Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension-A Challenging Mystery

Sarcoidosis has been a well-recognised risk factor for pulmonary hypertension (PH) for a long time, but still, the knowledge about this concatenation is incomplete. Sarcoidosis-associated PH (SAPH) is an uncommon but serious complication associated with increased morbidity and mortality among sarcoidosis patients. The real epidemiology of SAPH remains unknown, and its pathomechanisms are not fully explained. Sarcoidosis is a heterogeneous and dynamic condition, and SAPH pathogenesis is believed to be multifactorial. The main roles in SAPH development play: parenchymal lung disease with the destruction of pulmonary vessels, the extrinsic compression of pulmonary vessels by conglomerate masses, lymphadenopathy or fibrosing mediastinitis, pulmonary vasculopathy, LV dysfunction, and portal hypertension. Recently, it has been recommended to individually tailor SAPH management according to the predominant pathomechanism, i.e., SAPH phenotype. Unfortunately, SAPH phenotyping is not a straightforward process. First, there are gaps in our understanding of undergoing processes. Second, the assessment of such a pivotal element as pulmonary vasculature on a microscopic level is non-feasible in SAPH patients antemortem. Finally, SAPH is a dynamic condition, multiple phenotypes usually coexist, and patients can switch between phenotypes during the course of sarcoidosis. In this article, we summarise the basic knowledge of SAPH, describe SAPH phenotypes, and highlight some practical problems related to SAPH phenotyping.

Sudden Vision Loss Due to Optic Neuritis-An Uncommon Presentation of Neurosarcoidosis

Sarcoidosis is a systemic, granulomatous disease of unknown etiology, most often manifested by mediastinal and hilar lymph node enlargement and parenchymal nodules in the lungs. However, it may involve any other organ. Neuro-sarcoidosis, a condition that affects up to 20% of sarcoidosis patients, can be found in any part of the central or peripheral nervous system and has important ophthalmic and neuro-ophthalmic manifestations. We present two patients with sudden vision loss due to neurosarcoidosis. In both cases, biopsy of the mediastinal lymph node showed non-caseating granulomas consistent with sarcoidosis. Treatment involved high doses of methylprednisolone intravenously, followed by topical dexamethasone eye drops in the first case and a systemic steroid treatment in the second, resulting in symptom relief. Those two cases demonstrate that sarcoidosis should be considered as a differential diagnosis in cases of optic neuritis.

Pulmonary Hypertension in the Course of Interstitial Lung Diseases-A Personalised Approach Is Needed to Identify a Dominant Cause and Provide an Effective Therapy

The prevalence of pulmonary hypertension (PH) complicating interstitial lung diseases (ILDs) is 3.5-15% at an early stage, and up to 90% in ILD patients listed for lung transplantation. In addition, other types of PH may occur in patients with ILDs due to concomitant conditions. Therefore, any significant PH occurring in the setting of ILD requires a proper differential workup. PH increases morbidity and mortality in ILDs. The pathomechanisms underlying PH due to ILD (PH-ILD) are not fully known, and there is no straightforward correlation between the presence or severity of PH-ILD and the severity of ILD. Severe PH in mild ILD without other explanatory causes constitutes a dilemma of differentiating between PH due to ILD and pulmonary arterial hypertension coexisting with ILDs. The heterogeneity and poor prognosis of patients with ILDs coexisting with PH necessitate an individualised approach to the management of this condition. This review presents recent advances in understanding and treatment options in PH-ILD. It also addresses practical issues, such as when to suspect and how to screen for PH in ILD, what are the indications for right heart catheterisation, and how to approach an individual ILD patient to determine the dominant PH cause and apply adequate management.

