung: update 1995. 2. New developments in the pulmonary diseases affecting HIV infected individuals. Thorax 1995; 50:294-302. [PMID: 7660346 PMCID: PMC1021197 DOI: 10.1136/thx.50.3.294] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- D M Mitchell
- Chest and Allergy Clinic, St Mary's Hospital, London, UK
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Isaacs SM, Mora M. Fulminant reexpansion pulmonary edema in a patient with AIDS. Ann Emerg Med 1994; 24:975-8. [PMID: 7978577 DOI: 10.1016/s0196-0644(94)70216-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A 23-year-old man with AIDS presented to the emergency department with recurrent spontaneous pneumothoraces secondary to recent Pneumocystis carinii pneumonia. Shortly after placement of bilateral pigtail catheters for chest reexpansion, he developed fatal unilateral reexpansion pulmonary edema. The association between P carinii pneumonia and pneumothorax, and the risk factors and pathophysiology of reexpansion pulmonary edema are reviewed. Emergency physicians should recognize that reexpansion pulmonary edema is an important complication in the treatment of prolonged spontaneous pneumothorax that can lead rapidly to severe hypoxia, hypotension, and death.
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Affiliation(s)
- S M Isaacs
- Department of Emergency Services, University of California, San Francisco General Hospital
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Lazard T, Guidet B, Meynard JL, Capron F, Offenstadt G. Generalized air cysts complicated by fatal bilateral pneumothoraces in a patient with AIDS-related Pneumocystis carinii pneumonia. Chest 1994; 106:1271-2. [PMID: 7924511 DOI: 10.1378/chest.106.4.1271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
We describe a case of air cyst lesions in an AIDS patient suffering from Pneumocystis carinii pneumonia. This case is unique because these lesions were generalized to both lungs and initially well tolerated. Pathologic examination revealed extensive tissue invasion by P carinii. The prognosis was complicated by bilateral pneumothoraces. Surgical right pleurodesis allowed lung re-expansion but did not prevent recurrence of fatal contralateral pneumothorax.
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Affiliation(s)
- T Lazard
- Service de Réanimation Polyvalente, Hôpital Saint-Antoine, Paris, France
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40
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Abstract
The acquired immune deficiency syndrome (AIDS) was recognized as a distinct entity in 1981. It began as a medical curiosity affecting only several dozen individuals in a restricted segment of the U.S. population. In the 12 years since its description, AIDS has become a pandemic affecting tens of millions with cases reported from all major countries. The illness is caused by a retrovirus, termed human immunodeficiency virus (HIV). It is a blood-borne disease with sexual, parenteral, and perinatal modes of transmission. Infection with the virus can be determined by a number of serologic techniques as well as viral culture. The pathophysiology of illness is incompletely understood, but is in large part related to destruction of helper, CD4 lymphocytes. This results in immune dysfunction and the development of a variety of opportunistic infections and malignancies. A great deal has been learned over the last decade, with important advances in treatment. Zidovudine (AZT) remains the most important agent in slowing progression of the disease and has resulted in prolonging survival. All organ systems can be affected by HIV, and many clinical manifestations are protein. Fever, weight loss, and diarrhea are often encountered general symptoms. The skin is frequently involved, with Kaposi's Sarcoma the most common malignancy and a variety of fungi and viruses the most frequent cause of infection. The lung is involved in the majority of patients, with Pneumocystis Carinii (PCP) and mycobacteria emerging as the most important pathogens. A variety of treatments have demonstrated efficacy for PCP. The risk of PCP is related to the decay in CD4 lymphocytes so that prophylactic treatment is recommended when CD4 counts fall below 200. Mycobacterial infection with multiresistant organisms has complicated the management of these infections and poses new risks to health care workers. Part 1 of this two-part series on AIDS discusses the pathophysiology and clinical expression, epidemiology, laboratory testing, and the general clinical manifestations of AIDS, as well as dermatologic, pulmonary, and cardiac symptoms. Part 2 will discuss the gastrointestinal, neurologic, and ocular symptoms, as well as the treatment and management of the AIDS patient.
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Affiliation(s)
- D A Guss
- University of California, San Diego Medical Center 92103-8676
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Read CA, Reddy VD, O'Mara TE, Richardson MS. Doxycycline pleurodesis for pneumothorax in patients with AIDS. Chest 1994; 105:823-5. [PMID: 7510600 DOI: 10.1378/chest.105.3.823] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Since first described in 1984, nontraumatic pneumothoraces in patients with AIDS has become more common. When compared with spontaneous pneumothorax in the general population, pneumothoraces in patients with AIDS are often complicated by prolonged air leaks as well as higher recurrence rates. Chemical pleurodesis has an important role in the management of these complications. The most experience with chemical pleurodesis uses tetracycline hydrochloride as the sclerosing agent; however, this agent is no longer available. Doxycycline has been used in pleurodesis of malignant effusions, but its use in managing pneumothoraces is limited. We present five patients who have AIDS with a total of seven pneumothoraces. Each patient experienced a persistent air leak. Six of the pneumothoraces were managed successfully with doxycycline. Although the follow-up period was limited, there were no recurrences noted and the only side effect seen was chest pain in four which was easily controlled with narcotics. Doxycycline sclerotherapy can be used effectively for pleurodesis in the management of nontraumatic pneumothorax in the patient with AIDS.
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Affiliation(s)
- C A Read
- Georgetown University Department of Medicine, District of Columbia General Hospital, Washington, DC
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Wassermann K, Pothoff G, Kirn E, Fätkenheuer G, Krueger GR. Chronic Pneumocystis carinii pneumonia in AIDS. Chest 1993; 104:667-72. [PMID: 8365272 DOI: 10.1378/chest.104.3.667] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The clinical and radiologic presentation as well as the macroscopic and histologic characteristics of lung parenchyma in three HIV-infected patients with Pneumocystis carinii pneumonia (PCP) are detailed. The distinguishing clinical feature in these patients was a prolonged stable clinical course of the disease over at least 4 to approximately 24 months. Serial chest radiographs in two patients demonstrated persistent focal radiographic lesions. In one patient blebs in both upper lobes were not recognized until thoracoscopy/thoracotomy was performed. Biopsy specimens of affected areas revealed extensive interstitial fibrosis, occasional giant cell reactions, and honeycombing. In view of the combined clinical, radiologic, macroscopic, and histologic patterns, it is suggested that these patients had a chronic productive form of PCP rather than the well-known acute presentation of the disease. Data from the literature confirm the impression that atypical histologic lesions of PCP, either of a productive or destructive nature, are frequently related to a prolonged clinical course. It is unlikely that prophylactic pentamidine contributes to this entity. Coinfection with other pathogens may have a role. Given the recent evidence on augmented release of tumor necrosis factor a (TNFa) in HIV-associated pulmonary complications, it is speculated that TNFa may be of importance in producing focal fibrosis in Pneumocystis infection of the lung.
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Affiliation(s)
- K Wassermann
- Medical Department III, University of Cologne, Germany
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44
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Soubani AO. Pneumothorax during pulmonary tuberculosis in an HIV-infected patient. Chest 1993; 103:1926-7. [PMID: 8404144 DOI: 10.1378/chest.103.6.1926b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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45
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Affiliation(s)
- S E Weinberger
- Pulmonary and Critical Care Division, Beth Israel Hospital, Boston, MA 02215
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