[Alveolar proteinosis: signs and prognosis using high-resolution computed tomography in 5 patients]

Pulmonary alveolar proteinosis is a rare idiopathic diffuse airspace disease characterized by intraalveolar accumulation of large quantities of lipoproteinaceous material. The clinical presentation and course are variable and the definite diagnosis is made by biopsy or broncho-alveolar lavage (BAL) that also constitutes the unique and empiric treatment. We report the extremely typical HRCT features of the disease found in a series of five patients diagnosed in our institution over a ten-year period. The HRCT signs and their evolution are discussed. A continuous spectrum of findings going from isolated ground glass opacities to lobular consolidation is found, but the most common and invariably present pattern consists of ground glass areas with superimposed smooth septal thickening; these areas have a patchy or geographic distribution--often termed the "crazy-paving" pattern--and are unlike pulmonary findings in any other disease.

[Diagnosis of intralobar pulmonary sequestration using helical computed tomography angiography: apropos of 3 patients]

Pulmonary sequestration is a rare congenital anomaly that consists of abnormal pulmonary tissue for which the arterial supply is usually derived from the aorta or its major branches. Considering clinical and anatomical aspects two types of sequestration, intralobar and extralobar, have been described. The definite diagnosis requires exact visualization of the anomalous feeding and draining vessels and this condition is essential when surgical treatment is necessary because of recurrent pulmonary infections. We report on 3 cases of intralobar sequestration successfully and extensively diagnosed in adults by spiral angioCT. Our series includes one symptomatic left case confirmed by surgery and two rare fortuitous asymptomatic right cases. In the three cases, the pulmonary abnormal tissue, the arterial supply and venous drainage were clearly identified. We conclude that, probably more than MRI, spiral angio-CT can presently be considered the first choice procedure to diagnose and evaluate pulmonary sequestration; the equal performance of spiral CT in imaging lung and vessels makes classical angiography unnecessary.

Chronic obstructive pulmonary disease and sleep apnea syndrome

The term "overlap syndrome" was introduced by Flenley to describe the association of sleep apnea syndrome (SAS) with chronic obstructive pulmonary disease (COPD). Epidemiologic data on the prevalence of the overlap syndrome are not available, but the frequency of an associated COPD in SAS patients has been emphasized in almost all the studies analyzing the development of respiratory insufficiency in SAS patients. In a large series (n = 264) of unselected SAS patients who had undergone detailed pulmonary function tests, we observed an obstructive ventilatory defect (FEV1/VC < 60%) in 30 of 264 patients (11%). These patients had lower daytime PaO2 and higher PaCO2 than the other patients and they had higher resting and exercising pulmonary artery mean pressure (right heart catheterization was performed in 215 of 264 patients). We conclude that the risk of developing respiratory insufficiency and cor pulmonale is higher in overlap patients.

Pulmonary hemodynamics in chronic obstructive pulmonary disease of the emphysematous type

Pulmonary hemodynamics have been extensively investigated in patients with chronic bronchitis or in 'mixed' patients (chronic bronchitis + emphysema) but rarely in patients with markedly predominant emphysema. We have investigated a large series (n = 151) of such patients, emphysema having been assessed on radiological, clinical and functional grounds. The mean age was 58 +/- 10 years; vital capacity (VC, % of predicted) = 81 +/- 19; forced expiratory volume in 1 s (FEV1) = 1,198 +/- 589 ml; FEV1/VC = 38 +/- 12%; PaO2 = 72 +/- 11 mm Hg; PaCO2 = 37.5 mm Hg. Pulmonary hypertension (PH), defined by a resting pulmonary artery pressure (PAP) of greater than or equal to 20 mm Hg, was present in only 31 of 151 patients. During steady-state exercise (40 W or less) an abnormally high PAP (greater than or equal to 30 mm Hg) was observed in 99 of 151 patients. Resting and exercising PAP were poorly correlated with resting PaO2 and PaCO2, but were better correlated with the amplitude of the respiratory pressure swings, FEV1, the transfer factor and exercising PaO2. Patients with PH (n = 31) showed significantly more obstruction and pulmonary distension than the remainder, but they did not differ from the non-PH patients with regard to resting PaO2. It is concluded that: (1) resting PH is not the rule in diffuse emphysema but exercising hypertension is frequent (2 of 3 patients), and (2) hypoxemia is not a determining factor of hemodynamic abnormalities in emphysema.