[Transbronchial cryobiopsy in diffuse interstitial lung diseases]

INTRODUCTION

In the diagnostic approach to interstitial lung disease (ILD), the use of transbronchial cryobiopsy (TBC) may offer an alternative to surgical lung biopsy (SLB). We report the diagnostic effectiveness and the safety of TBC in ILD based on the preliminary experience in two French university centers.

METHODS

Twenty four patients underwent TBC for the diagnosis of ILD in the operating room between 2014 and 2017. All the histological diagnoses obtained were then reviewed and validated during multidisciplinary discussions (MDD).

RESULTS

Patients had an average of 3 TBC.TBC samples were analyzable in 22/24 (91.7%) patients. In these, samples allowed a histological diagnosis to be made in 14/22 (63.6%) patients and a diagnosis with certainty in 13/22 (59%) after MDD. The overall diagnostic yield from TBC was 13/24 (54.2%). Nine (37.5%) patients had a pneumothorax. Five (20.8%) patients had a bleeding. There were no deaths. Taking into account a possible initial learning curve and considering only the 15 patients who had their TBC after 2015, we note that a diagnosis could be made after MDD for 12 of them, that is, 80%.

CONCLUSION

A prospective randomized study is needed to evaluate the technique in France in order to specify its diagnostic performance and its safety profile in comparison to SLB.

[Mediastinitis following endobronchial ultrasound-guided transbronchial needle aspiration]

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure designed to explore mediastinal lymphadenopathy. Its use and indications have increased recently and severe, though rare, complications have been reported.

CASE REPORT

EBUS-TBNA was performed in a 64-year-old patient presenting with mediastinal lymphadenopathy, probably due to sarcoidosis, but without histological proof. Within hours of the aspiration of subcarinal lymph nodes (station 7), the patient developed fever and dry cough associated with progressive dysphagia and dysphonia that persisted for four weeks. Mediastinitis was diagnosed after a CT-scan revealed a collection in the subcarinal space previously tapped using CT guidance. Intravenous antibiotics were started and both symptoms and the mediastinal collection resolved without need of a surgical procedure. The patient recovered fully.

CONCLUSION

EBUS-TBNA is associated with a risk of mediastinitis that may manifest as an isolated fever arising within hours of the procedure. The pathogens responsible are usually contaminants from the oropharynx such as Streptococcus sp, probably inoculated directly into the mediastinum during transbronchial needle aspiration. Rapid diagnosis and treatment are necessary in order to reduce morbidity and mortality associated with mediastinitis.

[The place of inhaled corticosteroids in COPD]

INTRODUCTION

Clinical trials have provided some evidence of a favorable effect of inhaled corticosteroids on the frequency of exacerbations and on the quality of life of patients with chronic obstructive pulmonary disease (COPD). In contrast, ICS have little or no impact on lung function decline and on mortality.

STATE OF THE ART

Inhaled corticosteroids are recommended only in a minority of COPD patients, those with severe disease and repeated exacerbations and probably those with the COPD and asthma overlap syndrome. However, surveys indicate that these drugs are inappropriately prescribed in a large population of patients with COPD. Overtreatment with inhaled corticosteroids exposes these patients to an increased risk of potentially severe side-effects such as pneumonia, osteoporosis, and oropharyngeal candidiasis. Moreover, it represents a major waste of health-care spending.

CONCLUSION

Primary care physicians as well as pulmonologists should be better aware of the benefits as well as the side-effects and costs of inhaled corticosteroids.

[Diagnosis of lung cancer. Image guided diagnostic endoscopy]

The scope of fibreoptic bronchoscopy, which has a high sensitivity for biopsy of visible bronchial lesions, has been extended to more difficult areas such as the mediastinum and the periphery of the lung. This has become possible thanks to technical developments in imaging including miniaturised ultrasound transducers, electromagnetic guidance and positron emission tomography. These techniques which are less invasive than mediastinoscopy or thoracotomy and are probably equally cost-effective.

[Impact of prior biological assessment of coagulation on the hemorrhagic risk of fiberoptic bronchoscopy]

INTRODUCTION

The goals of the study were to test the value of coagulation tests to predict bleeding events during fiberoptic bronchoscopy (FOB) and to identify risk factors.

METHODS

A monocentric prospective study of 426 procedures performed by one physician was realized. A standardized questionnaire and coagulation tests including prothrombine time, activated cephaline time and platelets counts were performed before the procedure. Bleeding events, defined by a loss of more than 50 ml of blood, were recorded for all patients.

