Diagnostic approach to the patient with diffuse lung disease

Chest X-ray Features of HIV-Associated Pneumocystis Pneumonia (PCP) in Adults: A Systematic Review and Meta-analysis

Background

The performance of chest x-ray (CXR) features for Pneumocystis pneumonia (PCP) diagnosis has been evaluated in small studies. We conducted a systematic review and meta-analysis to describe CXR changes in adults with HIV-associated laboratory-confirmed PCP, comparing these with non-PCP respiratory disease.

Methods

We searched databases for studies reporting CXR changes in people >15 years old with HIV and laboratory-confirmed PCP and those with non-PCP respiratory disease. CXR features were grouped using consensus terms. Proportions were pooled and odds ratios (ORs) generated using random-effects meta-analysis, with subgroup analyses by CD4 count, study period, radiology review method, and study region.

Results

Fifty-one studies (with 1821 PCP and 1052 non-PCP cases) were included. Interstitial infiltrate (59%; 95% CI, 52%-66%; 36 studies, n = 1380; I2 = 85%) and ground-glass opacification (48%; 95% CI, 15%-83%; 4 studies, n = 57; I2 = 86%) were common in PCP. Cystic lesions, central lymphadenopathy, and pneumothorax were infrequent. Pleural effusion was rare in PCP (0%; 95% CI, 0%-2%). Interstitial infiltrate (OR, 2.3; 95% CI, 1.4-3.9; I2 = 60%), interstitial-alveolar infiltrate (OR, 10.2; 95% CI, 3.2-32.4; I2 = 0%), and diffuse CXR changes (OR, 7.3; 95% CI, 2.7-20.2; I2 = 87%) were associated with PCP diagnosis. There was loss of association with alveolar infiltrate in African studies.

Conclusions

Diffuse CXR changes and interstitial-alveolar infiltrates indicate a higher likelihood of PCP. Pleural effusion, lymphadenopathy, and focal alveolar infiltrates suggest alternative causes. These findings could be incorporated into clinical algorithms to improve diagnosis of HIV-associated PCP.

Röntgenbefunde bei diffusen parenchymatösen Lungenerkrankungen

Klinisches Problem

Empfehlungen für die Praxis

[Chest radiography findings in diffuse parenchymal lung diseases]

CLINICAL ISSUE

Diffuse parenchymal lung diseases include a heterogeneous group of diseases of the lung parenchyma, the alveolar spaces, the vessels and the airways, which can be triggered by various pathomechanisms, such as inflammation and fibrotic changes. Since the therapeutic approaches and prognoses differ significantly between the diseases, the correct diagnosis is of fundamental importance. In routine clinical practice, next to the patients' history, the clinical presentation, the laboratory findings and the bronchoscopy, imaging plays a central role in establishing a diagnosis.

PRACTICAL RECOMMENDATIONS

The diagnosis of diffuse parenchymal lung diseases is an enormous challenge for clinicians, radiologists as well as pathologists and should therefore preferably be carried out in a multidisciplinary setting. Since patients often present with unspecific, respiratory symptoms, chest radiographs are the first imaging method used. Many patterns of diffuse parenchymal lung diseases (e.g., ground-glass opacities and consolidations), their distribution (e.g., cranial-caudal) and the presence of additional findings (e.g., mediastinal lymphadenopathy) are often already detectable on chest X‑rays. However, the imaging reference standard and thus, an integral part of the assessment of diffuse parenchymal lung disease, is the chest HR-CT. In some cases, the pattern of the HR-CT is pathognomonic, in others it is unspecific for a disease, so that further diagnostic steps are necessary.

Transbronchial cryobiopsy validity in diagnosing diffuse parenchymal lung diseases in Egyptian population

Objectives

We aimed to evaluate the efficacy, safety, and diagnostic utility of transbronchial cryobiopsy (TBCB) in diagnosing diffuse parenchymal lung diseases (DPLDs) in an Egyptian population and to identify common DPLD pathologies among them.

