Katayama syndrome disguised as eosinophilic asthma with acute systemic symptoms and pulmonary nodules

Background

Katayama syndrome is an acute manifestation of schistosomiasis, a parasitic infection that manifests itself through a hypersensitivity reaction to migrating larvae and early egg deposition. Left undiagnosed and untreated, acute schistosomiasis can develop into chronic schistosomiasis which can lead to debilitating morbidity such as pulmonary hypertension. This case highlights that Katayama syndrome can also been seen in regions where the parasite is not endemic, as it occurs in travelers returning from endemic regions or in immigrants.

Case presentation

We describe the case of a 26-year-old asthmatic male, who presented with systemic symptoms including fever, myalgia, night sweats as well as gastro-intestinal and pulmonary complaints since five days. At presentation, there was a raised blood eosinophil count and nodular lesions were seen on computed tomography. After considering diagnoses such as tuberculosis, vasculitis and hypereosinophilic syndrome, it was repeated history taking that revealed that the patient had suffered from swimmer's itch during a stay in Guinea. A stool sample showed microscopic presence of Schistosoma mansoni eggs, confirming the diagnosis of Katayama syndrome. The patient was treated with tapered corticosteroids to suppress the hypersensitivity reaction and praziquantel was added to cure the parasitic infection. This led to a complete resolution of the patients' symptoms and radiological abnormalities. Negative stool samples confirmed the eradication of the schistosomes.

Conclusions

Swimmer's itch and Katayama syndrome are manifestations of acute schistosomiasis. It is important to recognize the syndrome, because early diagnosis and adequate treatment can prevent chronic disease and significant morbidity.

COVID-19 vaccination acceptance, safety and side-effects in European patients with severe asthma

Background

Vaccination is vital for achieving population immunity to severe acute respiratory syndrome coronavirus 2, but vaccination hesitancy presents a threat to achieving widespread immunity. Vaccine acceptance in chronic potentially immunosuppressed patients is largely unclear, especially in patients with asthma. The aim of this study was to investigate the vaccination experience in people with severe asthma.

Methods

Questionnaires about vaccination beliefs (including the Vaccination Attitudes Examination (VAX) scale, a measure of vaccination hesitancy-related beliefs), vaccination side-effects, asthma control and overall safety perceptions following coronavirus disease 2019 (COVID-19) vaccination were sent to patients with severe asthma in 12 European countries between May and June 2021.

Results

660 participants returned completed questionnaires (87.4% response rate). Of these, 88% stated that they had been, or intended to be, vaccinated, 9.5% were undecided/hesitant and 3% had refused vaccination. Patients who hesitated or refused vaccination had more negative beliefs towards vaccination. Most patients reported mild (48.2%) or no side-effects (43.8%). Patients reporting severe side-effects (5.7%) had more negative beliefs. Most patients (88.8%) reported no change in asthma symptoms after vaccination, while 2.4% reported an improvement, 5.3% a slight deterioration and 1.2% a considerable deterioration. Almost all vaccinated (98%) patients would recommend vaccination to other severe asthma patients.

Conclusions

Uptake of vaccination in patients with severe asthma in Europe was high, with a small minority refusing vaccination. Beliefs predicted vaccination behaviour and side-effects. Vaccination had little impact on asthma control. Our findings in people with severe asthma support the broad message that COVID-19 vaccination is safe and well tolerated.

Getting the Most out of Spirometry: A Tool to Guide Dry Powder Inhaler Use

<b><i>Background:</i></b> Dry powder inhaler (DPI) use requires sufficient peak inspiratory flow over the DPI internal resistance (PIF_R). <b><i>Objectives:</i></b> We examined whether spirometric peak inspiratory flow (PIF_spiro) could serve to predict PIF_R in patients with obstructive lung disease. <b><i>Method:</i></b> Thirty healthy nonsmokers and 140 stable outpatients (70 COPD, 70 asthma) performed spirometry according to the 2019 ERS/ATS spirometry update, yielding PIF_spiro. Using a PIF_R measurement device with varying orifices, all subjects’ PIF_R values were recorded for 5 predefined resistance levels, characterized by 5 orifice cross sections (S_R). A test group including all healthy subjects, 30 of the asthma, and 30 of the COPD patients was used to establish the relationship between PIF_R and both PIF_spiro and S_R by multiple regression. A validation group including the remaining 40 asthma and 40 COPD patients, served to verify whether their predicted PIF_R value corresponded to the measured PIF_R for each resistance level. <b><i>Results:</i></b> The asthma (FEV₁ = 78 ± 17 [SD] %pred) and COPD (FEV₁ = 46 ± 17 [SD] %pred) patients under study had varying airway obstruction. In the test group, PIF_R could be predicted by ln[PIF_spiro] (<i>p</i> &#x3c; 0.0001), S_R (<i>p</i> &#x3c; 0.0001), and S_R² (<i>p</i> = 0.006), with an adjusted <i>R</i>² = 0.71. In the validation group, estimated PIF_R did not significantly differ from measured PIF_R (<i>p</i> &#x3e; 0.05 for the 5 resistance levels). <b><i>Conclusions:</i></b> We propose a simple method to predict PIF_R for a range of common DPI resistances, based on the device characteristics and on the patient’s characteristics reflected in PIF_spiro. As such, routine spirometry can serve to estimate a patient’s specific PIF_R without the need for additional testing.