RESULTS

44 patients (10.3%) had bleeding events, modifying the procedure in 19 cases. No death occurred following FOB during the study. Among the 17 patients with abnormalities on coagulation test before FOB, only one had significant bleeding. Two risk factors were found as predictors of bleeding events: nose or gum bleeding (OR=4.99, CI (95%) [2.6-9.5]; p<0.001) and left cardiac failure (OR=4.53, CI (95%) [1.7-12.1]; p<0.01).

CONCLUSION

This study shows that abnormalities on coagulation tests are not predictive for bleeding events. Nose or gum bleeding and left cardiac failure may be risk factors for bleeding events during FOB.

[Chemoradiotherapy-chemotherapy for grade III inoperable non-small-cell lung cancer]

PURPOSE

The purpose of this work was to assess results obtained with the MIP (mitomycin 6 mg/m(2) day 1, ifosfamide 1500 mg/m(2) days 1,2, 3, cisplatin 30 mg/m(2) days 1,2, 3) chemotherapy protocol combined with cisplatin-sensitized chest radiotherapy as developed in the French multicentric trial on perioperative chemotherapy.

PATIENTS AND METHODS

Thirty-five patients with grade III non-small-cell lung cancer (NSCLC) were given two or three starter MIP cycles every 4 weeks then underwent radiation therapy for six weeks for a total dose of 60 Gy with injection of 8 mg/m(2) cisplatin every day for the first two weeks and the last two weeks of treatment. In case of objective response (OR) to MIP before radiotherapy, the MIP protocol was repeated for one to four supplementary cycles according to tolerance.

RESULTS

The rate of OR after MIP was 51% and after chemoradiotherapy it was 69%. Toxic effects were limited to one death due to aplasia and 18 cases of grade 3-4 toxicity, mainly due to hematology disorders. Moderate esophagitis was observed in ten cases. Median survival was 13.5 months. Survival rates were 57% and 29% at one and two years.

DISCUSSION

This novel scheme, which can be improved, has demonstrated its efficacy. Tolerance is satisfactory and the cost is low compared with associations using "new" drugs.

Neurotensin induces mating in Saccharomyces cerevisiae cells that express human neurotensin receptor type 1 in place of the endogenous pheromone receptor

Heterologous expression of the human neurotensin receptor type I (hNT1-R) has been achieved in the yeast Saccharomyces cerevisiae. Immunoanalysis of membranes prepared from cells expressing a c-myc-tagged version of hNT1-R revealed multiple c-myc cross-reacting polypeptides of high molecular mass, suggesting that hNT1-R was glycosylated in yeast. High-affinity binding sites for 125I-labeled-[monoiodo-Tyr3]neurotensin ([125I-Tyr3]NT) were detected on hNT1-R-expressing cells with Kd and Bmax values of 3.2 nM and of 500 receptors per cell, respectively. Competition binding studies of neurotensin with SR142948 and SR48692, two nonpeptidic antagonists of hNT1-R, indicated that the yeast-produced recombinant receptor displayed the same pharmacological properties as hNT1-R expressed in mammalian cells. Interestingly, neurotensin activated the pheromone pathway in hNT1-R-expressing cells in a dose-dependent fashion, as revealed by a beta-galactosidase activity assay with a pheromone-responsive Fus1:lacZ construct. Mutational inactivation of the SST2 and STE2 genes increased the level of beta-galactosidase activity in response to neurotensin by twofold. Recombinant hNT1-R-producing cells, which lacked the endogenous G-protein-coupled receptor for the alpha pheromone, mated with wild-type MATalpha haploid cells in response to neurotensin, leading to bona fide diploid zygote formation. This is the first report of a mammalian receptor that can replace the endogenous pheromone receptor when produced in yeast, by signaling a fully effective, agonist-induced, mating process.

Pseudo-outbreak of Mycobacterium gordonae associated with water from refrigerated fountains

Between March 1997 and December 1997, acid-fast bacilli (AFB) were detected on sputum and/or gastric aspirates smears from five patients hospitalized in the chest medicine department. These specimens grew M. gordonae. Based on AFB-positive smear and clinical presentation, four out of five patients received antituberculous treatment until species identification was known. Epidemiological investigation revealed a heavy contamination of water collected from refrigerated fountains located on the same floor as the patient cases. Strains isolated from four patients and the refrigerated fountain exhibited the same pulsed gel electrophoresis pattern (using DraI and XbaI enzymes) suggesting that positive smears were related to drinking water from the refrigerated fountain. This cluster of pseudo-infections underlines the necessity for a proper maintenance of water supply equipment in order to avoid inappropriate decisions deleterious for patients.