Imaging Plays a Key Role in the Diagnosis and Control of the Treatment of Bone Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown origin. The most frequent localizations are thoracic lymph nodes and/or parenchymal lung disease, nevertheless any other organ may be involved. Musculoskeletal sarcoidosis, previously considered a rare manifestation of the disease, is presently recognized with increasing frequency, due to the development of modern imaging modalities. The classical X-ray sign of bone sarcoidosis is the image of lace in the phalanges of the hands. Most other locations present with atypical radiological images. Therefore, they may mimic metastatic neoplastic disease, especially when they are the first sign of sarcoidosis not previously recognized. On such occasions, none of the imaging methods will give the correct diagnosis, histopathological verification, monitoring of lesions or clinical data in a patient with confirmed sarcoidosis are indicated. The article summarizes the current status of knowledge concerning the recognition and therapy of bone sarcoidosis. In addition, an illustrative case of patient with bone and bone marrow sarcoidosis is presented.

The Presence of T Allele (rs35705950) of the MUC5B Gene Predicts Lower Baseline Forced Vital Capacity and Its Subsequent Decline in Patients with Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis (HP) is an exposure-related interstitial lung disease with two phenotypes-fibrotic and non-fibrotic. Genetic predisposition is an important factor in the disease pathogenesis and fibrosis development. Several genes are supposed to be associated with the fibrosing cascade in the lungs. One of the best-recognized and most prevalent is the common MUC5B gene promoter region polymorphism variant rs35705950. The aim of our study was to establish the frequency of the minor allele of the MUC5B gene in the population of patients with HP and to find the relationship between the MUC5B promoter region polymorphism and the development of lung fibrosis, the severity of the disease course, and the response to the treatment in patients with HP. Eighty-six consecutive patients with HP were tested for the genetic variant rs35705950 of the MUC-5B gene. Demographic, radiological, and functional parameters were collected. The relationship between the presence of the T allele and lung fibrosis, pulmonary function test parameters, and the treatment response were analyzed. The minor allele frequency in the study group was 17%, with the distribution of the genotypes GG in 69.8% of subjects and GT/TT in 30.2%. Patients with the GT/TT phenotype had significantly lower baseline forced vital capacity (FVC) and significantly more frequently had a decline in FVC with time. The prevalence of lung fibrosis in high-resolution computed tomography (HRCT) was not significantly increased in GT/TT variant carriers compared to GG ones. The patients with the T allele tended to respond worse to immunomodulatory treatment and more frequently received antifibrotic drugs. In conclusions: The frequency of MUC5B polymorphism in HP patients is high. The T allele may indicate a worse disease course, worse immunomodulatory treatment response, and earlier need for antifibrotic treatment.

New 6-Minute-Walking Test Parameter—Distance/Desaturation Index (DDI) Correctly Diagnoses Short-Term Response to Immunomodulatory Therapy in Hypersensitivity Pneumonitis

The six-minute-walking test (6MWT) is an easy-to-perform, cheap and valuable tool to assess the physical performance of patients. It has been used as one of the endpoints in many clinical trials investigating treatment efficacy in pulmonary arterial hypertension and idiopathic pulmonary fibrosis. However, the utility of 6MWT in patients diagnosed with hypersensitivity pneumonitis (HP) is still under investigation. The aim of the present retrospective study was to assess the value of different 6MWT parameters, including the newly developed distance-desaturation index (DDI), to evaluate immunomodulatory treatment outcomes in HP patients. Methods: 6MWT parameters (distance, initial saturation, final saturation, desaturation, distance-saturation product (DSP), and DDI) were analyzed at baseline and after 3 to 6 months of treatment with corticosteroids alone or in combination with azathioprine. Results: 91 consecutive HP patients diagnosed and treated in a single pulmonary unit from 2005 to 2017 entered the study. There were 44 (48%) males and 52 (57%) patients with fibrotic HP (fHP). Sixty-three patients (69%) responded to treatment (responders) and 28 (31%) did not respond (non-responders). In the responders group, all parameters assessed during 6MWT significantly improved, whereas in non-responders, they worsened. Medians (95% CI) of best indices were post-treatment DDI/baseline DDI—1.67 (1.85–3.63) in responders versus 0.88 (0.7–1.73) in non-responders (p = 0.0001) and change in walking distance–51 m (36–72 m) in responders, versus 10.5 m (−61.2–27.9) in non-responders (p = 0.0056). The area under the curve (AUC) of receiver operating characteristics (ROC) for post-treatment DDI/baseline DDI was 0.74 and the optimal cut-off was 1.075, with 71% of specificity and 71% of sensitivity. Conclusions: 6MWT may be used as a tool to assess and monitor the response to immunomodulatory therapy in HP patients, especially if indices incorporating both distance and desaturation are used. Based on the present study results, we recommend 6MWD and DDI use, in addition to FVC and TL,co, to monitor treatment efficacy in patients with interstitial lung diseases.

