[False images of endobronchial tumor in CT-scan]

Bronchoscopic identification of an endobronchial foreign body is an unexpected finding in adults. Modern imaging techniques such as computerised tomography (CT) may identify bronchial obstruction but not the cause. Moreover, images may be suggestive of other pathologies, especially when the previous aspiration cases are unknown. The most common CT findings in this setting are atelectasis, lung hyperlucency, localised bronchiectases and lobar consolidation. CT diagnosis of false endobronchial tumors in patients who have swallowed a foreign body is rarely described in the bibliography. In view of the potential adverse outcome in the case of wrong diagnosis we consider it is of interest to report two cases of endobronchial tumors diagnosed by CT in which flexible bronchoscopy allowed identification and extraction of an endobronchial foreign body.

[Lung cancer at a university hospital: epidemiological and histological characteristics of a recent and a historical series]

OBJECTIVE

To describe the clinical, histological, and epidemiological characteristics of patients diagnosed with lung cancer in our hospital over a period of 5 years and compare them with those of historical cases treated at the same hospital.

PATIENTS AND METHODS

The cases of patients diagnosed with lung cancer from January 1998 through December 2002 were studied retrospectively and compared with data published for the period from 1978 through March 1981.

RESULTS

A total of 678 patients (89% men, mean age 67 years) were studied. Fifty-six percent of the men and 38% of the women were smokers (P<.001). The most common histological types were squamous cell carcinoma (33%) and adenocarcinoma (30%): squamous carcinoma in men (36%) and adenocarcinoma in women (56%). Metastasis was present in 42% of the patients with non-small cell lung cancer and in 55% of those with small cell lung cancer. In patients with a history of neoplastic disease, laryngeal tumors were most common in patients with squamous carcinoma whereas bladder tumors were the most frequent in patients with adenocarcinoma. The ratio of men to women was lower in the recent series than in the historical one. The percentage of squamous carcinoma was lower and that of adenocarcinoma higher (P<.001). The percentage of patients diagnosed with regional involvement was greater in the recent series (P<.001).

CONCLUSIONS

Squamous cell carcinoma continues to be the most frequent histological type. Male sex and smoking are associated with squamous carcinoma and female sex is associated with adenocarcinoma. Epidemiological and histological patterns have changed, possibly in relation to changes in smoking habits.

[Fiber-optic bronchoscopic biopsy of bronchial smooth muscle. Efficacy of the technique in individuals with normal lung function and patients with COPD]

BACKGROUND AND OBJECTIVES

The epithelium and airway smooth muscles of patients with chronic obstructive pulmonary disease (COPD) or bronchial asthma undergo certain structural changes that are probably related to increased expression of inflammatory molecules and cell growth factors. Studying the relation between disease and changes in bronchial smooth muscle is difficult if investigation is restricted to samples from autopsies or thoracotomies. This study was designed to evaluate the probability of obtaining bronchial smooth muscle by endoscopic bronchial biopsy in patients with COPD and from individuals with normal lung function, the relation of disease to bronchial epithelial histology, and the potential usefulness of studying airway muscle remodeling events.

METHODS

Forty-two patients undergoing diagnostic fiberoptic bronchoscopy were enrolled. Bronchial biopsies were taken systematically from the lobar and segmental dividing ridges. The epithelial structure was analyzed by conventional histology. The smooth muscle was identified by immunohistochemistry (anti-desmin antibody assay) and Western-blot analysis (anti-desmin, actin and myosin antibodies).

RESULTS

Sixty-nine percent of the biopsies contained bronchial smooth muscle. The probability of obtaining smooth muscle was higher in segmental than in lobar biopsies (72 vs 30%, p < 0.05). This probability was unrelated to the presence of COPD or to signs of epithelial inflammation. The fragments allowed us to use electrophoresis to identify protein structures (myosin, actin, desmin) involved in muscle remodeling processes.

CONCLUSIONS

Endoscopic biopsy of the bronchi allows us to obtain bronchial smooth muscle samples in a large percentage of patients, particularly when performed on segmental bronchi. The technique may be useful for future studies examining the processes of airway smooth muscle remodeling.