Not a wild goose chase: long-lasting MRSA negative status following eradication therapy for chronic MRSA infection in patients with cystic fibrosis

OBJECTIVES

Prevalence of MRSA in patients with CF has risen over the past decades, and chronic infection with MRSA is associated with worse outcome in this patient group.

METHODS

This retrospective observational study investigated long-term eradication rate in pediatric and adult CF patients with chronic MRSA infection, using a 6-month eradication regimen containing 2 oral antibiotics, combined with topical decolonisation measures. Respiratory tract cultures were performed at least every three months, from the first MRSA-positive culture onwards.

RESULTS

A total of 24 patients with chronic MRSA infection were identified from our CF patient registry, of which 13 patients underwent an eradication attempt. The regimen consisted of 2 oral antibiotics: a combination of rifampicin, fusidic acid, clindamycin and co-trimoxazol, based on the sensitivity pattern of the MRSA strain. At the end of the study period (median 8.2 years), 12 out of 13 patients (92%) were MRSA negative. None of the patients interrupted treatment due to side-effects.

CONCLUSIONS

Eradication of chronic MRSA infection is feasible, well-tolerated and highly successful, and can offer a long-lasting MRSA-negative status, obviating the need for patient segregation.

Lung cancer in a CF patient: combination of bad luck or is there more to say?

Patients with cystic fibrosis have increased risk for gastrointestinal cancer, lymphoid leukemia and testicular carcinomas. Chronic inflammation does not seem to be the only contributing factor. Mutations and epigenetic alterations in the CFTR gene may alter susceptibility to develop cancer. Lung cancer is up to now not frequently observed in CF patients. In lung cancer patients without CF low CFTR expression is significantly associated with advanced staging, lymph node metastasis. As the management and life expectancy of patients with cystic fibrosis have improved substantially in recent years, we expect an increased number of these patients diagnosed with lung cancer. In addition, it is possible that they, as a result of CFTR-dysfunction, will present with more aggressive lung tumors. Treating cancer in CF patients is a challenge because of multi-organ involvement and chronic colonization by resistant pathogens. The effectiveness and safety of immunotherapy in this population needs to be further evaluated.

Anti-Interleukin-5 Therapy Is Associated with Attenuated Lung Function Decline in Severe Eosinophilic Asthma Patients from the Belgian Severe Asthma Registry

BACKGROUND

Asthmatics have accelerated lung function decline over time compared with healthy individuals.

OBJECTIVE

To evaluate risk factors for accelerated lung function decline.

METHODS

In a longitudinal analysis on severe asthmatics enrolled in the Belgian Severe Asthma Registry with at least 2 visits a minimum of 12 months apart, we compared characteristics of patients with and without decline (loss of post-bronchodilation forced expiratory volume in 1 s [FEV₁] (% predicted)/y greater than zero) over time. Multiple linear regression was applied to study the factors independently associated with FEV₁ decline.

RESULTS

In the overall population (n = 318), median annual FEV₁ decline was 0.27 (-4.22 to 3.80) % predicted/y over a period of 23 months (12-41 months). Asthma was less controlled at baseline in nondecliners than in decliners (53%). Lung function and residual volume at baseline were higher in the declining group. Decliners presented with increased bronchial reactivity (ie, a lower provocative concentration of methacholine causing a 20% fall in FEV₁) at baseline. Twenty-five percent of nondecliners were started on anti-interleukin-5 (anti-IL-5) for severe eosinophilic asthma during the study compared with 10% of decliners. The multivariable model suggested that Asthma Control Questionnaire score at baseline, late-onset asthma, and addition of anti-IL-5 during follow-up were associated with lower FEV₁ decline, independently from other variables such as evolution in exacerbations, smoking status, inhaled corticosteroids or oral corticosteroids dose, or add-on anti-immunoglobulin E over time, whereas reversibility to salbutamol and higher FEV₁ were associated with accelerated FEV₁ decline.