Methods

This prospective interventional study enrolled 25 Egyptian patients presenting to the Main Alexandria University Hospital who had clinical and radiological features of DPLD, but insufficient elements to achieve definite features of usual interstitial pneumonia on chest high-resolution computed tomography. Twelve patients were subjected to TBCB and 13 to forceps transbronchial lung biopsy (TBLB).

Results

The diagnostic yield was significantly higher among the TBCB group (83.3%), and increased to 100% with clinicopathological correlation vs the TBLB group (38.5%, P=0.041). Granulomatous diseases (24%, either sarcoidosis or hypersensitivity pneumonitis) were the commonest pathology, followed by malignancy (12%) in both groups. TBCB sizes were 2.5–5 mm vs 1-3 mm in TBLB (P<0.001), with preserved tissue architecture (91.7% vs 38.5%, respectively; P=0.011). Only 8.3% were complicated by insignificant bleeding grade 2 after TBCB, but no pneumothorax was detected.

Conclusion

TBCB is a safe, tolerable procedure with high diagnostic yield for evaluating DPLD with indefinite usual interstitial pneumonia pattern on high-resolution computed tomography.

Utility of Radial Probe Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Diffuse Lung Lesions

Background

Radial probe endobronchial ultrasound (R-EBUS) is widely used for diagnosing peripheral pulmonary lesions. However, the utility of R-EBUS-guided transbronchial lung biopsy (TBLB) for diffuse lung lesions (DLLs) remains unknown. We designed this study to evaluate the utility of R-EBUS-guided TBLB in DLLs.

Methods

This retrospective study enrolled patients admitted from January 2016 to November 2017 who underwent TBLB for DLLs. The R-EBUS-guided TBLB and blind TBLB groups were compared. DLL was defined as any lung disorder that involved more than one segment of the lung. In both the groups, fluoroscopy and guided sheath were not used during TBLB.

Results

A total of 127 patients underwent TBLB for DLLs (67 patients in the R-EBUS-guided TBLB group and 60 in the blind TBLB group). There were no differences in age, sex, and comorbid illnesses between the two groups. Furthermore, there was no difference in the TBLB diagnostic yield of the two groups (p=0.660) although more samples were collected from the R-EBUS-guided TBLB group (p=0.003). Procedure time was significantly longer in the R-EBUS-guided TBLB group than in the blind TBLB group (p<0.001). Thus, incidence of pneumothorax was significantly lower in the R-EBUS-guided TBLB group than in the blind TBLB group (p=0.032).

Conclusion

Diagnostic yield in DLLs did not differ between the R-EBUS-guided TBLB and blind TBLB groups. Findings show that R-EBUS-guided TBLB in DLLs may reduce risk of pneumothorax.

Validity of Ultrasound Lung Comets for Assessment of the Severity of Interstitial Pneumonia

OBJECTIVES

Ultrasound (US) lung comets are often observed in patients with interstitial lung disease or congestive heart failure, but few studies have explored the clinical importance of US lung comets in patients with the former condition. We explored whether the US lung comet number could be used to assess the severity of interstitial pneumonia.

METHODS

Forty stable patients with interstitial pneumonia were examined. Lung comets evident on transthoracic US imaging in 12 selected regions of the posterior chest wall were analyzed. We defined lung comets accompanied by thickened and irregular pleural lines as interstitial US lung comets; these predominated in patients with interstitial pneumonia. The total number of interstitial US lung comets was correlated with the data from chest high-resolution computed tomography, pulmonary function tests, serologic tests, and the 6-minute walk test.

RESULTS

The 40 patients included 16 with idiopathic pulmonary fibrosis and 24 with nonspecific interstitial pneumonia. Thirty-four patients had interstitial US lung comets, which were more common in the lower than the upper lung area. Good correlations were evident between the lung comet number and the extent of the reticular pattern on chest high-resolution computed tomography (r = 0.710; P < .01), predicted forced vital capacity (r = -0.614; P < .01), and lung diffusion capacity for carbon monoxide (r = -0.577; P < .01). Notably, the lung comet number had a strong negative correlation with the percutaneous oxygen saturation level after the 6-minute walk test (r = -0.751; P < .01).

CONCLUSIONS

The number of interstitial US lung comets evident on transthoracic US imaging may be a valuable marker of disease severity in patients with interstitial pneumonia.