Adaptation of the Asthma Quality of Life Questionnaire to a second language preserves its critical properties: the Spanish version

To test the metric proprieties of the Spanish version of the Juniper Asthma Quality of Life Questionnaire (AQLQ), we studied 116 adult asthmatic patients with a wide range of disease severity (53 patients were recruited from the respiratory outpatient department, 38 from a primary health care centre and 25 were patients admitted into hospital due to acute asthma). The patients were assessed twice, at recruitment and after 2 months. The AQLQ showed a high internal consistency (Cronbach's alpha = 0.78 to 0.96) and a high 2-week reproducibility (ICC = 0.82 to 0.92). Expected significant differences in AQLQ scores were observed according to disease severity as measured by symptoms, medication, use of services and recruitment setting. The cross-sectional and longitudinal correlations between AQLQ and the overall St. George's Respiratory Questionnaire were strong, moderate to strong between AQLQ and dyspnea and weak to moderate between AQLQ and FEV(1). The changes in AQLQ scores were significantly different in patients who either improved or deteriorated from those patients who remained stable (P <.0001 and P <.01, respectively, for the overall AQLQ). We conclude that the Spanish version of the AQLQ is reliable, valid and sensitive to changes.

Mucins as differentiation markers in bronchial epithelium. Squamous cell carcinoma and adenocarcinoma display similar expression patterns

Highly glycosylated apomucins are important to maintain the viscoelastic properties of the mucus. Changes in their expression are frequently associated with inflammatory and neoplastic conditions. We analyzed the expression of apomucins in normal respiratory tract (n = 8) and compared it with distal, peritumoral, and tumoral epithelia from patients with squamous cell carcinoma (n = 20), adenocarcinoma (n = 13), and small cell carcinoma (n = 12). Squamous metaplasia (n = 16) was also analyzed. MUC1, MUC2, MUC4, MUC5AC, MUC6, and MUC8 apomucins were detected by immunohistochemistry, and mucin transcripts by in situ hybridization and reverse transcriptase polymerase chain reaction. Bronchial epithelium from normal individuals and distal epithelium from cancer patients showed a similar expression pattern: MUC1, MUC4, and MUC8 were always present, MUC2 and MUC5AC showed more variability, and MUC6 was focally detected. MUC5AC was downregulated in peritumoral epithelium and in squamous metaplasia, and MUC6 was upregulated in peritumoral epithelium. A reduced expression of MUC4, MUC5AC, and MUC8 was observed in non-small cell carcinomas, regardless of their histologic subtype. In small cell tumors, only MUC1 was consistently expressed.

CONCLUSIONS

(1) peritumoral epithelium and squamous metaplasia show an abnormal pattern of mucin expression; (2) squamous cell carcinomas and adenocarcinomas display a similar pattern of mucin gene expression, supporting the concept of a common cellular origin.

[Effects of Sjögren's syndrome on pulmonary function impairment in patients with rheumatoid arthritis]

The influence of Sjögren syndrome (SS) on pulmonary function impairment in rheumatoid arthritis (RA) patients has been few studied. The aim of this study was to analyse the pulmonary function impairment in RA patients, and to establish differences between patients associated or not to SS. Pulmonary function of 57 patients, non smokers and without another pulmonary disease, diagnosed of RA were studied. Fourteen (24.6%) were associated to SS, and 43 (75.4%) to RA without SS. Age and time of evolution of disease were similar. Eight patients with associated SS (57.2%), and in 20 (46.5%) without SS showed pulmonary function disorder. Airflow obstruction and DLCO diminution were the most common types of impairment, respectively. The comparison between the types of impairment and the mean values of FEVI, FVC, FEVI/FVC %, FEF 25-75 and DLCO were not statistical different. This results suggest a poor influence on pulmonary function impairment in RA patients with SS.

[Indications, performance and complications of bronchofibroscopy in the aged]

Bronchofibroscopy is a widely used exploration for the diagnosis of several pulmonary processes. However, its use in aged patients, these being considered a high risk group, is still a controversial issue. The aim of this study was to analyze the indications, diagnostic performance and complications of the bronchofibroscopy in the elderly and to determine if there are any differences with respect to the adult population. A retrospective case control study was conducted, taking as cases those patients with 70 or more years of age, and as controls, those patients with less than 70 years. The study period was 1 year, with 54 bronchofibroscopies performed in 49 patients from the study group and 149 in 145 patients from the control group. The indications were similar in both groups, except for the study of opportunistic infections, these being more frequent among the control group. Diagnostic performance and complications did not show any differences between both groups. Indications, performance and complications of bronchofibroscopy in aged patients are similar to those in the adult population. Hence, the age in itself should not be a limiting factor for the indication of this exploration.