Characteristics of missed lung cancer on chest radiographs: a French experience

The purpose of this study was to report 30 cases of missed lung cancers and describe characteristics of each case. Reasons for misdiagnosis were analyzed from the report. Each radiograph was subsequently reviewed by a panel of two experts who quantified several parameters regarding image analysis and film quality. Lesions were not described in 67% of the cases and were misinterpreted as benign processes in 33% of cases. Comparison to previous chest radiographs and clinical information were seldom available on the report. Size of the lesions varied between 1 and 7 cm, location was primarily apical and paramediastinal, normal anatomy was highly or moderately complex in 87%, and distracting lesions were present in 63% of the cases. Image quality was considered perfect in 3 cases only. Among all the factors responsible for missed lung cancer, certain factors can be improved as film quality, comparison with previous radiographs, and better awareness of clinical information.

A high voltage electrical burn of lung parenchyma

High voltage electrical trauma may cause severe visceral injuries. We report a case of direct electrical injury to the lung parenchyma, without evidence of any thoracic wall contact injury, in an electrician who sustained a 20 kV-electrical shock while working in a substation cubicle. The diagnosis of a true electrical burn of the left lower lobe was suggested early on by imaging and then confirmed by surgical exploration, histological findings and the significant improvement of the patient's condition following resection of the infarcted lobe. All possible causes of bronchial and pulmonary pathologies in such a context were ruled out. The fatal outcome of two previous similar cases and the generally high mortality of any electrical visceral injury support early surgical management as the only rational life-saving treatment. Current pathophysiological knowledge substantiates the theory of an isolated visceral injury located far away from the contact wounds. However, the pathogenesis of such severe injuries is not entirely understood.

[Pulmonary toxoplasmosis in patients with human immunodeficiency virus infection. 21 cases]

OBJECTIVES

Assess expression of pulmonary toxoplasmosis, the second most frequent localization after brain, in patients infected with the human immunodeficiency virus (HIV).

METHODS

Twenty-one HIV-infected patients (18M, 3F) were admitted for pulmonary toxoplasmosis between September 1987 and February 1995. Mode of HIV transmission was unprotected homosexual sexual activity (n = 16), intravenous drug abuse (n = 3) and transfusion (n = 2).

RESULTS

Isolated pulmonary toxoplasmosis was found in 11 patients. In 10 patients pulmonary toxoplasmosis was associated with cerebral (n = 4), bone marrow (n = 2), ocular (n = 1) and multifocal (n = 3) localizations. Seven patients were admitted for acute pulmonary distress. Fever (reported for 20 patients) and nonproductive cough (reported for 16 patients) were the most common clinical symptoms. Chest roentgenogram revealed bilateral pulmonary infiltrates in 16 (76%) patients. Mean absolute CD4 count was 25 +/- 57 (range 0-110). Serologic evidence of past infection was observed in 18 patients. Serology tests were not done for two patients and negative for one. Two patients presented co-infection with Pneumocystis carinii. Fourteen patients had elevated serum lactic dehydrogenase (LDH) concentration. Among those, 4 patients whose LDH concentration was elevated more than ten fold died of respiratory distress. Patients received pyrimethamine and sulfadiazine (n = 13) or clindamycin (n = 8). Seven patients died during the first month after diagnosis was made. For the other patients, mean survival was 8 months. No relapse of toxoplasmosis was observed. All the patients took a secondary prophylaxis.

CONCLUSION

No difference between patient with isolated pulmonary toxoplasmosis and patients with associated extra-pulmonary localization was noted for clinical, biological, radiological presentations and outcome.