The diagnostic yield and complications of open lung biopsies in kidney transplant patients with pulmonary disease

BACKGROUND

The purpose of this study was to assess the efficacy of open lung biopsy (OLB) in determining the specific diagnosis and the related complications in patients with undiagnosed diffuse pulmonary infiltrates.

METHODS

This single center, retrospective study included adult kidney transplant patients who underwent OLB. The patients had diffuse pulmonary infiltrates without definitive diagnoses and failed to respond to empiric antibiotic treatment. We analyzed the number of specific diagnoses, changes in treatment and the occurrence of complications in these patients. A logistic regression was used to determine which variables were predictors of hospital mortality.

RESULTS

From April 2010 to April 2014, 87 patients consecutively underwent OLB. A specific diagnosis was reached in 74 (85.1%) patients. In 46 patients (53%), their therapeutic management was changed after the OLB results. Twenty-five (28.7%) patients had complications related to the OLB. The hospital mortality rate was 25.2%. Age, SAPS3 score and complications related to the procedure were independent predictors of all-cause mortality.

CONCLUSIONS

OLB is a high-risk procedure with a high diagnostic yield in kidney transplant patients with diffuse pulmonary infiltrates who did not have a definitive diagnosis and who failed to respond to empiric antibiotic treatment. Complications related to OLB were common and were independently associated with intra-hospital mortality.

Invasive diagnostic techniques in idiopathic interstitial pneumonias

Fibrosing interstitial lung diseases (f-ILDs) represent a heterogeneous group of disorders in which the aetiology may be identified or, not infrequently, remain unknown. Establishing a correct diagnosis of a distinct f-ILD requires a multidisciplinary approach, integrating clinical profile, physiological and laboratory data, radiological appearance and, when appropriate, histological findings. Surgical lung biopsy is still considered the most important diagnostic tool as it is able to provide lung samples large enough for identification of complex patterns such as usual interstitial pneumonitis (UIP) and nonspecific interstitial pneumonitis. However, this procedure is accompanied by significant morbidity and mortality. Bronchoalveolar lavage is still a popular diagnostic tool allowing identification of alternative diagnoses in patients with suspected idiopathic pulmonary fibrosis (IPF) when an increase in lymphocytes is detected. Conventional transbronchial lung biopsy has a very low sensitivity in detecting the UIP pattern and its role in this clinical-radiological context is marginal. The introduction of less invasive methods such as transbronchial cryobiopsy show great promise to clinical practice as they can be used to obtain samples large enough to morphologically support a diagnosis of IPF or other idiopathic interstitial pneumonias, along with fewer complications. Recent advances in the field suggest that less invasive methods of lung sampling, without significant side effects, in combination with other diagnostic methods could replace the need for surgical lung biopsy in the future. Indeed, these new multidisciplinary procedures may become the main diagnostic work-up method for patients with suspected idiopathic interstitial pneumonia.

Locality-constrained Subcluster Representation Ensemble for lung image classification

In this paper, we propose a new Locality-constrained Subcluster Representation Ensemble (LSRE) model, to classify high-resolution computed tomography (HRCT) images of interstitial lung diseases (ILDs). Medical images normally exhibit large intra-class variation and inter-class ambiguity in the feature space. Modelling of feature space separation between different classes is thus problematic and this affects the classification performance. Our LSRE model tackles this issue in an ensemble classification construct. The image set is first partitioned into subclusters based on spectral clustering with approximation-based affinity matrix. Basis representations of the test image are then generated with sparse approximation from the subclusters. These basis representations are finally fused with approximation- and distribution-based weights to classify the test image. Our experimental results on a large HRCT database show good performance improvement over existing popular classifiers.

Influence of autoimmune biomarkers on interstitial lung diseases: A tertiary referral center based case-control study

Background

The benefit of routinely measuring autoimmune biomarkers to evaluate patients with interstitial lung disease (ILD) remains debated outside specific contexts such as connective tissue disease (CTD). This study aimed at evaluating the influence of biomarkers on outcome on patients with ILD in a case-control study at a tertiary referral center. We hypothesized that patients with positive autoimmune biomarkers have increased odds of developing ILD even in the absence of CTD.