[Thoracic actinomycosis]

BACKGROUND

Thoracic actinomycosis is an rare disease in our medium. This fact, together with the variability of its forms of presentation and the difficulty in isolating its etiologic agent, make its diagnosis, particularly difficult.

METHODS

A series of 8 cases diagnosed in the years 1988, 1989 and 1990 in two centers (Hospital de Bellvitge-Prínceps d'Espanya and Hospital de l'Esperança) is described with evaluation of the clinical and analytical data and the therapy applied.

RESULTS

Species were only identified in 3 cases with Actinomyces israelii in two and Actinomyces odontolyticus in the third. The proven association with Mycobacterium tuberculosis, the presence of distant septic metastasis and eosinophilic pleuritis as forms of presentation are of note. Medical treatment was penicillin or derivatives in all the cases except one which was treated with diagnostic/therapeutic segmentectomy.

CONCLUSIONS

It is concluded that when any subacute involvement of the thoracic and/or pleuropulmonary wall specific cultures should be carried out to discard eventual thoracic actinomycosis.

Controlled trial of intravenous corticosteroids in severe acute asthma

BACKGROUND

The value of corticosteroids in severe acute asthma continues to be debated.

METHODS

Ninety consecutive patients admitted to the emergency room with severe acute asthma were studied in a randomised, double blind, controlled trial to determine the efficacy of corticosteroids. Eighty two patients completed the study. All received oxygen therapy and intensive bronchodilator treatment. The patients were divided into three groups for steroid treatment, receiving intravenous methylprednisolone 10 mg/kg every four hours for 48 hours (29 patients, group A); intravenous methylprednisolone 2 mg/kg every 4 hours for 48 hours (27 patients, group B); or no intravenous corticosteroids (26 patients, group C).

RESULTS

There were no differences on admission among the three groups in forced expiratory volume in one second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), or arterial oxygen or carbon dioxide tension; and the rates of recovery in FEV1, FVC, and PEF were similar.

CONCLUSIONS

Corticosteroids given with bronchodilators have not shown a beneficial effect in the first 48 hours of recovery of severe acute asthma. Only in those patients who failed to respond by the third hour of treatment, and in those who were previously taking oral corticosteroids, does a favourable, though not statistically significant, effect appear to occur.

Adenosine deaminase activity in rheumatoid pleural effusion

Images

Time of exposure as a prognostic factor in avian hypersensitivity pneumonitis

Spirometric values were subsequently evaluated in 22 patients suffering from hypersensitivity pneumonitis caused by avian problems. First spirometric values were abnormal in 18/22 (82%) of patients. A restrictive pattern was observed in 16/22 (72%) of patients and an obstructive pattern in 6/22 (27%). The TLCO was reduced in all cases (12/12). Improvement or normalization of the respiratory function occurred 3.4 +/- 2.4 months after the avian contact had ceased. At the end of the follow-up, parameters were normal in 13/22 (59%) of patients. The restrictive pattern remained unchanged in 7/22 (32%), and the obstructive pattern persisted in 4/22 (18%) of the patients. The TLCO was normal in 6/12 (50%) of patients. Neither age nor treatment with corticosteroids (13 patients) had a significant influence upon the evolution of the lung function. However, total recovery or significant improvement was observed in 12/12 (100%) of patients who had been in contact with birds less than 2 years, in contrast to 6/10 (60%) of patients with more than 2 years of contact (P = 0.002).

