Lessons from prospective longitudinal follow-up of a French APECED cohort

BACKGROUND

APECED syndrome is a rare disease caused by biallelic mutations of the AIRE gene, usually presenting with the triad "hypoparathyroidism-adrenal failure-chronic mucocutaneous candidiasis (CMC)" and non-endocrine manifestations. The aim of this study was to determine the molecular profile of the AIRE gene, the prevalence of rare manifestations and to characterize immunological disturbances in a French cohort.

PATIENTS AND METHODS

A national, multicenter prospective observational study to collect genetic, clinical, biological and immunological data (NCT03751683).

RESULTS

25 patients (23 families) were enrolled. Eleven distinct AIRE variants were identified, two of which were not previously reported: an intronic variant, c.653-70G > A, and a c.1066del (p.Arg356GlyfsX22) variant (exon 9). The most common was the Finnish variant c.769C > T (16 alleles), followed by the variant c.967_979del13 (15 alleles), which seemed associated with a less severe phenotype. 17/25 patients were homozygote. The median number of clinical manifestations was seven; 19/25 patients presented with the hypoparathyroidism-adrenal failure-CMC triad, 8/13 showed pulmonary involvement, 20/25 had ectodermal dystrophy, 8/25 had malabsorption, and 6/23 had asplenia. Fifteen out of 19 patients had NK cell lymphopenia with an increase in CD4+ and CD8+ T lymphocytes and an age-dependent alteration of B lymphocyte homeostasis compared with matched controls (p < 0.001), related to the severity of the disease. All tested sera (n = 18) were positive for anti-interferon-α, 15/18 for anti-interleukin-22 antibodies, and 13/18 for anti-interleukin-17F antibodies, without clear phenotypic correlation other than with CMC.

CONCLUSION

This first prospective cohort showed a high AIRE genotype variability, with two new gene variants. The prevalence of potentially life-threatening non-endocrine manifestations, was higher with systematic screening. These manifestations could, along with age-dependent B-cell lymphopenia, contribute to disease severity. Systematic screening for all the manifestations of the syndrome would allow earlier diagnosis, supporting vaccination, and targeted therapeutic approaches.

Best clinical practice in the treatment of juvenile systemic sclerosis: expert panel guidance - the result of the International Hamburg Consensus Meeting December 2022

INTRODUCTION

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1,000,000 children. Currently there is only one consensus treatment guideline concerning skin, pulmonary and vascular involvement for jSSc, the jSSc SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) initiative, which was based on data procured up to 2014. Therefore, an update of these guidelines, with a more recent literature and expert experience, and extension of the guidance to more aspects of the disease is needed.

AREAS COVERED

Treatment options were reviewed, and opinions were provided for most facets of jSSc including general management, some of which differs from adult systemic sclerosis, such as the use of corticosteroids, and specific organ involvement, such as skin, musculoskeletal, pulmonary, and gastroenterology.

EXPERT OPINION

We are suggesting the treat to target strategy to treat early to prevent cumulative disease damage in jSSc. Conclusions are derived from both expert opinion and available literature, which is mostly based on adult systemic sclerosis (aSSc), given shared pathophysiology, extrapolation of results from aSSc studies was judged reasonable.

Pulmonary Involvement in Recurrent Respiratory Papillomatosis: A Systematic Review

Recurrent respiratory papillomatosis (RRP) is a non-malignant disease, characterized by the production of wart-like growths in the respiratory tract, affecting both young people and adults (juvenile-onset recurrent respiratory papillomatosis, JORRP, and adult-onset recurrent respiratory papillomatosis, AORRP, respectively). Infection caused by human papillomavirus (HPV) is known as the main factor involved in RRP development. Complications of RRP may rarely occur, including lung involvement and malignant transformation. The present systematic review aimed to evaluate the prevalence of severe complications, such as lung involvement and lung tumor in JORRP and AORRP patients, and assess the role of HPV genotypes in the progression of disease severity following the guideline for reporting systematic reviews and meta-analysis (PRISMA Statement). A total of 378 studies were found on PubMed and Scopus using the following MESH terms: "recurrent respiratory papillomatosis and lung tumor" and "pulmonary tumor and recurrent respiratory papillomatosis". Basing on inclusion and exclusion criteria, a total of 11 studies were included in the systematic review. We found a pooled prevalence of 8% (95% CI: 4-14%; I2: 87.5%) for lung involvement in RRP patients. In addition, we found a pooled risk difference of 5% in lung involvement between JORRP and AORRP (95% CI: -7-18%; I2: 85.6%, p-value: 0.41). Among patients with lung involvement, we observed a pooled prevalence of lung tumor of 4% (95% CI:1-7%; I2: 67.1%) and a pooled prevalence mortality for this group of 4% (95% CI:2-6%; I2: 0%). Overall, the positivity rate for HPV-6 and -11 in patients with RRP was 91%. Considering only cases with pulmonary involvement, the pooled prevalence for HPV-11 was 21% (95% CI: 5-45%; I2: 77.2%). Our results evidenced a low/middle risk of pulmonary involvement and lung tumor in JORRP and AORRP patients, with an increased risk for HPV-11-positive patients. Further studies should be performed to improve knowledge and adopt preventive measures to contrast the progression to severe diseases in RRP patients.

Clinical features and outcomes of small airway disease in ANCA-associated vasculitis

BACKGROUND AND OBJECTIVE

To clarify the prevalence, features and outcomes of small airway disease (SAD) in a Chinese cohort with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) related pulmonary involvement.

METHODS

SAD was recorded when the manifestations of either centrilobular nodules or air trapping were observed according to CT scans, except for infection or other airway-related comorbidities. Baseline and follow-up data were collected retrospectively.

RESULTS

Of the 359 newly diagnosed AAV patients with pulmonary involvement, 92 (25.6%) had SAD, including 79 (85.9%) cases of anti-MPO-ANCA positive, 9 (9.8%) cases of anti-PR3-ANCA positive and 2 (2.2%) cases of double positive. Patients with SAD were more likely to be younger, female, non-smokers, have more ear-nose-throat (ENT) involvement, and have higher baseline Birmingham Vasculitis Activity Score (BVAS) compared to patients without SAD. Several AAV-related SAD patients have improved lung function and CT scans after immunosuppressive therapy. Patients with SAD had a better prognosis compared to those without SAD. When dividing all patients into three groups: isolated SAD (only small airway involvements), SAD with other lower airway involvements, and non-SAD, patients in the SAD with other lower airway involvements group had the highest risk of infection, while patients in the non-SAD group had the worst long-term outcomes. Similar results were observed in anti-MPO-ANCA positive patients when performing subgroup analyses.

CONCLUSION

SAD is a unique manifestation of AAV-related lung involvement and exhibits distinct clinical features. It is vital to focus on SAD because of its association with prognosis and infection in AAV patients, especially in anti-MPO-ANCA positive patients. Moreover, SAD might represent a better response to immunosuppressors.

Respiratory impairments in patients suffering from Fabry disease - A cross-sectional study

BACKGROUND

The inherited X-linked disorder, Fabry disease, is caused by deficient lysosomal enzyme α-galactosidase A, with progressive accumulation of globotriaosylceramide in multiple organs including the upper and lower airways.