D-Dimers Variability in the Perioperative Period of Breast Cancer Surgery Helps to Predict Cancer Relapse: A Single-Centre Prospective Study

BACKGROUND

The importance of D-dimers (DD) assessment in the diagnostic algorithm of venous thromboembolic (VTE) disease is well known. Increase of DD concentration may be also associated with neoplastic disease. Many studies documented that high concentration of DD before solid tumour surgery indicates more advanced disease and poor life expectancy. The prognostic value of the DD concentration variability in the perioperative period, in women undergoing breast cancer surgery, has not been analysed so far. Thus, the aim of the present prospective study was to assess whether the trend of DD concentration changes in the perioperative period may predict cancer recurrence in women undergoing breast cancer surgery.

MATERIALS AND METHODS

189 consecutive women with histopathological diagnosis of breast cancer (BC) referred for surgical treatment were included. DD concentration was measured twice in each patient: at the time of admission to hospital and at the time of discharge home. Enoxaparin in standard dose of 40 mg daily s. c. was used as primary VTE prophylaxis in all of the patients.

RESULTS

The recurrence of BC, within 1 year observation time, occurred in 13 patients (6.8%), in 11 (5.8%) patients with DD increase after surgery and only in 2 (1.1%) without an increase in DD, P = .0179. Increase in DD concentration after BC surgery was an independent positive predictor of disease relapse (OR 8.600, LCI 1.451, UCI 96.80, P = .0371) together with the lack of postoperative radiotherapy (OR 6.009, LCI 1.305, UCI 31.95, P = .0245), whereas the lack of postoperative chemotherapy predicted no BC relapse (OR .07355, LCI .0056, UCI .58, P = .0245).

CONCLUSIONS

Increase of DD in the early postoperative period may be considered as additional independent predictor of recurrence of BC within 1 year.

Factors Predictive for Immunomodulatory Therapy Response and Survival in Patients with Hypersensitivity Pneumonitis-Retrospective Cohort Analysis

Hypersensitivity pneumonitis (HP) is one of the interstitial lung diseases with clearly established diagnostic criteria. Nevertheless, pharmacologic treatment recommendations are still lacking. Most specialists use steroids as first-line drugs, sometimes combined with an immunosuppressive agent. Aim: The aim of the present retrospective study was to establish predictive factors for treatment success and survival advantage in HP patients. Methods: We analyzed the short-term treatment outcome and overall survival in consecutive HP patients treated with prednisone alone or combined with azathioprine. Results: The study group consisted of 93 HP patients, 54 (58%) with fibrotic HP and 39 (42%) with non-fibrotic HP. Mean (± SD) VCmax % pred. and TL,co % pred. before treatment initiation were 81.5 (±20.8)% and 48.3 (±15.7)%, respectively. Mean relative VCmax and TL,co change after 3−6 months of therapy were 9.5 (±18.8)% and 21.4 (±35.2)%, respectively. The short-term treatment outcomes were improvement in 49 (53%) patients, stabilization in 16 (17%) patients, and progression in 28 (30%) patients. Among those with fibrotic HP, improvement was noted in 19 (35%) cases. Significant positive treatment outcome predictors were fever after antigen exposure, lymphocyte count in broncho-alveolar lavage fluid (BALF) exceeding 54%, RV/TLC > 120% pred., and ill-defined centrilobular nodules in high-resolution computed tomography (HRCT). An increased eosinophil count in BALF and fibrosis in HRCT were significant negative treatment outcome predictors. The presence of fibrosis in HRCT remained significant in a multivariate analysis. A positive response to treatment, as well as preserved baseline VCmax (% pred.) and TLC (% pred.), predicted longer survival, while fibrosis in HRCT was related to a worse prognosis. Conclusion: Immunomodulatory treatment may be effective in a significant proportion of patients with HP, including those with fibrotic changes in HRCT. Therefore, future trials are urgently needed to establish the role of immunosuppressive treatment in fibrotic HP.