Impaired non-specific delayed cutaneous hypersensitivity in bird fancier's lung

The relation between non-specific delayed cutaneous hypersensitivity and bird fancier's lung was investigated in 13 patients with the disorder. They were compared with 50 subjects who had no reason to have decreased non-specific delayed cutaneous hypersensitivity (control group) and 34 patients with pulmonary sarcoidosis. In addition, 13 patients with bird fancier's lung (11 of the original group) were tested at least one year after avoiding exposure to the causal antigen. Five antigens (candidine, staphylococcal toxoid, tuberculin purified protein derivative, trichophyton, and streptokinase-streptodornase) were injected intradermally (0.1 ml) and the mean weal diameter was measured at 48 hours. The mean weal size was significantly less in the subjects with bird fancier's lung at the time of diagnosis than in the control group (2.23 v 5.66 mm) but did not differ significantly from that of the subjects with sarcoidosis (2.80 mm) or from that of the bird fanciers with no exposure to the causal antigen for one year (2.75 mm). The impairment of non-specific delayed cutaneous hypersensitivity in patients with bird fancier's lung appears to be quantitatively similar to that occurring in sarcoidosis.

Diagnostic value of bronchoalveolar lavage in suspected pulmonary tuberculosis

Of 222 patients suspected of having pulmonary tuberculosis (PT), studied during a one-year period, we performed fiberoptic bronchoscopy together with bronchoalveolar lavage (BAL), bronchial washing and postbronchoscopy sputum smears and Löwenstein cultures in 20 patients. Bronchoalveolar lavage proved to be the most effective method leading to diagnosis in 17 of 20 cases. Diagnosis was obtained in 11 of 20 cases using bronchial washing and postbronchoscopy sputum. The results of this study suggest that bronchoscopy may be required in selected cases for the diagnosis of PT. However, it should be accompanied by BAL, bronchial washings and postbronchoscopy sputum smears. Indications for bronchoscopy as a diagnostic tool for PT may include: (a) patients suspected of having PT with negative smears and in whom treatment must be started due to clinical status; (b) suspicion of associated neoplasia; (c) selected patients with negative Löwenstein cultures; (d) lack of material being obtained by simpler methods.

Skin tests in bird breeder's disease

The diagnostic value of skin tests was assessed in 35 patients affected by bird breeder's disease by comparing the results with those obtained in a group of 27 symptomless breeders and 10 symptomless unexposed individuals. Sterilised and diluted serum and lyophilised extracts of faeces prepared from the breeder's own birds were injected intradermally. Skinprick tests using the same materials were carried out simultaneously. The intradermal test using serum showed a positive reaction in 18 out of 20 patients tested and in three out of 20 symptomless breeders (p less than 0.0005); later reactions occurred in eight of the patients and one of the symptomless breeders (p less than 0.01). A delayed reaction was seen in five of the patients and one of the symptomless breeders (p = 0.09). No positive reactions were recorded in symptomless unexposed individuals. Intradermal skin testing using extracts of faeces yielded an immediate reaction in 19 of 21 patients and in three of 11 symptomless breeders tested (p less than 0.001); a late reaction was seen in 18 of the patients and in five of the symptomless breeders (p less than 0.05). Delayed reactions occurred in 11 of the 21 patients tested, whereas no positive responses were seen in symptomless breeders (p less than 0.025). Skinprick tests gave negative results in all cases. Skin testing constitutes a simple, quick, and safe procedure that can assist the differential diagnosis between individuals with bird breeder's disease and symptomless breeders, the immediate reaction being similar in its sensitivity to testing for serum precipitins but possessing greater specificity.

Non immunological analytic data for the differential diagnosis between miliary tuberculosis (MTBC) and bird breeder's disease (BBD)

A group of 86 patients diagnosed as having MTBC were compared to a group of 25 patients with BBD on the basis of various blood values included in routine analysis (hemogram, leukocyte count and differential, blood electrolyte values, urea, creatinine, total proteins and proteinogram). After statistical evaluation of the results, we concluded that the finding of low values for hemoglobin, and red blood cell (RBC) count and hematocrit, alterations of leukocyte count and differential, hypoalbuminemia, and hyponatremia, in a patient with fever and a miliary chest X-ray pattern, supports the diagnosis of MTBC. On the other hand, normal values for the above parameters, together with hypergammaglobulinemia favors the diagnosis of BBD. Our data also demonstrated a 79% mortality rate in patients with MTBC and plasma urea levels of more than 55 mg/100 ml (p less than 0.001).