OBJECTIVES

To assess pulmonary function at the time of the first pulmonary function test (PFT) performed among the National Danish Fabry cohort and define the prevalence of affected lung function variables.

MATERIALS AND METHOD

A cross-sectional retrospective cohort study of 86 adult patients enrolled in one or both international patient registry databases for Fabry disease, Fabry Registry or FollowME with at least one PFT. The Mainz Severity Score Index (MSSI) was calculated to determine the disease severity. Lung function variables were examined by multivariate regression adjusted for important variables for developing airway illness.

RESULTS

Seventeen patients (20%) showed obstructive airflow limitation and 7 (8%) a restrictive lung deficiency. Smoking status (p = .016) and MSSI (p < .001) were associated with increasing obstructive airway limitation.

CONCLUSION

The prevalence of affected lung function among the National Danish Fabry cohort was 28%. Patients with classic gene variants frequently developed a decrease in lung function regardless of their smoking status, with significant relationship with disease severity.

The COVID-19 in athletes (COVA) study: a national study on cardio-pulmonary involvement of SARS-CoV-2 infection among elite athletes

Background

COVID-19 can cause cardiopulmonary involvement. Physical activity and cardiac complications can worsen prognosis, while pulmonary complications can reduce performance.

Aims

To determine the prevalence and clinical implications of SARS-CoV-2 cardiopulmonary involvement in elite athletes.

Methods

An observational study between 1 July 2020 and 30 June 2021 with the assessment of coronary biomarkers, electrocardiogram, echocardiography, Holter-monitoring, spirometry, and chest X-ray in Danish elite athletes showed that PCR-tested positive for SARS-CoV-2. The cohort consisted of male football players screened weekly (cohort I) and elite athletes on an international level only tested if they had symptoms, were near-contact, or participated in international competitions (cohort II). All athletes were categorized into two groups based on symptoms and duration of COVID-19: Group 1 had no cardiopulmonary symptoms and duration ≤7 days, and; Group 2 had cardiopulmonary symptoms or disease duration >7 days.

Results

In total 121 athletes who tested positive for SARS-CoV-2 were investigated. Cardiac involvement was identified in 2/121 (2%) and pulmonary involvement in 15/121 (12%) participants. In group 1, 87 (72%), no athletes presented with signs of cardiac involvement, and 8 (7%) were diagnosed with radiological COVID-19-related findings or obstructive lung function. In group 2, 34 (28%), two had myocarditis (6%), and 8 (24%) were diagnosed with radiological COVID-19-related findings or obstructive lung function.

Conclusions

These clinically-driven data show no signs of cardiac involvement among athletes who tested positive for SARS-CoV-2 infection without cardiopulmonary symptoms and duration <7 days. Athletes with cardiopulmonary symptoms or prolonged duration of COVID-19 display, exercise-limiting cardiopulmonary involvement.

Vaccination Can Prevent Severe Pulmonary Disease in COVID-19 Positive Patients: A Case-Control Study

BACKGROUND

The COVID-19 pandemic was a global health emergency, which brought lives to a standstill. To combat this deadly virus, two vaccines were deployed widely: COVISHIELD (ChAdOx1 nCoV-19) and COVAXIN (BBV152). These were approved based on the immunological response they elicit in standardized conditions; however, the real-life scenario after deployment was completely different. Only in such situations can the true effectiveness of vaccines be assessed. The primary objective was to assess the effectiveness (VE) of COVAXIN/COVISHIELD in preventing severe pulmonary disease in RT-PCR-positive COVID-19 patients greater than 18 years of age.

MATERIALS AND METHODS

A case-control study was conducted among 260 subjects aged above 18 years, positive for COVID-19 through RT-PCR. 130 cases and 130 controls were enrolled. Radiological findings were obtained and subjects with >50% lung involvement were considered as cases. Subjects were interviewed about their vaccination status. Odds ratio was calculated, and the adjusted odds ratio was estimated for vaccine effectiveness, using the formula (1-adjusted ODDS ratio)*100.

RESULTS

The vaccine effectiveness for a single dose of vaccine was 55.2% (95% C.I. 11.0%-77.5%) and with two doses was 98.0% (95% C.I. 85.0%-99.7%). Hence two doses are highly effective than a single dose of vaccine in reducing lung involvement.

CONCLUSION

Two doses of vaccine are more effective than a single dose vaccine in reducing lung involvement. Since sporadic cases of COVID-19 still persist, it is important to emphasize the role of vaccination in preventing severe COVID-19 infections, particularly in the elderly and those with comorbidities.

Evolution of Pulmonary Involvement in Idiopathic Multicentric Castleman Disease-Not Otherwise Specified: From Nodules to Cysts or Consolidation

BACKGROUND

Previous studies about multicentric Castleman disease-associated pulmonary manifestations have been limited by small cohorts and not following the Castleman Disease Collaborative Network classification criteria of multicentric Castleman disease. The pulmonary manifestations in idiopathic multicentric Castleman disease-not otherwise specified (iMCD-NOS), a distinct clinical phenotype in the classification criteria, have not been reported.

RESEARCH QUESTION

Which pulmonary abnormalities in iMCD-NOS are advanced manifestations and which are reversible after effective treatment?

STUDY DESIGN AND METHODS

Patients diagnosed with iMCD-NOS with pulmonary involvement were enrolled. The baseline CT scan was evaluated for the presence and anatomic locations of pulmonary abnormalities. Patients were further divided into different subgroups according to baseline CT scan manifestations. Follow-up CT scan was reviewed to assess the changes in pulmonary lesions among patients without and with treatment.

RESULTS

Of 162 patients with iMCD-NOS, 58 individuals (35.8%) with pulmonary involvement were identified. Pulmonary manifestations included nodules (96.6%), cysts (65.5%), consolidation (22.4%), interstitial thickening (50.0%-87.9%), and ground-glass opacities (55.2%). Patients (n = 58) were further classified into nodule (n = 15), cyst (n = 33), and consolidation (n = 10) subgroups. Patients in the consolidation (median, 67 months) and cyst (median, 23 months) subgroups had a longer duration of symptoms before the baseline CT examination than those in the nodule subgroup (median, 12 months) (P = .016). During follow-up, the evolution of pulmonary lesions from nodules to cysts was observed in two patients without treatment. After treatment, pulmonary lesions, except for cysts, improved in most patients. Moreover, nodules or cysts progressed into consolidation in two patients.

INTERPRETATION

Pulmonary involvement is not rare in iMCD-NOS. Chest CT scan examination is very essential in finding potential pulmonary abnormalities. Pulmonary manifestations follow a unique pattern with evolution from nodules to cysts or consolidation, the latter of which can also form in cystic areas. Timely diagnosis of pulmonary involvement is crucial because of possible reversibility after treatment.