Methods

We reviewed the medical records of 3573 patients seen at the ILD clinic in Mayo Clinic Rochester between September 2001 and September 2006. We assessed their clinical course through June 25, 2013. We included patients with patterns of ILD most often associated with CTD (n=1256) while excluding patients with other known causes of ILD. Controls (n=2317) included cases seen at the ILD clinic without evidence of ILD.

Results

We identified 930 (26%) cases of ILD alone, 124 (3%) CTD alone, 326 (9%) ILD combined with CTD, and 2193 (61%) with no ILD or CTD. Positive antinuclear antibodies (ANA), rheumatoid factor and aldolase were associated with ILD. After adjustment for age, gender, race, smoking history and CTD, ANA remained an independent risk factor for ILD (OR 1.70, 95% CI 1.33–2.17). Among patients with ILD, the presence of CTD but not biomarker alone was associated with a better survival.

Conclusion

In this study, the presence of positive biomarkers was associated with increased odds of ILD, even in the absence of overt CTD, but was not associated with a better outcome.

Surgical lung biopsy in transplant patients with diffuse lung disease: how much worse when the lung is the graft?

BACKGROUND

There are no data that compare the clinical presentation and results of surgical lung biopsy (SLB) for diffuse lung disease (DLD) in lung transplant patients, in contrast to individuals with other type of solid organ grafts. Our objective was to compare the clinical picture, radiologic pattern, pathology results, and outcomes of SLB for DLD in these two subsets of patients.

METHODS

We retrospectively reviewed the clinical records of transplant patients undergoing SLB for DLD at our institution between 2004 and 2011. Patients with lung transplants and those with other transplants were compared.

RESULTS

During the study period, 1,232 solid organ transplants were done at our institution. Of these, 49 patients (4%) had DLD that needed SLB for diagnosis, and 24 of these patients had a lung transplant. Dyspnea and a radiologic reticular pattern were more frequent in lung transplant patients, 21 of 24 vs 11 of 25 (p = 0.001) and 14 of 24 vs 7 of 25 (p = 0.03), respectively. Although postoperative complications and in-hospital deaths were more common in lung transplant patients, the differences were not statistically significant. Having the SLB performed for diagnosis, as opposed to being conducted for DLD that did not improve on medical treatment, had a protective effect on multivariate analysis (hazard ratio, 0.39; 95% confidence interval, 0.16 to 0.96; p = 0.042). A prior lung transplant was the only independent predictor of survival (hazard ratio, 4.62; 95% confidence interval, 1.53 to 13.92, p = 0.006).

CONCLUSIONS

It is relatively uncommon for a solid organ transplant patient with DLD to require a SLB. Clinical and radiologic presentation differ in patients with lung transplants compared with other transplants. Postoperative outcomes are not significantly different between the groups. SLB performed early in the course of the disease might be beneficial. Having a lung transplant is a significant negative predictor of survival.

The A2B adenosine receptor modulates pulmonary hypertension associated with interstitial lung disease

Development of pulmonary hypertension is a common and deadly complication of interstitial lung disease. Little is known regarding the cellular and molecular mechanisms that lead to pulmonary hypertension in patients with interstitial lung disease, and effective treatment options are lacking. The purpose of this study was to examine the adenosine 2B receptor (A(2B)R) as a regulator of vascular remodeling and pulmonary hypertension secondary to pulmonary fibrosis. To accomplish this, cellular and molecular changes in vascular remodeling were monitored in mice exposed to bleomycin in conjunction with genetic removal of the A(2B)R or treatment with the A(2B)R antagonist GS-6201. Results demonstrated that GS-6201 treatment or genetic removal of the A(2B)R attenuated vascular remodeling and hypertension in our model. Furthermore, direct A(2B)R activation on vascular cells promoted interleukin-6 and endothelin-1 release. These studies identify a novel mechanism of disease progression to pulmonary hypertension and support the development of A(2B)R antagonists for the treatment of pulmonary hypertension secondary to interstitial lung disease.