CONCLUSIONS

Add-on therapy with anti-IL-5 in severe eosinophilic asthma was associated with an attenuated FEV₁ decline. The causality of this observation should, however, be confirmed in future prospective controlled studies.

A woman and her breathtaking jewelry

We present the case of a 45-year-old woman, working as a silver polisher since 11 years, complaining of dyspnea on exertion and dry cough. Intensive diagnostic workup, including high-resolution CT scan of the chest and lung biopsy by VATS led to the diagnosis of pulmonary siderosis. Pulmonary siderosis is a benign, non-fibrotic type of pneumoconiosis caused by inhalation of iron oxide, which is generally asymptomatic (except in concurrent smoking or concurrent silicosis). Combination of relevant exposure and the typical findings on CT-imaging (centrilobular nodules without cranio-caudal gradient) usually strongly suggest the diagnosis, but this should always be discussed at a multidisciplinary consultation. This includes discussing whether to perform a lung biopsy for histological confirmation. Cessation of the causative exposure is the only-treatment one can take and then radiological features can improve and even disappear of time. Unfortunately, this treatment has an enormous impact on patient's life because it implies changing profession. Preventive measures can be taken by employers (respiratory equipment and ventilation). This case illustrates that physicians should stay vigilant about occupational exposures in clinical practice as well as the need for multidisciplinary consult in patients suspected of having interstitial lung disease.

Peak In- and Expiratory Flow Revisited: Reliability and Reference Values in Adults

BACKGROUND

While peak in- and expiratory flow rates offer valuable information for diagnosis and monitoring in respiratory disease, these indices are usually considered too variable to be routinely used for quantification in clinical practice.

OBJECTIVES

The aim of the study was to obtain reproducible measurements of maximal inspiratory flow rates and to construct reference equations for peak in- and expiratory flows (PIF and PEF).

METHOD

With coaching for maximal effort, 187 healthy Caucasian subjects (20-80 years) performed at least 3 combined forced inspiratory and expiratory manoeuvres, until at least 2 peak inspiratory flow measurements were within 10% of each other. The effect on PIF preceded by a slow expiration instead of a forced expiration and PIF repeatability over 3 different days was also investigated in subgroups. Reference values and limits of normal for PIF, mid-inspiratory flow, and PEF were obtained according to the Lambda-Mu-Sigma statistical method.

RESULTS

A valid PIF could be obtained within 3.3 ± 0.6(SD) attempts, resulting in an overall within-test PIF variability of 4.6 ± 3.2(SD)%. A slow instead of a forced expiration prior to forced inspiration resulted in a significant (p < 0.001) but small PIF increase (2.5% on average). Intraclass correlation coefficient for between-day PIF was 0.981 (95% CI: 0.960-0.992). Over the entire age range, inter-subject PIF variability was smaller than in previous reports, and PIF could be predicted based on its determinants gender, age, and height (r2 = 0.53).

CONCLUSIONS

When adhering to similar criteria for the measurement of effort-dependent portions of inspiratory and expiratory flow-volume curves, performed according to current ATS/ERS standards, it is possible to obtain reproducible PIF and PEF values for use in routine clinical practice.

Clinical status and lung function 10 weeks after severe SARS-CoV-2 infection

INTRODUCTION

Since studies about clinical status after COVID-19 are scarce, we conducted a cross sectional study with assessment of residual symptoms, lung function and chest CT.

MATERIALS AND METHODS

During an outpatient follow-up visit, chest CT, pulmonary function and COVID-19 related symptoms were assessed approximately 10 weeks after diagnosis. Demographics, baseline (time of diagnosis) CT score and blood results were collected from patient files. Association between lung function and clinical characteristics (baseline), blood markers (baseline), chest CT (baseline and follow-up) and symptom score (followup) was analysed. Mann-Whitney U tests and Chi squared tests were used for statistical comparison between subgroups with and without restriction.

RESULTS AND DISCUSSION

Two hundred-twenty subjects were evaluated at a median follow-up of 74±12 (SD) days. Median symptom and median CT score at follow-up were 1(IQR=0- 2) and 2(IQR=0-6) respectively. Forty-six percent of patients had normal lung function, while TLC and TLCO below the lower limit of normal were observed in 38% and 22% of subjects respectively. This restrictive pulmonary impairment was associated with length of hospital stay (8 vs 6 days; p=0.003), admission to the intensive care unit (27% vs 13%;p=0.009), and invasive mechanical ventilation (10% vs 0.7%;p=0.001), but not with symptom score or CT score at baseline and follow-up.