Self-Reported Systemic Sclerosis-Related Symptoms Are More Prevalent in Subjects with Raynaud's Phenomenon in the Lifelines Population: Focus on Pulmonary Complications

Puffy fingers and Raynaud's phenomenon (RP) are important clinical predictors of the development of systemic sclerosis (SSc). We aim to assess the prevalence of SSc-related symptoms, explore pulmonary symptoms, and test the usefulness of skin autofluorescence (SAF) as a non-invasive marker for Advanced Glycation Endproducts (AGEs). Subjects from the Lifelines Cohort Study with known connective tissue disease (CTD) were excluded. Patient characteristics, SAF, self-reported pulmonary symptoms, and spirometry were obtained. Subjects (n = 73,948) were categorized into definite RP (5.3%) with and without SSc-related symptoms and non-RP. Prevalence of at least one potential SSc-related symptom (other than RP) was 8.7%; 23.5% in subjects with RP and 7.1% without RP (p < 0.001). Subjects with RP and additional SSc-related symptoms more frequently reported dyspnea at rest, dyspnea after exertion, and self-reported pulmonary fibrosis, and had the lowest mean forced vital capacity compared to the other groups (RP without SSc-related symptoms and no RP, both p < 0.001). In multivariate regression, dyspnea at rest/on exertion remained associated with an increased risk of SSc-related symptoms in subjects with RP (both p < 0.001). SAF was higher in subjects with RP and SSc-related symptoms compared to the other groups (p < 0.001), but this difference was not significant after correction for potential confounders. The prevalence of SSc-related symptoms was approximately three-fold higher in subjects with RP. Pulmonary symptoms are more prevalent in subjects with RP who also reported additional potential SSc-related symptoms. This might suggest that (suspected) early SSc develops more insidiously than acknowledged. According to this study, SAF is no marker for early detection of SSc.

Pulmonary hypertension in Behçet's disease: echocardiographic screening and multidisciplinary approach

BACKGROUND

Little is known about the prevalence and causes of pulmonary hypertension (PH) in Behçet's disease (BD). This study was conducted to determine the prevalence and causes of PH in BD.

METHODS

In this descriptive study, we screened 154 patients with BD for PH using transthoracic echocardiography between February 2017 and October 2017. An estimated systolic pulmonary arterial pressure (sPAP ≥ 40 mmHg) was used as the cutoff value to define PH. Patients with BD were categorized into 5 groups according to organ involvement including mucocutaneous/ articular, ocular, vascular, gastrointestinal, and neurologic involvement. Additional laboratory and imaging results were obtained from hospital file records to determine the causes of PH.

RESULTS

PH was detected in 17 (11%) patients. Nine (52.9%) of these patients had group II PH (due to left heart disease), 4 (23.5%) had IV PH (due to pulmonary arterial involvement), and 1 had III PH (due to chronic obstructive lung disease). The frequency of PH was higher in BD patients with vascular involvement than those without (52.9% vs 28.5%; p = 0.04). Among 10 patients with pulmonary artery involvement (PAI) 4 (40%) had PH. Although the vascular BD group had the highest rate of PH, we observed no statistically significant difference in the frequency of PH between the predefined BD subgroups.

DISCUSSION

: PH is not rare in patients with BD. The majority of BD patients with PH are in group II or IV PH. Patients with vascularinvolvement carry a higher risk for the development of PH. Monitoring BD patients with PAI should be considered for the development of group IV PH.

18F-FDG PET/CT Imaging of a Grade 3 Lymphomatoid Granulomatosis in an Immunocompromised Pediatric Patient

Lymphomatoid granulomatosis is a rare extranodal Epstein-Barr virus-driven B-cell lymphoproliferative disease, involving predominantly lung, less often skin, kidney, and central nervous system. Here, we present a pediatric case with primary immunodeficiency, diagnosed with pathologically proven pulmonary grade-III lymphomatoid granulomatosis. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging demonstrated ¹⁸F-FDG avid pulmonary masses with central air-bronchograms and cavitations. Although the definitive diagnosis depends on biopsy, ¹⁸F-FDG PET/CT serves as a complementary imaging tool to evaluate the extent of the disease and response to treatment.

Predictors of pulmonary involvement in children with COVID-19: How strongly associated is viral load?

The purpose of this study was to identify risk factors for pulmonary involvement by examining the demographic, clinical, and laboratory characteristics of children with COVID-19. We performed a retrospective single-center study of COVID-19 in children treated at a tertiary care hospital in Turkey from December 2020 to June 2021. During the course of the study, 126 patients were evaluated, of whom 70/126 were male. The patients' ages ranged from 1 to 216 (mean, 4.73 ± 81.11) months. Fever (65.9%), cough (52.4%), and shortness of breath (18.3%) were the most common symptoms of COVID-19. Ten patients required noninvasive mechanical ventilation. Sixty-nine patients (54.8%) had pneumonia. Longer duration of fever, hospitalization, and the presence of cough were significantly associated with pulmonary involvement. Children with pneumonia had significantly higher levels of C-reactive protein (CRP), procalcitonin, erythrocyte sedimentation rate (ESR), and viral load, and significantly lower counts of lymphocytes and thrombocytes. The cutoff viral load, CRP, and procalcitonin values for predicting pulmonary involvement were 26.5 cycle threshold (Ct; 95% confidence interval [CI], 0.54-0.74; sensitivity, 0.65; specificity, 0.56; area under curve [AUC]: 0.647, p = 0.005), 7.85 mg/L (95% CI, 0.56-0.75; sensitivity, 0.66; specificity, 0.64; AUC = 0.656; p = 0.003) and 0.105 ng/ml (95% CI, 0.52-0.72; sensitivity, 0.55; specificity, 0.58; AUC = 0.626; p = 0.02), respectively. High CRP, procalcitonin levels, ESR, and viral load, and low lymphocyte and thrombocyte counts can predict pulmonary involvement in children with COVID-19, so better management may be provided for good prognosis.

Pneumonia in the presentation of Kawasaki disease: The syndrome or a sequence of two diseases?

Two cases of Kawasaki disease (KD) presented as persistent lung consolidation associated with Group A Streptococcus and Influenza A co-infection, which resolved following intravenous immunoglobulin. Thus, pediatricians should consider the diagnosis of KD in the presence of pneumonia that is nonresponsive to antibiotic therapy with prolonged fever and inflammatory reactions.

Difficult-to-treat rheumatoid arthritis: Current concept and unsolved problems

Over the past several decades, the treatment of rheumatoid arthritis (RA) has advanced significantly, and clinical, structural, and functional remission are achievable therapeutic goals. However, a substantial number of patients show resistance to multiple drugs. In particular, patients whose disease activity cannot be controlled despite the use of two or more biological disease-modifying antirheumatic drugs (DMARDs) or targeted synthetic DMARDs (tsDMARDs) with different mechanisms of action (MOA) have recently been referred to as having difficult-to-treat RA (D2T RA). D2T RA is a heterogeneous and multifactorial disease state, and the major problems are uncontrolled disease activity and decreased quality of life, as well as the economic burden due to frequent healthcare utilization and multiple admissions. Since the concept of D2T RA is relatively new and publication regarding D2T RA is limited, the mechanism underlying DMARD inefficacy and which factors form a "difficult-to-treat" state in such patients are not yet fully understood. It is also possible that factors contributing to D2T RA may differ by patient, sex, country, and race. The present Mini Review introduces the current concept and unsolved problems of D2T RA, including the definition, prevalence, and factors contributing to D2T RA. We then discuss the management and therapeutic strategies for D2T RA. Finally, we explore a clinical approach to prevent patients from developing D2T RA.