Dyspnea in palliative care: expanding the role of corticosteroids

Dyspnea is one of the most common symptoms in advanced cancer patients at the end of their life. It is often multifactorial with diverse malignant, nonmalignant, and cancer treatment related etiologies. Oxygen, opiates, and anxiolytics are commonly administered. Here a complex case of progressive dyspnea and its treatments in a patient with advanced pancreatic cancer is described, and its multiple potential contributing causes are identified and clinical responses evaluated. Literature review is conducted on pulmonary drug toxicity and tumor lymphangitic spread, and the role of corticosteroids in relieving dyspnea in the palliative care setting.

Interstitial lung disease: the initial approach

In the last decade, significant progress has been made toward a better understanding of interstitial lung disease (ILD). A valuable tool for the clinician is high-resolution computed tomography, which aids in narrowing the differential diagnosis in patients with ILD and obviates the need for surgical lung biopsy when a usual interstitial pneumonia pattern is present. Clinicians evaluating and caring for patients with ILD need to recognize associated comorbidities. Substantial evidence shows that implementation of a multidisciplinary approach provides a high standard of care for patients, leading to improvements in the accuracy of clinical diagnosis that can significantly affect patient outcome.

Bayesian probit regression model for the diagnosis of pulmonary fibrosis: proof-of-principle

Background

The accurate diagnosis of idiopathic pulmonary fibrosis (IPF) is a major clinical challenge. We developed a model to diagnose IPF by applying Bayesian probit regression (BPR) modelling to gene expression profiles of whole lung tissue.

Methods

Whole lung tissue was obtained from patients with idiopathic pulmonary fibrosis (IPF) undergoing surgical lung biopsy or lung transplantation. Controls were obtained from normal organ donors. We performed cluster analyses to explore differences in our dataset. No significant difference was found between samples obtained from different lobes of the same patient. A significant difference was found between samples obtained at biopsy versus explant. Following preliminary analysis of the complete dataset, we selected three subsets for the development of diagnostic gene signatures: the first signature was developed from all IPF samples (as compared to controls); the second signature was developed from the subset of IPF samples obtained at biopsy; the third signature was developed from IPF explants. To assess the validity of each signature, we used an independent cohort of IPF and normal samples. Each signature was used to predict phenotype (IPF versus normal) in samples from the validation cohort. We compared the models' predictions to the true phenotype of each validation sample, and then calculated sensitivity, specificity and accuracy.

Results

Surprisingly, we found that all three signatures were reasonably valid predictors of diagnosis, with small differences in test sensitivity, specificity and overall accuracy.

Conclusions

This study represents the first use of BPR on whole lung tissue; previously, BPR was primarily used to develop predictive models for cancer. This also represents the first report of an independently validated IPF gene expression signature. In summary, BPR is a promising tool for the development of gene expression signatures from non-neoplastic lung tissue. In the future, BPR might be used to develop definitive diagnostic gene signatures for IPF, prognostic gene signatures for IPF or gene signatures for other non-neoplastic lung disorders such as bronchiolitis obliterans.

Open lung biopsy for diffuse disease in patients with and without previously transplanted solid organs

BACKGROUND

Studies on whether surgical lung biopsy (SLB) modifies the treatment of patients with diffuse lung disease are conflicting, and information is limited on whether it alters treatment in solid-organ transplant recipients. Our objective was to determine and compare the rate of treatment change after SLB for diffuse lung disease in patients with and without a history of solid-organ transplantation.

METHODS

Patients undergoing SLB for diffuse lung disease between March 2004 and March 2009 were identified. A retrospective review was performed.

RESULTS

Sixty patients had SLB. Thirty-four patients (57%) had solid-organ transplantation. Twenty of 60 patients (33%) had a change in treatment as a result of the findings of the SLB. No significant differences in the treatment change rate were found between the transplant and nontransplant groups (10 of 34 versus 10 of 26; p = 0.46). Transplant patients were more likely to be on mechanical ventilation at the time of SLB (12 of 34 versus 3 of 26; p = 0.03). Mechanical ventilatory support at the time of SLB was associated with increased postoperative complications (odds ratio, 6.20; 95% confidence interval [CI], 1.70 to 22.66; p = 0.006) and in-hospital mortality (odds ratio, 9.75; 95% CI, 2.54 to 37.38; p = 0.001). Being on mechanical ventilation (hazard ratio, 3.91; 95% CI, 1.40 to 10.93; p = 0.009), a diagnosis of cancer (hazard ratio, 13.20; 95% CI, 2.87 to 60.78; p = 0.001), and a history of solid-organ transplantation (hazard ratio, 5.52; 95% CI, 1.08 to 28.14; p = 0.04) were independent predictors of survival.