CONCLUSIONS

Fifty-four percent of COVID-19 survivors had abnormal lung function 10 weeks after diagnosis. Restriction was the most prevalent pulmonary function, with the more critically ill patients being more prone to this condition. Yet, restriction could not be linked with abnormal imaging results or residual symptoms.

COVID-19 and biologics in severe asthma: data from the Belgian Severe Asthma Registry

Epidemiological studies suggest that patients with asthma are not at an increased risk of severe coronavirus disease 2019 (COVID-19) caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1–3]. Recent studies indicate that the severity of COVID-19 in patients with asthma is likely to depend on multiple factors. A type 2-low asthma phenotype, use of oral corticosteroids and severe asthma could be aggravating factors, while maintenance treatment with inhaled corticosteroids (ICS) and good asthma control are probably protective [4]. However, there is currently scarce information on the risk associated with COVID-19 in subjects with severe asthma and/or the use of biologics. Since eosinopenia is a biomarker for the severity of COVID-19 [5], the eosinophil depletion induced by anti-IL5 and anti-IL5 receptor blocking monoclonal antibodies raises concern in patients and their treating physicians.

In a cohort of severe asthma patients, a small number of COVID-19 cases was found; none resulted in death or a very severe disease course. Use of biologics for severe allergic or severe eosinophilic asthma was not associated with a higher risk of COVID-19. https://bit.ly/3ndZmyD

Chronic oral corticosteroids use and persistent eosinophilia in severe asthmatics from the Belgian severe asthma registry

BACKGROUND

Severe asthma (SA) may require frequent courses or chronic use of oral corticosteroids (OCS), inducing many known side effects and complications. Therefore, it is important to identify risk factors of chronic use of OCS in SA, considering the heterogeneity of clinical and inflammatory asthma phenotypes. Another aim of the present analysis is to characterize a subpopulation of severe asthmatics, in whom blood eosinophil counts (BEC) remain elevated despite chronic OCS treatment.

METHODS

In a cross-sectional analysis of 982 SA patients enrolled in the Belgian Severe Asthma Registry (BSAR) between March 2009 and February 2019, we investigated the characteristics of the OCS treated patients with special attention to their inflammatory profile.

RESULTS

At enrollment, 211 (21%) SA patients were taking maintenance OCS (median dose: 8 [IQR: 5-10]) mg prednisone equivalent). BEC was high (> 400/mm3) in 44% of the OCS treated population. Multivariable logistic regression analysis showed that risk factors for chronic use of OCS in SA were late-onset asthma (i.e. age of onset > 40 yr), frequent exacerbations (i.e. ≥2 exacerbations in the previous year) and non-atopic asthma. Late-onset asthma was also a predictor for persistently high BEC in OCS treated SA patients.

CONCLUSION

These data showed a significant association between a persistently high BEC and late-onset asthma in OCS treated SA patients. Whether it is poor compliance to treatment or corticosteroid insensitivity the reasons for this association warrants further investigation.

The stability of blood eosinophils in stable chronic obstructive pulmonary disease: a retrospective study in Belgian primary care

Background

Blood eosinophil counts (BEC) were recently included in the 2019 Global Initiative for Obstructive Lung Disease (GOLD) guideline as an easily accessible theragnostic biomarker for Chronic Obstructive Pulmonary Disease (COPD). However, the stability of BEC remains insufficiently studied.

Methods

We conducted a retrospective study in six primary care practices in Belgium on data from Electronic Health Records of stable COPD patients, to characterise the stability of blood eosinophils over time. We report the percentage of patients with BEC persistently below or above the 2019 GOLD guideline thresholds (100 and 300 cells/μL). For each patient the mean, standard deviation (SD) and relative standard deviation (RSD) of the BEC were calculated to determine the intra-patient variability.

Results

Ninety-eight patients were included, yielding 1082 eosinophil measurements (median 8 measurements/patient), with BEC ranging between 0 and 1504 cells/μL. Four (4.1%) patients had BEC persistently below 100 cells/μL, 34 (34.7%) had measurements persistently above this threshold. Approximately half of the patients (51.0%) had BEC persistently below 300 cells/μL and 3 (3.1%) patients had counts persistently above this threshold. 28.6% of patients crossed both threshold values throughout the registration period. The mean BEC per patient ranged between 15 and 846 cells/μL with an intra-patient SD between 5 and 658 cells/μL. The mean intra-patient RSD was 0.46. There was a significant strong positive correlation (Pearson analyses) between the mean BEC and SD (r = 0.765; n = 98). Simple linear regression was used to further describe the influence of the mean eosinophil count on the SD (B = 0.500; 95%CI 0.415–0.586; n = 98; p < 0.001).