Case Report on Pulmonary Involvement in a Patient with Adult Still's Disease

BACKGROUND

Pulmonary manifestations and lung impairment are rarely associated with the Adult Still's Disease and are reported in less than 5%.

CASE PRESENTATION

The present clinical case describes the Adult Still's Disease with pulmonary involvement in a 45- year-old male. The main clinical manifestations included continuous fever, failure to respond to antibiotic therapy, skin rashes, musculoskeletal syndrome and pharyngitis. Additionally, bronchopulmonary lymphadenopathy, interstitial changes and dense foci with clear contours were detected in the lungs. Laboratory abnormalities included neutrophilic leukocytosis, increased ALT, AST, and elevated serum inflammatory marker levels. A cyclical course characterised the disease with strictly defined time intervals between flare-ups and remissions. After the prescription of methylprednisolone with the subsequent addition of methotrexate, complete regression of clinical symptoms, normalization of laboratory tests, and partial regression of computed tomography findings in the lungs were observed.

CONCLUSION

Despite the low incidence, pulmonary involvement is an unfavorable manifestation of Adult Still's Disease. An individual feature of this case report was the asymptomatic lung involvement manifested only by changes revealed through computed tomography. For a long time, flareups of the disease were considered bacterial infections of unclear nature requiring systemic antibiotics.

Lived Experiences of COVID-19 Patients With Pulmonary Involvement: A Hermeneutic Phenomenology

The aim of this study was to explore the lived experience of COVID-19 patients with pulmonary involvement. The hermeneutic phenomenology was chosen, as this approach can extract the participant experiences as COVID-19 patients. A total of 10 COVID-19 patients with the pulmonary disease were selected as participants after being discharged from the hospital by purposive sampling method until reaching saturation. Data were collected using semi-structured interviews and by using Greatrex-White and van Manen's methods were analyzed. As a result of data analysis, five main themes were emerged: Symptoms of inducing fear, Annoying loneliness, death anxiety, Spirituality healing factor, and Valuable life again. Based on the results of the interviews, the participants' experiences showed that patients infected with COVID-19, after being discharged from the hospital, due to mental and physical problems experienced during hospitalization, need comprehensive attention and care to regain their health during convalescence.

Circulating fibrocyte level in children with cystic fibrosis

BACKGROUND

This study aimed to evaluate circulating fibrocyte levels in cystic fibrosis (CF) patients during stable and exacerbation periods of the condition.

METHODS

The study group consisted of 39 patients diagnosed with CF and 20 healthy controls. Individuals included in the study were divided into three groups: CF, CF exacerbated, and a healthy control group. Their circulating fibrocyte levels were compared. Findings from a pulmonary function test and high-resolution computed tomography of the lung were evaluated and compared.

RESULTS

The circulating fibrocyte count was found to be significantly higher in patients with CF compared with the exacerbated and control groups. No correlation was found between the forced expiratory volume in 1 s and forced vital capacity values in the pulmonary function test and the circulating fibrocyte count. The circulating fibrocyte count in patients (in the CF group) with positive findings in the high-resolution computed tomography was statistically significantly lower.

CONCLUSIONS

The circulating fibrocyte level in the peripheral blood of the patients with CF was increased.

A Comparative Study of Children with MIS-C between Admitted to the Pediatric Intensive Care Unit and Pediatric Ward: A One-Year Retrospective Study

OBJECTIVES

This descriptive study aimed to compare the clinical and laboratory features of the children with the multisystem inflammatory syndrome in children (MIS-C), requiring pediatric intensive care unit (PICU), admission with the MIS-C patients who did not require PICU admission.

PATIENTS AND METHODS

This study was conducted between March 2020 and February 2021 at the University of Health Sciences Dr. Behçet Uz Children's Hospital, a referral center for pediatric infectious diseases in the Aegean Region of Turkey. All hospitalized patients aged 18 years old or less with MIS-C according to the definition of the universal guidelines were included in the study. Data of the patients with the diagnosis of MIS-C were recorded and collected from the electronic medical records of the hospital. The data included demographic characteristics, presenting signs and symptoms, laboratory findings and clinical data.

RESULTS

A total of 58 patients with MIS-C were included in this study. Thirty-eight (65.5%) patients were male. The median age was 6 years (2 months-16 years). The patients admitted to PICU were 15 (25.9%). The rate of pulmonary involvement was 81.3% (n = 13) in the PICU group. The median procalcitonin, C-reactive protein, erythrocyte sedimentation rate, D-Dimer and ferritin values were significantly higher in the PICU group compared to non-PICU group (p < 0.001, p = 0.02, p < 0.001, p = 0.006 and p = 0.031).

CONCLUSIONS

Besides the depressing cardiac functions reported before, the pulmonary involvement and signs of shock are important factors for PICU admission in children with MIS-C.

Kawasaki disease associated pulmonary involvement in infants

OBJECTIVES

Kawasaki disease (KD) is an acute, self-limited multisystemic vasculitis of unknown cause. Pulmonary involvement has been reported in case reports and limited small case series, which is not commonly recognized, especially in younger patients <1 year. Here, we describe clinical and radiological features of infants with KD-associated pulmonary involvement (KD-PI).

METHODS

Infants with KD were retrospectively enrolled during the period January 2017 to December 2020 in Shenzhen Children's hospital. Patients with KD-PI were matched 1:1 based on current age and sex with KD patients without clinically apparent PI. Clinical data were collected from inpatient or outpatient medical records, including clinical manifestations, laboratory parameters, radiological findings, management, and prognosis.

RESULTS

Of 248 infant patients with KD, 34 presented with KD-PI. Of these, 22 had only subtle respiratory symptoms. Compared to KD controls, patients with KD-PI had significantly higher mean Kobayashi score (mean ± SD: 2.85 ± 1.94; p = .004), more had extremely high C-reactive protein (≥10 mg/dl: 11/34, 32.3%; p = .0115) and procalcitonin levels (˃1 ng/ml: 16/34, 47%; p = .039), and more were administered with adjuvant corticosteroids as initial therapy (38.2% vs. 2.9%; p = .0005). Abnormal chest radiological findings included peripheral consolidation (97.0%), localized pleural thickening (73.0%), lobular septal thickening (70.6%), ground-glass opacities (55.9%), linear opacities (35.3%), and pleural effusion (20.6%). No statistical difference was observed in the incidence of coronary artery abnormalities (CAAs) between two groups either in the acute phase or follow-up phase.

CONCLUSIONS

Higher use of adjuvant corticosteroids during initial therapy in our population may result in no difference in CAAs between the two groups despite higher levels of inflammation in KD-PI. Those results suggest that use of adjuvant corticosteroids may be beneficial in this population.