Atypical Pulmonary Tuberculosis as the First Manifestation of Advanced HIV Disease—Diagnostic Difficulties

Tuberculosis (TB) is the leading cause of morbidity, hospitalisations, and mortality in people living with HIV (PLWH). The lower CD4+ T-lymphocyte count in the course of HIV infection, the higher risk of active TB, and the higher odds for atypical clinical and radiologic TB presentation. These HIV-related alterations in TB presentation may cause diagnostic problems in patients not knowing they are infected with HIV. We report on a patient without any background medical conditions, who was referred to a hospital with a 4-month history of chest and feet pains, mild dry cough, fatigue, reduced appetite, and decreasing body weight. Chest X-ray revealed mediastinal lymphadenopathy, bilateral reticulonodular parenchymal opacities, and pleural effusion. A preliminary diagnosis of lymphoma, possibly with a superimposed infection was established. Further differential diagnostic process revealed pulmonary TB in the course of advanced HIV-1 disease, with a CD4+ T-lymphocyte count of 107 cells/mm3. The patient completed anti-tuberculous therapy and successfully continues on antiretroviral treatment. This case underlines the importance of screening for HIV in patients with newly diagnosed TB.

Large Pericardial Effusion—Diagnostic and Therapeutic Options, with a Special Attention to the Role of Prolonged Pericardial Fluid Drainage

Background: Large pericardial effusion (LPE) is associated with high mortality. In patients with cardiac tamponade or with suspected bacterial etiology of pericardial effusion, urgent pericardial decompression is necessary. Aim: The aim of the present retrospective study was to assess the short-term results of pericardial decompression combined with prolonged drainage in LPE. Material: This study included consecutive patients with LPE who had been treated with pericardial fluid drainage between 2007 and 2017 in the National Tuberculosis and Lung Diseases Research Institute. Methods: Echocardiographic examination was used to confirm LPE and the signs of cardiac tamponade. Pericardiocentesis or surgical decompression were combined with pericardial fluid (PF) drainage. Short-term effectiveness of therapy was defined as less than 5 mm of fluid behind the left ventricular posterior wall in echocardiography. Results: The analysis included 74 patients treated with pericardial fluid drainage (33 female and 41 male), mean age 58 years, who underwent pericardial decompression. Out of 74 patients, 26 presented with cardiac tamponade symptoms. Pericardiocentesis was performed in 18 patients and pericardiotomy in 56 patients. Median PF drainage duration was 13 days. In 17 out of 25 patients with neoplastic PF, intrapericardial cisplatin therapy was implemented. In 4 out of 49 patients with non-malignant PF, purulent pericarditis was recognized and intrapericardial fibrinolysis was used. Short-term effectiveness of the therapy was obtained in all of patients. Non-infective complications were noted in 16% of patients and infective ones in 10%. Conclusion: Pericardial decompression combined with prolonged PF drainage was safe and efficient method of LPE treatment.

Acute Eosinophilic Pneumonia Complicated with Venous Thromboembolic Disease—Diagnostic and Therapeutic Considerations

Acute Eosinophilic Pneumonia (AEP) is a rare idiopathic disease caused by an accumulation of eosinophils in the pulmonary alveoli and interstitial tissue of the lungs. The onset of symptoms is acute; some patients develop respiratory failure. The diagnosis is based on clinical symptoms, diffuse interstitial infiltrates in the lungs on imaging studies, and eosinophilia exceeding 25% on bronchoalveolar lavage or pleural fluid smear. Smokers are primarily at increased risk for the disease. We present a case of venous thromboembolic disease (VTE) that developed in the course of AEP in a previously healthy male smoker. Complete remission of the disease was achieved with anticoagulation therapy combined with a low dose of steroids. Surprisingly, further diagnostics revealed the presence of thrombophilia: antithrombin (AT) deficiency and increased homocysteine level. According to our knowledge, this is the first case of VTE diagnosed in the course of AEP combined with thrombophilia.