Conclusion

BEC can be variable in individual COPD patients. Therefore, the use of a single measurement to guide therapeutic decisions remains debatable. Further prospective research remains necessary to validate the reproducibility of this biomarker.

Abstract P2-13-01: Quality of life in survivors of stage I-II breast cancer, 10 years outcome of a randomized clinical trial comparing post-operative hypofractionation with Tomotherapy versus conventional radiation treatment (TomoBreast)

Purpose: TomoBreast compared normofractionated conventional radiotherapy (CR) with hypofractionated tomotherapy (TT), on the hypothesis that normal-tissue sparing by tomotherapy should reduce lung-heart toxicity. Quality of life (QOL) outcomes at 8-12 years are presented herein. Materials-Methods: The trial enrolled 123 women in 2007-2011, 64 were randomized to CR, 59 to TT. CR delivered 50 Gy in 25 fractions/5 weeks to the breast/chest wall and regional nodes if node-positive, 16 Gy/8 fractions/1.6 weeks sequential-boost in patients who underwent lumpectomy. TT delivered 42 Gy/15 fractions/3 weeks to the breast/chest wall and regional nodes if node-positive, concurrently with chemotherapy by institution's practice, 51 Gy simultaneous-integrated-boost in patients with lumpectomy. QOL assessments used the EORTC questionnaires QLQ-C30 and QLQ-BR23. Intent-to-treat analyses used the linear mixed-effect model (LMM), and survival analysis applied to time to &gt;10% deterioration (TTD) in QOL-measures. A cardiorespiratory composite TTD event was defined as deterioration in any of the dyspnea, fatigue, physical functioning, or pain measures. Results: On survival and tumor control, there were no differences in overall and disease-free survival. On QOL analysis by LMM, TT in late &gt;2 years period was associated with poorer nausea-scores (modeled deterioration 21.2%, P&lt;0.001), better cognitive functioning (15.7%, P&lt;0.001), better freedom from dyspnea (9.4%, P=0.027), and better freedom from financial stress (13.3%, P&lt;0.001) (Table 1, P-values * ≤.05; ** ≤.01; *** ≤.001). By TTD, the composite outcome showed reduced risk of cardiorespiratory deterioration; the estimated 10-years risk of deterioration was 29.8% in the CR arm versus 13.8% in the TT arm, P=0.033. Conclusion: The long term result shows significantly better cardiorespiratory and other QOL scores in favor of hypofractionation with tomotherapy. Clinical trials to further enhance lung-heart outcome in breast cancer radiotherapy should be considered.

Linear mixed model by Time and Tomotherapy. Coef: %change from baselineEarly (≤2 years) assessmentLate (&gt;2 years) assessmentTime Early effect coef/yearP- Tomotherapy Early effectP- Time Late effect coef/yearP- Tomotherapy Late effectP- Global health status11.3*-7.4*-0.6-4.7C30 summary5.8**-1.2-0.62.2Physical functioning5.30.3-0.5-1.0Role functioning25.0***-4.5-1.32.1Emotional functioning2.20.7-0.75.2Cognitive functioning3.63.1-1.5*15.7***Social functioning13.4**-2.1-1.0-8.4Fatigue free13.7**-1.6-0.62.3Appetence12.2**-0.70.52.1Nausea vomiting free9.3-12.1*-0.6-21.2***Constipation free-0.50.5-1.07.3Diarhea free3.1-3.3-0.7-3.6Pain free10.8-4.7-0.1-2.3Dyspnea free4.90.8-0.89.4*Sleep loss free3.2-2.80.3-1.4Financial stress free1.03.1-0.213.3***Good body image24.3**1.7-0.99.5Sexual functioning13.10.5-3.3-3.3Sexual enjoyment-1.6-4.31.8-2.1Future worry-free18.0**-5.6-1.0-13.3Systemic symptom free3.30.30.14.3Breast symptom free12.1**-0.50.65.2Arm symptom free-0.80.2-0.53.8Hair loss free23.40.5-0.3-20.6

Citation Format: Hilde Van Parijs, Vincent Vinh-Hung, Christel Fontaine, Guy A Storme, Nele Adriaenssens, Shane Hanon, Marian Vanhoeij, Maryam B Lustberg, Nicole Williams, Dung M Nguyen, Nam P Nguyen, Claire Verschraegen, Mark De Ridder. Quality of life in survivors of stage I-II breast cancer, 10 years outcome of a randomized clinical trial comparing post-operative hypofractionation with Tomotherapy versus conventional radiation treatment (TomoBreast) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-13-01.