Diagnosis and management of lung involvement in systemic lupus erythematosus and Sjögren's syndrome: a literature review

Lung involvement in systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (pSS) has extensively been outlined with a multiplicity of different manifestations. In SLE, the most frequent finding is pleural effusion, while in pSS, airway disease and parenchymal disorders prevail. In both cases, there is an increased risk of pre-capillary and post-capillary pulmonary arterial hypertension (PAH) and pulmonary venous thromboembolism (VTE). The risk of VTE is in part due to an increased thrombophilic status secondary to systemic inflammation or to the well-established association with antiphospholipid antibody syndrome (APS). The lung can also be the site of an organ-specific complication due to the aberrant pathologic immune-hyperactivation as occurs in the development of lymphoma or amyloidosis in pSS. Respiratory infections are a major issue to be addressed when approaching the differential diagnosis, and their exclusion is required to safely start an immunosuppressive therapy. Treatment strategy is mainly based on glucocorticoids (GCs) and immunosuppressants, with a variable response according to the primary pathologic process. Anticoagulation is recommended in case of VTE and multi-targeted treatment regimens including different drugs are the mainstay for PAH management. Antibiotics and respiratory physiotherapy can be considered relevant complement therapeutic measures. In this article, we reviewed lung manifestations in SLE and pSS with the aim to provide a comprehensive overview of their diagnosis and management to physicians taking care of patients with connective tissue diseases.

Pulmonary manifestations of Erdheim-Chester disease: clinical characteristics, outcomes and comparison with Langerhans cell histiocytosis

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis that typically affects many organs, including the lung and pleura. However, there are few studies concerning pulmonary involvement in ECD patients, as well as the difference of pulmonary involvement between ECD and Langerhans cell histiocytosis (LCH). We performed a retrospective study of 54 ECD patients, and compared the pulmonary manifestations with those of adult LCH patients in our centre. The median age of diagnosis of the 54 ECD patients was 48 years (range 9-66 years). Chest computed tomography (CT) scans revealed lung involvement in 49 (91%) patients and pleural involvement in 34 (63%). Thirty-three (61%) patients had interstitial lung disease (ILD) with varying degrees of interlobular septal thickening, micronodules, and ground-glass opacities. ECD and LCH patients with pulmonary involvement showed significant differences in smoking status (P < 0·001), respiratory symptoms (P = 0·001) such as cough and pneumothorax (P < 0·001), and radiological findings, including cysts (P < 0·001), opacities (P < 0·001), and pleural thickening (P < 0·001). With a median follow-up duration of 24 months (range, 1-84 months), the estimated three-year overall survival (OS) of this entire ECD cohort was 90·2%. Patients with ILD tended to have worse progression-free survival (PFS) than those with no ILD (P = 0·29).

Prevalence and predictive factors of difficult-to-treat rheumatoid arthritis: the KURAMA cohort

Difficult-to-treat rheumatoid arthritis (D2T RA) is a multifactorial condition in which disease activity of RA persists despite consecutive treatment with biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). To evaluate the prevalence and predictive risk factors of D2T RA in our institution, a single-center, retrospective study was conducted. Medical records of RA patients, who visited our hospital from 2011 to 2020 and had a follow-up of more than 6 months, were retrospectively reviewed. D2T RA was defined as RA with a disease activity score of 28 - erythrocyte sedimentation rate (DAS28-ESR) of 3.2 or higher at the last visit, despite the use of at least two b/tsDMARDs. A logistic regression model was used to identify risk factors. A total of 672 patients were enrolled. The mean age at disease onset was 52.1 years and females were dominant (76.3%). After a mean follow-up of 46.6 months, patients with D2T RA accounted for 7.9% of overall patients. Multivariate analysis identified high rheumatoid factor (RF) levels (≥156.4 IU/mL, odds ratio [OR]: 1.95), DAS28-ESR (OR: 1.24), and coexisting pulmonary disease (OR: 2.03) as predictive risk factors of D2T RA. In conclusion, high RF levels, high DAS28-ESR, and coexisting pulmonary disease at baseline can predict the development of D2T RA.

The Relationship between Pulmonary Damage and Peripheral Vascular Manifestations in Systemic Sclerosis Patients

Systemic sclerosis (SSc) is an autoimmune disease, characterized by the presence of generalized vasculopathy and tissue fibrosis. Collagen vascular disorder in SSc is due to fibroblast and endothelial cell dysfunctions. This leads to collagen overproduction, vascular impairment and immune system abnormalities and, in the last stage, multi-organ damage. Thus, to avoid organ damage, which has a poor prognosis, all patients should be carefully evaluated and followed. This is particularly important in the initial disease phase, so as to facilitate early identification of any organ involvement and to allow for appropriate therapy. Pulmonary disease in SSc mainly involves interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). High-resolution computed tomography (HRCT) and pulmonary function tests (PFT) have been proposed to monitor parenchymal damage. Although transthoracic echocardiography is the most commonly used screening tool for PAH in SSc patients, definitive diagnosis necessitates confirmation by right heart catheterization (RHC). Moreover, some studies have demonstrated that nailfold videocapillaroscopy (NVC) provides an accurate evaluation of the microvascular damage in SSc and is able to predict internal organ involvement, such as lung impairment. This review provides an overview of the correlation between lung damage and microvascular involvement in SSc patients.

Pulmonary Manifestations in Systemic Sclerosis: Hospital-Based Descriptive Study

Introduction

Prevalence of systemic sclerosis (SSc)-related organ injury is difficult to estimate as it occurs early in SSc, even though patients are often asymptomatic. As the patients with organ damage have a poor prognosis, all the patients should be carefully evaluated and followed‑up in the initial periods. This facilitates the early identification and initiation of appropriate therapy. This study emphasizes on different clinical manifestations and early predictors of lung involvement by using clinical, radiological, and pulmonary function tests in a tertiary care centre.

 

Materials and methods

A total of 53 SSc cases, who satisfied American College of Rheumatology (ACR) 2013 criteria, without any overlap syndromes were included in the study. All patients underwent thorough clinical examination along with Modified Rodnan Scoring (MRS) assessment, nailfold capillaroscopy (NFC), chest X-ray (CXR), HRCT thorax, 2D-echocardiography, spirometry and diffusion lung study by carbon monoxide (DLco).

Results

Out of 53 patients, four were male and 49 were female. Twenty-one patients had limited SSc (lcSSc) and 32 had diffuse SSc (dcSSc). Eighty-three per cent of subjects presented with skin manifestations and 34% with respiratory complaints. Reticulonodular opacities and ground glassing were the predominant radiological abnormalities suggestive of non-specific interstitial pneumonia (NSIP) followed by usual interstitial pneumonia (UIP). Pulmonary hypertension was predominant in patients with lcSSc. Thirty-eight patients had a restrictive pattern of spirometry. Forty-four patients showed deranged DLco, among which two patients showed an isolated decrease in DLco. Thirty-seven patients had abnormal NFC among which dropout pattern was predominant. MRS was significantly correlated with pulmonary involvement by DLco and HRCT.

Conclusions

SSc can affect the lungs even before developing obvious clinical pulmonary manifestations. DLco and HRCT play a critical role in detecting early lung involvement and predicting the outcomes in SSc. Higher modified Rodnan’s score, which has a significant correlation with DLco and HRCT can be used to predict early visceral involvement in resource-limited settings.