CONCLUSIONS

Surgical lung biopsy changes treatment in one third of patients, with no significant difference between patients without transplantation and solid-organ transplant recipients. Patients who undergo SLB while on mechanical ventilation have a significantly increased risk of postoperative complications and death.

Pulmonary function tests

Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is the leading cause of morbidity and mortality in SSc patients. In autopsy studies, up to 70% of the SSc patients show histological evidence of lung involvement. In surgical lung biopsies from SSc-ILD patients, a pattern of non-specific interstitial pneumonia is present in a majority, while usual interstitial pneumonia is found in a more variable proportion of patients. Up to 90% of the SSc patients have lung function abnormalities, especially with respect to gas transfer. Pulmonary function testing, therefore, is a major tool of investigation of lung involvement in SSc.

Diagnosis of interstitial lung diseases

Interstitial lung diseases (ILDs), a broad heterogeneous group of parenchymal lung disorders, can be classified into those with known and unknown causes. The definitions and diagnostic criteria for several major forms of ILDs have been revised in recent years. Although well over 100 distinct entities of ILDs are recognized, a limited number of disorders, including idiopathic pulmonary fibrosis, sarcoidosis, and connective tissue disease-related ILDs, account for most ILDs encountered clinically. In evaluating patients with suspected ILD, the clinician should confirm the presence of the disease and then try to determine its underlying cause or recognized clinicopathologic syndrome. Clues from the medical history along with the clinical context and radiologic findings provide the initial basis for prioritizing diagnostic possibilities for a patient with ILD. High-resolution computed tomography of the chest has become an invaluable tool in the diagnostic process. A confident diagnosis can sometimes be made on the basis of high-resolution computed tomography and clinical context. Serologic testing can be helpful in selected cases. Histopathologic findings procured through bronchoscopic or surgical lung biopsy are often needed in deriving a specific diagnosis. An accurate prognosis and optimal treatment strategy for patients with ILDs depend on an accurate diagnosis, one guided by recent advances in our understanding of the causes and pathogenetic mechanisms of ILDs.

Two distinct clinical types of interstitial lung disease associated with polymyositis-dermatomyositis

Most patients with interstitial lung disease (ILD) associated with collagen vascular diseases (CVD) have a chronic indolent course with a relatively favorable prognosis; however, acute progression has been reported in some polymyositis-dermatomyositis patients. This study evaluated the prevalence, clinical features, and outcome relative to the presentation type of ILD in polymyositis-dermatomyositis (PM-DM). Ninety-nine patients with newly diagnosed polymyositis-dermatomyositis seen at the Asan Medical Center in Korea between January 1990 and December 2004 were enrolled. The clinical, radiological, and pathological findings were retrospectively reviewed. ILD were divided into acute (dyspnea within 1 month before diagnosis) or chronic types. ILD was found on chest radiographs in 33 patients (33.3%), and 11 (33.3%) of these were considered acute. The acute group presented with more severe respiratory symptoms, hypoxemia, and poorer lung function. Patients with an acute presentation had ground glass opacity and consolidation on high-resolution computed tomography (HRCT), in contrast to reticulation and honeycombing in the chronic type. Surgical lung biopsy of one acute-type patient revealed diffuse alveolar damage, whereas biopsies in the chronic type showed usual interstitial pneumonia (UIP) in four cases and nonspecific interstitial pneumonia (NSIP) in another four. Eight acute-type patients (72.7%) died of respiratory failure within 1-2 months despite steroid therapy. The 3-year mortality rate of the chronic-type patients (21.2%) was not statistically significantly different from that of the patients without ILD (10.2%). In polymyositis-dermatomyositis, the acute, severe form of ILD was not infrequent.