Severe asthma: oral corticosteroid alternatives and the need for optimal referral pathways

OBJECTIVE

Patients with severe asthma require high-dose inhaled corticosteroids, with or without add-on treatments, to maintain asthma control. Because symptom control remains unsatisfactory in some patients despite these therapies, maintenance therapy with oral corticosteroids (OCS) remains considered a treatment option by physicians. Besides physician-diagnosed exacerbations, many patients intermittently self-medicate with OCS during episodes of worsening symptoms or as a prevention of such episodes. However, long-term OCS use is associated with several comorbidities that may decrease health-related quality of life, worsen prognosis, and should ideally require monitoring and management. In this review, we discuss the adverse effects of OCS use, the OCS-sparing effect of biologics in severe asthma, and the need for optimal referral pathways to ensure the best outcomes for those at-risk asthma patients.

DATA SOURCES

PubMed.

STUDY SELECTION

Studies with results on the OCS-sparing effect of biologics in adult severe asthma were selected.

RESULTS

Chronic and intermittent OCS use in asthma is associated with considerable adverse effects in asthma. Omalizumab, mepolizumab, benralizumab, and dupilumab reduce the need for OCS in severe asthma, while also reducing the exacerbation rate and improving several patient-related outcomes.

CONCLUSION

Targeted biologic therapies have revolutionized the treatment of uncontrolled severe asthma by reducing or even eliminating the need for OCS and improving other major outcomes. Novel agents are now rapidly increasing the therapeutic armamentarium, but additional efforts are needed to optimize referral pathways in order to ensure sustainable access to these therapies.

Platypnea-orthodeoxia syndrome: an unusual presentation of a complex disease

BACKGROUND

Platypnea-orthodeoxia syndrome (POS) is an uncommon disorder characterized by dyspnea (=platypnea) and desaturation (=orthodeoxia) in upright position and improvement of symptoms and blood oxygenation in supine position. Clinical presentation is heterogeneous and often confuses the clinician.

OBJECTIVES

The present case report illustrates a complicated presentation of the underlying syndrome.

METHODS

Description of a POS case in a 73-year-old female with thorough workup and tailored treatment.

RESULTS

In this case report, we describe a rather unusual presentation of POS, with posture-dependent hypoxemic-induced psychiatric symptoms. Further investigations revealed the presence of a patent foramen ovale with atrial septum aneurysm, an aortic root dilatation up to 41 mm and bilateral lower lobe lung emboli. The ventilation-perfusion mismatch aggravated the desaturation in upright position. Since the patient remained symptomatic after treatment of the functional trigger, we choose for the percutaneous closure of the anatomical defect. We used an Occlutech Figulla Flex II UNI 33/33 mm occluder resulting in a perfect closure of the defect.

CONCLUSION

Abnormal shunting in upright position may be the result of different underlying conditions, requiring a thorough workup and a tailored treatment. In case of serious co-morbid conditions, an endovascular procedure to close a patent foramen ovale, after unsuccessful treatment of precipitating conditions, should be considered.

Mild Lung Restriction in Breast Cancer Patients After Hypofractionated and Conventional Radiation Therapy: A 3-Year Follow-Up

PURPOSE

To assess the effect of radiation therapy on lung function over the course of 3 years.

METHODS AND MATERIALS

Evolution of restrictive and obstructive lung function parameters was investigated in 108 breast cancer participants in a randomized, controlled trial comparing conventional radiation therapy (CR) and hypofractionated tomotherapy (TT) (age at inclusion ranging 32-81 years). Spirometry, plethysmography, and hemoglobin-corrected diffusing capacity were assessed at baseline and after 3 months and 1, 2, and 3 years. Natural aging was accounted for by considering all lung function parameters in terms of percent predicted values using the most recent reference values for women aged up to 80 years.

RESULTS

In the patients with negligible history of respiratory disease or smoking (n=77), the greatest rate of functional decline was observed during the initial 3 months, this acute decrease being more marked in the CR versus the TT arm. During the remainder of the 3-year follow-up period, values (in terms of percent predicted) were maintained (diffusing capacity) or continued to decline at a slower rate (forced vital capacity). However, the average decline of the restrictive lung function parameters over a 3-year period did not exceed 9% predicted in either the TT or the CR arm. Obstructive lung function parameters remained unaffected throughout. Including also the 31 patients with a history of respiratory disease or more than 10 pack-years showed a very similar restrictive pattern.

CONCLUSIONS

In women with breast cancer, both conventional radiation therapy and hypofractionated tomotherapy induce small but consistent restrictive lung patterns over the course of a 3-year period, irrespective of baseline respiratory status or smoking history. The fastest rate of lung function decline generally occurred in the first 3 months.