Relapsing Tubulointerstitial Nephritis with Antimitochondrial M2 Antibody Accompanied by Pulmonary Involvement

We herein report a 50-year-old woman who suffered from tubulointerstitial nephritis with antimitochondrial M2 antibody, distal renal tubular acidosis, and Fanconi syndrome. Our case also had interstitial pneumonia. After initially successful glucocorticoid therapy, tubulointerstitial nephritis and interstitial pneumonia relapsed. After the second successful round of glucocorticoid therapy, tubulointerstitial nephritis relapsed again and responded to glucocorticoid and azathioprine. This case might indicate (1) the association between pulmonary involvement and tubulointerstitial nephritis with antimitochondrial antibodies and (2) the need for a maintenance dose of glucocorticoid and immunosuppressants in tubulointerstitial nephritis with antimitochondrial antibodies.

Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome Complicated with Organizing Pneumonia

We herein report a 62-year-old man with idiopathic pulmonary fibrosis who developed remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome during follow-up. Pulmonary infiltrations were detected concomitantly with the development of RS3PE syndrome, and prednisolone improved both the pulmonary and extrapulmonary lesions. Recognizing the pulmonary manifestations of RS3PE syndrome is necessary to provide an appropriate diagnosis and disease management.

Pulmonary Involvement in Children With Systemic Lupus Erythematosus

Background: Symptomatic pulmonary involvement in systemic lupus erythematosus (SLE) seems not uncommon in children. However, there are few data on the characteristics and laboratory parameters of SLE patients with pulmonary involvement. Methods: This was a hospital-based study involving 111 SLE patients from 1 January 2012 to 31 December 2016. The demographic, clinical, and laboratory data of the patients were prospectively collected. They were followed as outpatients until December 2019. Clinical characteristics and laboratory parameters of patients with and without pulmonary involvement were compared. Results: Of the 111 patients with SLE, we identified 18 patients (16.2%) with pulmonary involvement. The most common HRCT findings were ground glass opacity, interlobular septal thickening, bilateral diffuse infiltrates, and pleurisy/pleural effusion (55.6, 50, 50, and 44.4%, respectively). SLE patients with pulmonary involvement tended to have a longer disease duration (14 [12-24.5] vs. 5 [2-9] months, P < 0.01). We also observed a significant association between the presence of anti-Sm antibody, ANCA, Anti-RNP and the presence of pulmonary involvement of SLE (all P < 0.001). Conclusions: Lung involvement was frequent in SLE patients from Southeast China. Patients with a longer duration of symptoms before SLE diagnosis tended to have pulmonary involvement. When children with SLE are found to have anti-RNP antibody and positive ANCA, it should be alert to the occurrence of pulmonary involvement.

Primary nasal diffuse large B-cell lymphoma with synchronous pulmonary involvement: A case report

RATIONALE

Diffuse large B-cell lymphoma (DLBCL) is the most commonly occurring type of non-Hodgkin's lymphoma, which may be found at various extranodal sites. The nose is not a common site for DLBCL as compared with natural killer/T-cell lymphoma, and synchronous pulmonary involvement is even rarer. We report a case of primary nasal DLBCL who presented with a mass in the left lower lobe, mimicking primary lung carcinoma.

PATIENT CONCERNS

A 62-year-old Chinese female visited the Ear-Nose-Throat Department of our hospital with nasal congestion and rhinorrhea for 2 months.

DIAGNOSIS

Computed tomography scan revealed a mass with soft tissue density in the left vestibule and nasal cavity. Histopathological examination revealed a large number of lymphoma cells, and immunohistochemistry confirmed the diagnosis of DLBCL.

INTERVENTIONS

The patient was treated with 6 cycles of R-CHOP (cyclophosphamide, adriamycin, vincristine, prednisone, and rituximab).

OUTCOMES

The treatment was well tolerated and led to complete remission for the patient. There was no sign of relapse over the 3-year close follow-up LESSONS:: DLBCL can be present at various extranodal sites and clinicians irrespective of their specialty must be vigilant for the synchronous mode of presentation of such lesions. Immunohistochemical techniques play a vital role in the diagnosis, because clinical characteristics may be misleading.

Primary pulmonary Langerhans cell histiocytosis associated with smoking in an adolescent boy

Pulmonary Langerhans cell histiocytosis (PLCH) is a well known entity in adults but is exceedingly rare in children. It is better described in adults than in children. Smoking is a major etiological factor in adulthood. We report a case of a previously healthy 16-year-old male with a history of cigarette smoking, who presented with cough with sputum, breathlessness, easy fatigability and loss of appetite for two weeks. He was first diagnosed with bronchiectasis according to the cystic pulmonary changes demonstrated by computed tomography. After appropriate treatment, there was no sign of clinical improvement. A lung biopsy confirmed Langerhans cell histiocytosis (LCH). The definitive diagnosis was isolated pulmonary LCH. PLCH should be considered in the etiology of cystic lung diseases. Isolated pulmonary LCH is rare so such cases are needed to be reported and followed-up to understand the treatment response and course of this illness.

An Unusual Case of Pulmonary Cryptococcus

Cryptococcal infections are caused by encapsulated fungi Cryptococcus gattii and C. neoformans. Inhalation commonly causes innocuous colonization but may cause meningitis or disseminated disease via hematogenous spread. Cryptococcosis occurs most commonly in immunocompromised patients including those with acquired immunodeficiency syndrome, meningoencephalitis or disseminated disease. However, cryptococcosis can occur as asymptomatic isolated pulmonary nodules in immunocompetent patients. Here we present a unique retrospective case report of a 55-year-old immunocompetent man who presented with pleuritic chest pain, productive cough, dyspnea on exertion, chills, night sweats, and weight loss. A computed tomography scan of his chest revealed multiple ground-glass opacities throughout both lung fields. The results of his autoimmune evaluation and human immunodeficiency virus tests were negative. A biopsy obtained through video-assisted thoracoscopic surgery revealed mucicarmine staining capsules confirming Cryptococcus, requiring treatment with amphotericin, flucytosine, and fluconazole. This case highlights the rarely studied presentation of symptomatic diffuse pulmonary cryptococcal infection in an immunocompetent patient requiring treatment.

Prevalence, risk factors, and prognosis of interstitial lung disease in a large cohort of Chinese primary Sjögren syndrome patients: A case-control study

To determine the prevalence of pulmonary complications in primary Sjögren syndrome (pSS), and to identify the risk factors and the prognosis associated with pulmonary involvement in pSS patients.A total of 1341 hospitalized patients (853 with pSS and 488 with secondary Sjögren syndrome [sSS]) were retrospectively reviewed. Of these, 165 hospitalized patients with pSS-associated interstitial lung disease (ILD) were analyzed and recruited as a study group. Eighty-four pSS patients without organ damage were included as a control group.One hundred and sixty-five patients (19.34%) from the pSS group and 126 patients (25.82%) from the sSS group presented with lung involvement. Of the 165 pSS patients with lung complications, 151 (91.5%) were women. The mean age was 61.25 ± 9.79 years, and the median disease duration was 84 (24-156) months. Non-specific interstitial pneumonia (NSIP; 39.1%) was the predominant pattern on high-resolution computed tomography (HRCT). The total HRCT score was 9.71 ± 4.77. Impairment in diffusion capacity was the most common (74.3%) and severe complication (predicted value of TLCO was 57.5 ± 21.2%). The 5-year survival rate for all patients with pSS-ILD was 88.5%. Age, disease duration, rheumatoid factor (RF), and C-reactive protein (CRP) were significantly higher than in controls, whereas anti-SSA was less common. Age, RF, and CRP were independent predictors of ILD after adjustment for confounders.Lung involvement is a common and severe complication of Sjögren syndrome. Age and disease activity are correlated with pulmonary involvement in pSS patients.

