Mycosis fungoides presenting as ARDS and diagnosed by bronchoalveolar lavage. Radiographic and pathologic pulmonary manifestations

Pulmonary manifestations in patients with cutaneous T-cell lymphomas

BACKGROUND

Lungs are among the most common organs of extranodal involvement by cutaneous T-cell lymphomas (CTCLs), yet the magnitude of lung involvement is not clear, and only a few case reports have addressed this issue to date. The objective of this study was to present the authors' observations on how to recognize lung involvement by CTCL and evaluate the clinical and radiologic differences between involvement of the lungs by CTCL and by pneumonia.

METHODS

A retrospective analysis was conducted of all 710 patients with confirmed CTCL who presented to The University of Texas M. D. Anderson Cancer Center between January 1996 and January 2005. Demographics, tumor characteristics, respiratory symptoms, thoracic imaging, microbiology, and laboratory studies were reviewed.

RESULTS

During the 9-year period that was studied, 122 patients presented with pulmonary radiologic abnormalities, including 67 patients who also had respiratory symptoms. Pneumonia (n = 27 patients) or lung involvement (n = 6 patients) in patients with CTCL were associated with high mortality rates (hazard ratio, 1.82; 95% confidence interval, 1.08-3.07%; P = .026). The pathogens that were isolated from lower respiratory cultures were Staphylococcus aureus (n = 4 patients), Aspergillus fumigatus (n = 2 patients), Mycobacterium avium-intracellulare (n = 2 patients), Pseudomonas aeruginosa (n = 1 patient), respiratory syncytial virus (n = 1 patient), and Candida parapsilosis (n = 1 patient). Most of the radiologic findings in patients with pneumonia were opacities. Six patients had involvement of lung by CTCL, and most common radiologic pulmonary findings were either a solitary nodule or multiple progressing pulmonary nodules.

CONCLUSIONS

Pneumonia and lung involvement by CTCL are relatively rare but portend poor survival. Thus, patients with CTCL should be evaluated thoroughly with thoracic imaging when they experience respiratory symptoms.

Gastric tube placement in young children

In this study, the internal position of a nasogastric/orogastric tube was determined in 72 children, prior to an abdominal radiograph, by measuring CO2 and pH and bilirubin of tube aspirate. Fifteen of the 72 tubes (20.8%) were incorrectly placed on radiograph. Using the suggested adult cutoff of pH 5, pH of aspirate correctly predicted misplacement outside the stomach in 7/28 (25%) of children and correctly predicted correct placement in the stomach in 34 of 40 children (85%). Using the suggested adult cutoff of bilirubin > or = 5 mg/dL, bilirubin monitoring failed to identify either of two incorrectly placed tubes. In this study, using an algorithm of assuming stomach placement if the pH of aspirate is < or = 5 and obtaining an abdominal radiograph when either no aspirate is obtained or the pH is >5 would have resulted in 92% accuracy. Alternatively, obtaining an abdominal radiograph would result in nearly 100% accuracy.

Diffuse large B-cell lymphoma manifesting as acute respiratory distress syndrome

Diffuse large B-cell lymphoma initially appears with intrathoracic manifestations in up to 26% of patients. However, pulmonary involvement with hematologic malignancies rarely manifests clinically as acute respiratory distress syndrome (ARDS). We report a case of diffuse large B-cell lymphoma manifesting as ARDS in a 39-year-old Filipina woman. This case illustrates the importance of including lymphoma in the differential diagnosis of otherwise unexplained ARDS. Early recognition and prompt treatment may affect survival.