Whole-lung lavage: a successful treatment for restoring acinar ventilation distribution in primary acquired pulmonary alveolar proteinosis

A 51-year-old active smoker with primary acquired pulmonary alveolar proteinosis (PAP) diagnosed by biopsy and anti-GM-CSF antibodies was treated safely with whole-lung lavage (WLL). This resulted in a rapid improvement of symptoms and arterial blood oxygenation, but not of standard lung function parameters. However, we also performed the multiple-breath nitrogen washout (MBW) test to determine the lung clearance index (LCI) as well as indices of acinar ventilation heterogeneity (S(acin)) and conductive ventilation heterogeneity (S(cond)). At baseline, a distinct abnormality was seen for S(acin) and LCI, while S(cond) was at the upper limit of normal for this subject. S(acin), in particular, was in excess of the S(acin) abnormality corresponding to a 20-pack-year smoking history. Immediately after WLL, S(acin) and S(cond) both fell to within a normal range while LCI also decreased but remained abnormal. The S(acin) decrease was much greater than the S(cond) decrease, which was to be expected after 1 week of smoking cessation at the hospital (smoking was resumed after release from hospital). A follow-up visit 7 weeks after WLL revealed a spectacular improvement on CT scan and improvements in standard lung function. Another follow-up visit 14 weeks after WLL showed further improvements in standard lung function, and both S(acin) and S(cond) remained well within the normal range, and LCI was above the upper limit of normal. We conclude that in this patient, removal of excess surfactant by WLL resulted in a restored ventilation distribution in most of the distal air spaces.

Ventilation heterogeneity in the acinar and conductive zones of the normal ageing lung

RATIONALE

Small airways function studies in lung disease have used three promising multiple breath washout (MBW) derived indices: indices of ventilation heterogeneity in the acinar (S(acin)) and conductive (S(cond)) lung zones, and the lung clearance index (LCI). Since peripheral lung structure is known to change with age, ventilation heterogeneity is expected to be affected too. However, the age dependence of the MBW indices of ventilation heterogeneity in the normal lung is unknown.

OBJECTIVES

The authors systematically investigated S(acin), S(cond) or LCI as a function of age, testing also the robustness of these relationships across two laboratories.

METHODS

MBW tests were performed by never-smokers (50% men) in the age range 25-65 years, with data gathered across two laboratories (n=120 and n=60). For comparison with the literature, the phase III slopes from classical single breath washout tests were also acquired in one group (n=120).

MEASUREMENTS AND MAIN RESULTS

All three MBW indices consistently increased with age, representing a steady worsening of ventilation heterogeneity in the age range 25-65. Age explained 7-16% of the variability in S(acin) and S(cond) and 36% of the variability in LCI. There was a small but significant gender difference only for S(acin). Classical single breath washout phase III slopes also showed age dependencies, with gender effects depending on the normalisation method used.

CONCLUSIONS

With respect to the clinical response, age is a small but consistent effect that needs to be factored in when using the MBW indices for the detection of small airways abnormality in disease.

Sarcoidosis in a patient with metastatic melanoma sequentially treated with anti-CTLA-4 monoclonal antibody and selective BRAF inhibitor

A female patient with stage IV-M1c (distant lymph node and breast metastases), chemotherapy-refractory melanoma was treated with the cytotoxic T-lymphocyte antigen 4 (CTLA-4)-inhibitory monoclonal antibody ipilimumab. At first evaluation following induction treatment, there was marked increase in the volume of the lymphadenopathies (including new adenopathies) and strong uptake of (18)Fluorodeoxy-D-glucose ((18)FDG); marked enlargement of the spleen and interstitial lung infiltrates were also observed. Non-necrotising granulomas were discovered on transbronchial mucosal biopsy and cytology on bronchoalveolar lavage established the diagnosis of sarcoidosis. There was a marked clinical and (18)FDG-positron emission tomography/computed tomography ((18)FDG-PET/CT) documented response following six weeks of corticotherapy. At follow-up, progression of subdiaphragmatic melanoma lymph node metastases was documented. Regression of these metastatic sites was observed during treatment with the selective v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) inhibitor vemurafenib. The patient died due to progressive disease after three months of vemurafenib treatment. Our case report illustrates the need to take into consideration exacerbation of sarcoidosis as a potential confounder in the assessment of tumor response in a melanoma patient treated with the anti-CTLA-4 mononclonal antibody ipilimumab.