IgA Vasculitis with Simultaneous Cardiopulmonary Involvement

A 60-year-old man with a history of hypertension, type 2 diabetes, and reflux esophagitis was admitted to our hospital with hemoptysis, dyspnea, and leg edema. We diagnosed him with adult IgA vasculitis based on the presence of purpura, elevated serum IgA fibronectin complexes, pathophysiological findings, a skin biopsy showing leukocytoclastic vasculitis, and immunofluorescence studies demonstrating granular IgA and C3 deposits in the blood vessel wall. He showed concurrent cardiopulmonary involvement without involvement of the gastrointestinal system and kidneys, which are commonly affected in IgA vasculitis patients. Following treatment with prednisolone, the patient recovered with improvement in cardiopulmonary manifestations.

Secondary Syphilis with Pulmonary Involvement

A 39-year-old Japanese man presented to our hospital complaining of left chest pain and rash on the hands and feet. Plain thoracic computed tomography (CT) revealed multiple nodular shadows in the left lower lobe of the lung. A diagnosis of secondary syphilis was made based on the appearance of the rash and positive serologic tests for syphilis. The patient was started on amoxicillin but was switched to minocycline due to amoxicillin-induced rash on both forearms. Thoracic CT after five months of treatment revealed that the multiple lung nodular shadows had contracted, and secondary syphilis with pulmonary involvement was diagnosed.

Pulmonary involvement of secondary syphilis

Pulmonary involvement in secondary syphilis is considered a rare occurrence; however, the number of cases has increased in the 2000s. This is likely due to the increased use of computed tomography scans and molecular diagnostic testing. We report a case of an HIV-positive man with pleural chest pain and bilateral subpleural nodules on chest computed tomography. His rapid plasma reagin and Treponema pallidum hemagglutination tests were positive, and the specimen of one of the pulmonary nodules obtained by transthoracic biopsy was positive for the polA gene of Treponema pallidum. Since clinical manifestations of syphilis are highly variable, clinicians should bear in mind that pleural chest pain with bilateral subpleural nodules can be caused by pulmonary syphilis.

Relationship Between Smoking and Structural Damage, Autoimmune Antibodies, and Disability in Rheumatoid Arthritis Patients

Objectives

This study aims to investigate the relationship between smoking and structural damage, autoimmune antibodies, and disability in rheumatoid arthritis (RA) patients.

Patients and methods

This cross-sectional study included 165 RA patients (36 males, 129 females; mean age 52.4±12.8 years; range 21 to 82 years). Disease duration, age at disease onset, smoking habits, rheumatoid factor (RF), and anti-cyclic citrullinated peptide levels were recorded. Morning stiffness, pain with visual analog scale, Health Assessment Questionnaire Scores And Disease Activity Score 28 were calculated. Patients' standard hand radiographs were evaluated.

Results

Patients were divided into three groups according to their smoking habits. Ninety-nine patients (60%) were never smokers, 45 patients (27.3%) were long-term smokers and 21 patients (12.7%) were new smokers. Three groups were compared for disease activity. Disease activity score 28 scores were 3.2±1.2, 3.2±1.3, and 3.2±1.4, respectively (p>0.05). The erosion score (2.6±5.8, 7.1±10.9, and 11.1±19.2, respectively) and joint space narrowing score (9.9±7.3, 18.6±14.9, and 17.3±12.3, respectively) according to modified Sharp method were significantly lower in never smokers group than other groups (p<0.05). RF titrations were 55.2±58.9, 60.5±63.1, and 84.9±71.5, respectively, and levels of long-term smokers group were significantly higher than the other groups (p<0.05). Joint space narrowing score was 16.2±11.9 and 6.4±10.4 in RF (+) and RF (-) patients, respectively (p<0.05). There was no significant relationship between anti-cyclic citrullinated peptide levels and others parameters.

Conclusion

Although smoking is known as a poor prognostic factor in RA, there was no correlation between disease activity and smoking in our study. However, less radiographic damage was found in never smokers. Smoking does not appear to correlate with RA disease activity but it may be effective in the long-term joint damage.

[Pulmonary sarcoidosis presenting as multiple scattered pulmonary nodules: about a case]

Sarcoidosis is a multisystem granulomatous disease that can affect all organs, thoracic involvement often predominates representing its most evocative manifestation. Atypical manifestations, such as the presence of multiple scattered pulmonary nodules may indicate malignancy. Our study reports the case of a 56-year-old patient investigated for asthenia associated with paresthesia of the lower limbs evolving since 6 months. Chest CT scan showed multiple scattered pulmonary nodules. Histological examination of specimens obtained by bronchial biopsy allowed to exclude neoplastic origin and confirmed the diagnosis of sarcoidosis. On the basis of normal pulmonary function tests and the absence of extrapulmonary visceral involvement, simple patient monitoring was recommended. Radiologically sarcoidosis can exceptionally present as multiple scattered pulmonary nodules. Histological evidence is necessary to exclude other etiologies including tumors. Corticosteroids are indicated only in the presence of severe respiratory functional impairment and/or associated visceral involvement.

[Pulmonary manifestations in systemic lupus erythematosus]

Systemic lupus erythematosus is the most common connective tissue disease that is associated with pulmonary manifestations. Although lupus has the potential to affect any organ, lung involvement is observed during the course of the disease in most cases and it is prognostic for outcome. Pulmonary manifestations in lupus can be classified into five groups based on the anatomical involvement: pleura, lung parenchyma, bronchi and bronchioli, lung vasculature and respiratory muscles can be involved. The most common respiratory manifestations attributable to lupus are pleuritis with or without pleural effusion, pulmonary vascular disease, upper and lower airway dysfunction, parenchymal disease, and diaphragmatic dysfunction (shrinking lung syndrome). In this article the authors summarize lung involvement of lupus, its diagnosis, therapy and prognosis. Orv. Hetil., 2016, 157(29), 1154-1160.

Abnormalities in lung volumes and airflow in children with newly diagnosed connective tissue disease

INTRODUCTION

Connective tissue diseases (CTDs) of childhood are rare inflammatory disorders, involving various organs and tissues including respiratory system. Pulmonary involvement in patients with CTDs is uncommon but may cause functional impairment. Data on prevalence and type of lung function abnormalities in children with CTDs are scarce. Thus, the aim of this study was to asses pulmonary functional status in children with newly diagnosed CTD and follow the results after two years of the disease course.

MATERIAL AND METHODS

There were 98 children (mean age: 13 ± 3; 76 girls), treated in Department of Pediatric Rheumatology, Institute of Rheumatology, Warsaw and 80 aged-matched, healthy controls (mean age 12.7 ± 2.4; 50 girls) included into the study. Study procedures included medical history, physical examination, chest radiograph and PFT (spirometry and whole body-plethysmography). Then, the assessment of PFT was performed after 24 months.