What Is Known About Methods of Correctly Placing Gastric Tubes in Adults and Children

An abdominal radiograph is considered the "gold standard" for determining the position of flexible small-bore nasogastric/orogastric tubes. However, placement must be checked frequently while a tube is in place, and the summative radiation risk of multiple radiographs, as well as their expense, make the development of adequate bedside placement-locating methods imperative. Several methods of detecting tube placement have been investigated in adults, including: aspirating gastric contents and measuring the pH, bilirubin, pepsin, and trypsin levels; examining the visual characteristics of aspirate; placing the proximal end of the tube under water and observing for bubbles in synchrony with expirations; measuring the carbon dioxide level at the proximal end of the nasogastric/orogastric tube; auscultation for a gurgling sound over the epigastrium or left upper quadrant of the abdomen; and measuring the length from the nose/mouth to the proximal end of the tube. Many researchers have already concluded simple auscultation is not a reliable method to assess tube position because injection of air into the tracheobronchial tree or into the pleural space can produce a sound indistinguishable from that produced by injecting air into the gastrointestinal tract. In adults, only pH and bilirubin of aspirate have been shown both to reliably predict tube position and to have inexpensive simple bedside tests. In children, only pH of aspirate has been shown to be reliable. Research on gastric tube placement in children is relatively new because children are challenging to study in that they are considered a vulnerable population. This review of the literature includes results of both adult and pediatric studies. Tube placement error rates varied from 1.9% to 89.5% in adults and between 20.9% and 43.5% in children.

Exfoliative respiratory cytology in the diagnosis of leukemias and lymphomas in the lung

Leukemias and lymphomas involving the lung were diagnosed by means of exfoliative cytology in 31 specimens from 20 patients. Initial diagnostic categorizations included 29 specimens "positive for malignancy," including two thought to represent "carcinoma vs. lymphoma," and two considered suspicious for lymphoma. Previous diagnoses of lymphoma (13 patients) and acute myelogenous leukemia (AML) (2 patients) were available. In 5 additional patients, exfoliative respiratory cytology yielded the first diagnosis of hematopoietic malignancy. Cytologic diagnosis included nine large-cell and six small-cell non-Hodgkin's lymphomas (NHL), three Hodgkin's lymphomas (HD), and two AML. Key cytologic features included markedly pleomorphic and monomorphic cell populations in HD and NHL, respectively, as well as lack of tumor cell cohesion and necrosis in all cases. Cytologically, acute leukemia may be difficult to differentiate from large-cell NHL, and small-cell NHL from reactive/benign small lymphocytes. Blood, scant cellularity, crush artifacts, and apparent molding may affect diagnostic accuracy. Immunocytochemistry in cell block sections of sputa and washings is useful in the diagnostic workup in selected cases. Although involvement of the respiratory system by leukemias and lymphomas is uncommon and not always preceded by a history of malignancy, cytologic diagnosis is usually prompt, reliable, and accurate.

Bronchoalveolar lavage in the diagnosis of cancer

Bronchoalveolar lavage (BAL) is a widely used clinical procedure. To determine if BAL could provide useful information in the detection of cancer, 850 lavages from 421 patients having BAL for a variety of indications, 50 lavages in patients with Hodgkin's disease and 20 patients with breast cancer undergoing bone marrow transplant were reviewed. BALs were performed with 5 successive 20 cc aliquots in a wedged position. The return from the first aliquot was processed separately from the subsequent four aliquots. Diff-Quik stained cytocentrifuge preparations and Papanicolaou stained millipore filter preparations were analyzed. Thirty-five patients had biopsy-proven lung cancer. In 24 (68.6%) of these, BAL revealed cells diagnostic of malignancy. There were no false positives. Six out of 50 Hodgkin's disease patients had Reed Sternberg cells detected on BAL, and 7/20 breast cancer patients had malignant cells on BAL prior to chemotherapy. In summary, the routine performance of BAL, an easily performed and well-tolerated procedure, may prove to be useful in the routine assessment of patients for cancer.

Primary testicular choriocarcinoma with pulmonary metastases presenting as ARDS

We report a case in which ARDS was the presenting manifestation of testicular choriocarcinoma with numerous metastases to the lungs. We also review the literature on other cases in which ARDS developed as a result of neoplastic infiltration of the lungs and stress the fact that it may be indistinguishable from ARDS from other causes. Because potentially effective chemotherapy for the neoplastic processes most commonly involved (ie, germ cell tumors, acute leukemia and lymphoma) is available, we emphasize the importance of considering a neoplastic disorder in the differential diagnosis of cases of otherwise unexplained ARDS. Early accurate diagnosis could conceivably result in an improved outcome in these cases.