Relationships between the lung clearance index and conductive and acinar ventilation heterogeneity

The lung clearance index (LCI) derived from a multiple breath washout test has regained considerable popularity in recent years, alternatively being promoted as an early detection tool or a marker of small airways function. In this study, we systematically investigated the link between LCI and indexes of acinar and conductive airways ventilation heterogeneity (Sacin, Scond) to assess potential contributions from both lung zones. Relationships were examined in 55 normal subjects after provocation, where only Scond is known to be markedly increased, and in 55 asthma patients after bronchodilation, in whom both Scond and Sacin ranged between normal and abnormal. LCI was correlated to Scond in both groups (R = 0.37-0.43; P < 0.01 for both); in the asthma group, LCI was also tightly correlated to Sacin (R = 0.70; P < 0.001). Potential mechanisms operational at various levels of the bronchial tree were identified by considering washout curvilinearity in addition to LCI to distinguish specific ventilation and dead space effects (also illustrated by simple 2-compartment model simulations). Although the asthma data clearly demonstrate that LCI can reflect very peripheral ventilation heterogeneities, the normal provocation data also convincingly show that LCI increases may be the exclusive result of far more proximal ventilation heterogeneities. Because LCI potentially includes heterogeneities at all length scales, it is suggested that ventilation imaging in combination with LCI measurement at the mouth could identify the scale of relevant ventilation heterogeneities. In the meantime, interpretations of LCI results in the clinic based on washout curves collected at the mouth should be handled with caution.

Primary tracheobronchial amyloidosis: a series of 3 cases

Primary tracheobronchial amyloidosis is a form of localized pulmonary amyloidosis, characterised by the deposition of AL-amyloid in trachea and bronchi. It is a rare and slowly progressive disease, usually requiring repeated endoscopic treatment. In this case series we describe symptoms, diagnostic and therapeutic procedures, radiological findings and pulmonary function testing in 3 cases of different presentation and severity. Two patients were treated by endoscopic debulking and stent placement during rigid bronchoscopy, both with excellent clinical and functional results. In one of these patients regular endoscopic and clinical control exams were performed in the 5 years following the initial treatment, showing stable disease, requiring no further therapeutic intervention until today.

Successful Treatment of a Giant Emphysematous Bulla by Bronchoscopic Placement of Endobronchial Valves

Surgical bullectomy is the treatment of choice for giant emphysematous bulla. We report a case of successful nonsurgical treatment with bronchoscopic placement of one-way endobronchial valves that are currently under investigation for the treatment of end-stage emphysema. In patients who are poor surgical candidates, this noninvasive bronchoscopic treatment may represent a valuable alternative.

Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects

RATIONALE

The exact site(s) and pathophysiology of air leakage in patients with primary spontaneous pneumothorax (PSP) are unknown. In one patient with PSP, fluorescein-enhanced autofluorescence thoracoscopy (FEAT) has shown areas of parenchymal abnormality unnoticed during white light thoracoscopy (WLT).

OBJECTIVES

To prospectively perform and compare WLT and FEAT in patients with spontaneous pneumothorax and in normal subjects.

METHODS

One-time FEAT and WLT inspection with systematic mapping of semiquantified lesions in 12 consecutive patients with PSP was compared with one-time FEAT and WLT during sequential bilateral thoracoscopy in 17 control subjects.

RESULTS

WLT abnormalities (anthracosis, cobblestone malformation, and blebs/bullae) were more prevalent in PSP. FEAT, however, showed high-grade lesions in PSP only, which often were present at areas that were normal, or that only showed anthracosis at WLT. When blebs/bullae were present, bleb-associated FEAT abnormalities were only present in two. Actual fluorescein leakage was seen in two patients with PSP.

CONCLUSIONS

Lungs in patients with PSP show significantly more abnormalities at WLT when compared with normal subjects. High-grade FEAT lesions were exclusively present in PSP, and predominantly at lung zones that appeared normal at white light inspection. These findings suggest that significant parenchymal abnormalities are not limited to lesions visible during WLT, such as blebs and bullae.

Antioxidants reverse the antiproliferative effect of high glucose and advanced glycosylation end products in cultured rat mesangial cells

High glucose and elevated levels of advanced glycosylation end products (AGEs) exert an antiproliferative effect on cultured mesangial cells. In view of the role of oxygen free radicals in the pathogenesis of diabetic nephropathy, we tested whether two endogenous antioxidants, taurine and vitamin E, ameliorate the effects of an elevated ambient glucose and/or AGEs on mesangial cell growth in vitro. Regardless of whether cell proliferation was assayed by the incorporation of [3H]thymidine, direct cell counting or bromodeoxyuridine (BrdU) cell staining, both taurine and vitamin E reversed the inhibitory effect of high glucose and AGEs on mesangial cell growth. In conjunction with our previous studies indicating that taurine and vitamin E reduce collagen production in mesangial cells exposed to high glucose, these findings suggest that endogenous antioxidants attenuate diabetic glomerulosclerosis by interfering with the bioactivation of transforming growth factor-6.