RESULTS

FEV₁, FEV₁/FVC and MEF50 were significantly lower in CTD as compared to control group, there was no difference in FVC and TLC. The proportion of patients with abnormal lung function was significantly higher in the study group, 41 (42%) vs 9 (11%). 24-months observation didn't reveal progression in lung function impairment.

CONCLUSIONS

Lung function impairment is relatively common in children with CTDs. Although restrictive ventilatory pattern is considered typical feature of lung involvement in CTDs, airflow limitation could also be an initial abnormality.

Association between the serum level of vitamin D and systemic sclerosis in a Chinese population: a case control study

AIM

Several autoimmune diseases have been associated with reduced vitamin D levels. However, the serum level of vitamin D in Chinese systemic sclerosis (SSc) patients have not been reported. The aim of this study was to evaluate the serum levels of vitamin D in Chinese SSc patients and analyze the association between vitamin D and SSc.

METHODS

25-hydroxy vitamin D ¹²⁵ I RIA kit was applied to evaluate the serum levels of vitamin D in 60 SSc patients and 60 healthy controls from Anhui Provincial Hospital, China. The data of epidemiological and clinical characteristics of SSc patients were also collected.

RESULTS

The serum levels of vitamin D were significantly lower in SSc patients than that in healthy controls (26.51 ± 6.27 vs. 36.29 ± 14.24 ng/mL, P < 0.001). The ratio of pulmonary involvement in vitamin D insufficiency patients was higher than that in normal vitamin D patients, but the difference missed statistical significance. The differences in other aspects were not statistically significant in the two groups.

CONCLUSION

Serum levels of vitamin D in patients with SSc were lower than that in healthy controls. Further studies are needed to determine whether vitamin D supplement could provide some positive effects.

Fabry disease, respiratory symptoms, and airway limitation - a systematic review

Background

Fabry disease is an X-linked disorder caused by a deficiency of the lysosomal enzyme α-galactosidase A, resulting in accumulation of glycosphingolipids in multiple organs, primarily heart, kidneys, skin, CNS, and lungs.

Materials and method

A systematic literature search was performed using the PubMed database, leading to a total number of 154 hits. Due to language restriction, this number was reduced to 135; 53 papers did not concern Fabry disease, 19 were either animal studies or gene therapy studies, and 36 papers did not have lung involvement in Fabry disease as a topic. The remaining 27 articles were relevant for this review.

Results

The current literature concerning lung manifestations describes various respiratory symptoms such as dyspnoea or shortness of breath, wheezing, and dry cough. These symptoms are often related to cardiac involvement in Fabry disease as respiratory examinations are seldom performed. Pulmonary function tests primarily show obstructive airway limitation, but a few articles also report of patients with restrictive limitation and a mixture of both. No significant association has been found between smoking and the development of symptoms or spirometry abnormalities in patients with Fabry disease. Electron microscopy of lung biopsy and induced sputum show lamellar inclusion bodies (Zebra bodies) in the cytoplasm of cells in the airway wall. X-ray and CT scan have shown patchy ground-glass pulmonary infiltrations, fibrosis, and air trapping. Fibrosis diagnosed by high-resolution CT has not been significantly correlated with lung spirometry.

Conclusion

Consistent findings have not been shown in the current literature. Pulmonary function tests and registration of symptoms showed various results; however, there is a trend towards obstructive airway limitation in patients with Fabry disease. Further studies are needed to evaluate pathogenesis, progression, and the effects of treatment.

Diffuse cutaneous mastocytosis with bullous lesions and pulmonary involvement: a rare case

Mastocytosis is defined as a heterogeneous group of disorders characterized by an accumulation of mast cells in one or more organs, particularly in the skin, bone marrow, liver, spleen and lymph nodes. However here we describe an 11-month-old girl child presented with diffuse cutaneous mastocytosis with bullous lesion, having pulmonary involvement, which is very rare and there is no available case report from India.

Pulmonary manifestations in systemic lupus erythematosus: association with disease activity

Background and objective

Although systemic lupus erythematosus (SLE) is the most common connective tissue disease affecting the lung, few studies have assessed risk factors that predict pulmonary manifestations. The objectives of the present study were to determine the prevalence of lung manifestations in SLE patients from Western Saudi Arabia by analysing results from high-resolution computed tomography (HRCT) scans and to identify independent risk factors for lung involvement.

Methods

This was a 10-year retrospective study involving 184 SLE patients. We examined all HRCT lung abnormalities and determined whether findings were associated with the presence of lupus nephritis (LN), SLE disease activity (as defined by SLE Disease Activity Index 2000 item scores ≥4 for any and all items) or levels of complement and anti-double-stranded DNA (anti-dsDNA).

Results

We identified 61 patients (33%) with pulmonary involvement, and 52 (85%) of these subjects showed HRCT abnormalities. The most common HRCT findings were pleural effusion, consolidation and atelectasis (58%, 42% and 42%, respectively). There was a significant association between abnormal HRCT results and hypocomplementemia, high levels of anti-dsDNA and disease activity (P < 0.05), particularly with regard to pleuropericardial effusion and consolidation. Pulmonary abnormalities were significantly higher within the first five years after SLE diagnosis (P < 0.001). However, neither disease duration nor LN was associated with increased risk.

Conclusions

Lung manifestations were frequent in SLE patients from Saudi Arabia, with pleural effusion, consolidation and atelectasis being the most common. Low complement levels, high anti-dsDNA levels and disease activity were significantly associated with abnormal HRCT findings (all P < 0.001).

Pulmonary involvement in patients with Behçet's disease: report of 15 cases

BACKGROUND AND OBJECTIVES

Behçet's disease (BD) is a multisystem vasculitis, and pulmonary involvement in BD can have complex clinical manifestations. We aimed to analyze the clinical and radiological features, as well as the outcomes, of BD patients with pulmonary manifestation.

METHOD

We retrospectively reviewed the medical records of 106 patients with BD diagnosed in our institute between January 2000 and January 2013. Patients with pulmonary vascular or parenchymal abnormalities on chest radiography, thorax computed tomography, magnetic resonance imaging or pulmonary scintigraphy were included in this study.

RESULTS

Fifteen patients (14%) were identified to have pulmonary involvement. Pulmonary artery aneurysms (PAA) was observed in six patients, and all of them had concomitant thrombi, attenuation or occlusion of PAs, and five of them also had radiographic parenchymal changes. Three patients had solely pulmonary artery thrombus (PAT) without PAA. For the six patients with isolated radiographic parenchyma changes, pulmonary infiltration resolved with immunosuppressant therapy in four subjects; the lesion remained unchanged in one subject with radiographic interstitial changes, and acid-fast bacilli were found in the remaining subject. Patients with PAA or PAT had more frequency of hemoptysis and extra-pulmonary vascular lesions compared with isolated parenchymal involvement. Radiographic parenchyma changes are nonspecific, with ill-defined ground-glass opacity being the most common pulmonary radiographic parenchymal changes. Patients with isolated parenchymal changes had better prognosis than those with PAA or PAT.

CONCLUSIONS

BD with pulmonary involvement can have a wide spectrum of abnormal clinical and radiographic manifestations, and multiple pulmonary lesions can exit in the same patient.