Pulmonary hypertension in patients with interstitial lung diseases

Pulmonary hypertension (PH) in patients with interstitial lung diseases (ILDs) is not well recognized and can occur in the absence of advanced pulmonary dysfunction or hypoxemia. To address this topic, we identified relevant studies in the English language by searching the MEDLINE database (1966 to November 2006) and by individually reviewing the references of identified articles. Connective tissue disease-related ILD, sarcoidosis, idiopathic pulmonary fibrosis, and pulmonary Langerhans cell histiocytosis are the ILDs most commonly associated with PH. Pulmonary hypertension is an underrecognized complication in patients with ILDs and can adversely affect symptoms, functional capacity, and survival. Pulmonary hypertension can arise in patients with ILDs through various mechanisms, Including pulmonary vasoconstriction and vascular remodeling, vascular destruction associated with progressive parenchymal fibrosis, vascular inflammation, perivascular fibrosis, and thrombotic angiopathy. Diagnosis of PH in these patients requires a high index of suspicion because the clinical presentation tends to be nonspecific, particularly in the presence of an underlying parenchymal lung disease. Doppler echocardiography is an essential tool in the evaluation of suspected PH and allows ready recognition of cardiac causes. Right heart catheterization is needed to confirm the presence of PH, assess its severity, and guide therapy. Management of PH in patients with ILDs is guided by identification of the underlying mechanism and the clinical context. An increasing number of available pharmacologic agents in the treatment of PH allow possible treatment of PH in some patients with ILDs. Whether specific treatment of PH in these patients favorably alters functional capacity or outcome needs to be determined.

Procedure diagnostiche invasive nelle malattie infiltrative diffuse del polmone

Le malattie polmonari che, già all’esordio clinico e/o nel loro decorso, coinvolgono più di un lobo e caratterizzate dall’accumulo od infiltrazione nel lobulo polmonare secondario di sostanze o cellule non normalmente presenti in tale sede o presenti, comunque, in quantità anomala, possono essere definite con il termine di pneumopatie infiltrative diffuse (PID) [1].

Interstitial lung disease in patients with non-small-cell lung cancer treated with epidermal growth factor receptor inhibitors

Interstitial lung disease (ILD) refers to a diverse range of pulmonary fibrotic disorders and may be hard to accurately diagnose, as distinguishing it from other pulmonary diseases can be difficult. Estimations of the incidence in populations are confounded by the complexity of the different forms of the disorder. In addition, ILD is a comorbid disease of lung cancer and is seen after most forms of chemotherapy and radiotherapy for advanced lung cancer. Incidences of >or=10% have been reported; however, whatever the true incidence, both chemotherapy and radiotherapy enhance the risk of developing ILD. ILD has also been reported with the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, including erlotinib (Tarceva, OSI-774) and gefitinib (IRESSA). In a large number of gefitinib-treated patients (n > 185,000) an incidence of approx 1% has been observed (approx 2% in Japan; 0.3% in the rest of the world). Nevertheless, as with other treatments for advanced non-small-cell lung cancer, the clinical benefit outweighs the risk of ILD. In this article, we review the data on ILD with EGFR inhibitors and other common lung cancer treatments.

Pulmonary disease in systemic lupus erythematosus and the antiphospholpid syndrome

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by disturbances in innate and adaptive immune mechanisms. Multiple systems and organs may be involved. Tissue damage and dysfunction are mediated by autoantibodies and immune complex formation. The lungs are among the organ systems commonly involved. The pulmonary manifestations usually occur in patients with multisystem disease and include: pleural involvement, parenchymal disease, pulmonary vascular disease and diaphragmatic dysfunction. Manifestations may range from sub-clinical abnormalities to life threatening disorders. Many of the pulmonary manifestations characteristic of SLE are seen in the antiphospholipid syndrome (APS) as well, in both the primary and secondary syndrome. In this review the diverse pulmonary manifestations are described as well as the diagnostic modalities available, including the use of induced sputum evaluation for early diagnosis and follow up. New treatment modalities are referred to.