Efficacy and toxicity of mitomycin, ifosfamide, and cisplatin (MIP) in patients with inoperable non-small cell lung cancer

Seventy-two patients with advanced stage IIIB (42%) or stage IV (58%) non-small cell lung cancer (median age 57 years, Karnofsky PS 60-100) were treated with mitomycin C (6 mg/m2, day 1), ifosfamide (1500 mg/m2, days 1-3), and cisplatin (30 mg/m2, days 1-3) every 4 weeks. The objective response rate was 37% in the overall population; 50% in stage IIIB patients and 29% in stage IV patients. Twenty four patients achieved partial response (33%) and three patients achieved complete response. Despite this relatively high objective response rate, the overall median survival time was 32 weeks. The median survival was significantly better in stage IIIB patients (55 weeks) than in stage IV patients (25 weeks) (P = 0.003). MIP regimen was permanently suspended in 14 patients because of toxic events. Seventeen patients developed grade III or IV febrile neutropenia and two patients died from sepsis. Two patients experienced acute mitomycin peumonitis. Despite increased doses of cisplatin and ifosfamide, compared with the original description for MIC chemotherapy, with probably higher toxicity, no apparent increased response rate or median survival was observed in this study. The MIP regimen could be tested in a randomized trial in comparison with other administration plans in a comparable population.

Cost effectiveness of noninvasive oxygen saturation measurement during exercise for the diagnosis of Pneumocystis carinii pneumonia

We assessed (1) the sensitivity and specificity of exercise oxygen saturation measurement (EOS) for the diagnosis of Pneumocystis carinii pneumonia (PCP); and (2) the cost of introducing this indirect diagnostic test compared with that of standard diagnostic strategies for PCP. In a prospective study, 85 HIV-infected patients with suspected PCP underwent EOS, followed by induced sputum (IS) and bronchoalveolar lavage (BAL) if IS was negative for P. carinii. The prevalence of PCP was 0.22, the sensitivity of IS was 0.6, and its specificity was perfect. The cost ratios of IS to BAL and EOS to BAL were 0.1 and 0.2, respectively. A desaturation of three points was the best cutoff point, giving perfect sensitivity and a specificity of 0.77. The cost analysis showed that the introduction of EOS into diagnostic strategies for PCP is highly justified when the local prevalence is low. Exercise oxygen saturation measurement is simple and safe, and the results are available rapidly; its sensitivity is perfect and its specificity good. Its economic utility depends on its cost and the local prevalence of PCP in the test population.

[Consequences of specific prevention on the diagnosis of Pneumocystis carinii pneumonia in patients with HIV infection. Comité SIDA de l'Hôpital Saint-Antoine]

In a prospective study the authors compared the clinical, radiological, biochemical and diagnostic features of Pneumocystis carinii pneumonia (PCP) in HIV-infected patients who were or were not receiving a specific prophylactic treatment. The study included 386 patients with suspected PCP, 201 of whom were under specific prophylactic therapy. Induced expectoration and/or bronchoalveolar lavage provided a diagnosis of PCP in 89 patients, 21 of whom were under specific prophylaxis. Apart from a number of circulating CD4 lymphocytes that was significantly lower in the patients under prophylaxis, there was no significant difference between the two groups. Thus, being under specific prophylaxis should have no effect on the diagnosis of PCP in HIV-infected patients.

[Monitoring of small cell bronchopulmonary cancer by bronchial biopsies]

This retrospective study of 149 patients with small cell lung cancer highlights the value of bronchial endoscopies combined with biopsies for the follow-up of these cases. A control endoscopy performed during the third month showed that macroscopic lesions had completely disappeared in 42 percent of the patients. Each subsequent endoscopy offered a probability rising from 20 to 50 percent of diagnosing a recurrence in the patients explored. Our study particularly demonstrates the usefulness of bronchial biopsy at the initial site of the lesion, even when the bronchial mucosa seems to have returned to normal, since this biopsy is positive in 4.5 percent of the cases.

On plastid symbiosis in Tontonia appendiculariformis (Ciliophora, Oligotrichina)

Many hundreds of isolated plastids, in a good state of preservation in their living host, the planktonic ciliate Tontonia appendiculariformis (Oligotrichina), have been studied by electron microscopy. These distinctive plastids, located at the periphery of the host's body, which do not belong to complete symbiotic algae, are described in detail. All are bounded by three membranes. Although degenerating plastids were observed none were ever seen in division. Their possible origin, the significance of the three plastid membranes, and the degree of symbiosis established are discussed. From their organization, these plastids may have originated from several species of chromophyte algae, such as dinophyceae, Prymnesiophyceae, and Bacillariophyceae or Chrysophyceae. Because of their absence of division and of their possible degeneration, they are probably not integrated genetically. However, they appear to survive for some time and to remain functional. There is evidence that the outermost third plastid membrane arises from the host ciliate. Finally, hypotheses are proposed to explain the incorporation of the plastids into the ciliate, and their possible role in building cortical polysaccharide plates.