Use of a FluoroType® System for the Rapid Detection of Patients with Multidrug-Resistant Tuberculosis—State of the Art Case Presentations

According to the World Health Organization (WHO), there were 465,000 cases of tuberculosis caused by strains resistant to at least two first-line anti-tuberculosis drugs: rifampicin and isoniazid (MDR-TB). In light of the growing problem of drug resistance in Mycobacterium tuberculosis across laboratories worldwide, the rapid identification of drug-resistant strains of the Mycobacterium tuberculosis complex poses the greatest challenge. Progress in molecular biology and the development of nucleic acid amplification assays have paved the way for improvements to methods for the direct detection of Mycobacterium tuberculosis in specimens from patients. This paper presents two cases that illustrate the implementation of molecular tools in the recognition of drug-resistant tuberculosis.

Tuberculous Pericarditis—Own Experiences and Recent Recommendations

Tuberculous pericarditis (TBP) accounts for 1% of all forms of tuberculosis and for 1–2% of extrapulmonary tuberculosis. In endemic regions, TBP accounts for 50–90% of effusive pericarditis; in non-endemic, it only accounts for 4%. In the absence of prompt and effective treatment, TBP can lead to very serious sequelae, such as cardiac tamponade, constrictive pericarditis, and death. Early diagnosis of TBP is a cornerstone of effective treatment. The present article summarises the authors’ own experiences and highlights the current status of knowledge concerning the diagnostic and therapeutic algorithm of TBP. Special attention is drawn to new, emerging molecular methods used for confirmation of M. tuberculosis infection as a cause of pericarditis.

Chronic hypersensitivity pneumonitis is associated with an increased risk of venous thromboembolism: a retrospective cohort study

Background

Idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis share commonalities in pathogenesis shifting haemostasis balance towards the procoagulant and antifibrinolytic activity. Several studies have suggested an increased risk of venous thromboembolism in IPF. The association between venous thromboembolism and chronic hypersensitivity pneumonitis has not been studied yet.

Methods

A retrospective cohort study of IPF and chronic hypersensitivity pneumonitis patients diagnosed in single tertiary referral center between 2005 and 2018 was conducted. The incidence of symptomatic venous thromboembolism was evaluated. Risk factors for venous thromboembolism and survival among those with and without venous thromboembolism were assessed.

Results

A total of 411 (259 IPF and 152 chronic hypersensitivity) patients were included (mean age 66.7 ± 8.4 vs 51.0 ± 13.3 years, respectively). There were 12 (4.6%) incident cases of venous thromboembolism in IPF and 5 (3.3%) in chronic hypersensitivity pneumonitis cohort. The relative risk (RR) of venous thromboembolism in chronic hypersensitivity pneumonitis was not significantly different to that found in patients with IPF (7.1 vs 11.8/1000 person-years, RR 1.661 95% CI 0.545–6.019, respectively).

The treatment with systemic steroids (OR 5.38; 95% CI 1.65–18.8, p = 0.006) and GAP stage 3 (OR 7.85; 95% CI 1.49–34.9; p = 0.037) were significant risk factors for venous thromboembolism in IPF. Arterial hypertension and pulmonary hypertension significantly increased risk of venous thromboembolism in chronic hypersensitivity pneumonitis. There were no significant differences in survival between patients with and without venous thromboembolism.

Conclusions

The patients with chronic hypersensitivity pneumonitis have a marked increase in the risk of venous thromboembolism, similar to the patients with IPF. Venous thromboembolism does not affect the survival of patients with IPF and chronic hypersensitivity pneumonitis.

Mycobacterium chimaera as an Underestimated Cause of NTM Lung Diseases in Patients Hospitalized in Pulmonary Wards

Mycobacterium chimaera is the newly described species belonging to Mycobacterium avium complex (MAC), with morphology and growth characteristics closely related to Mycobacterium intracellulare. The aim of this retrospective study was to analyze the frequency and clinical significance of M. chimaera identification in the population of patients with previous positive respiratory cultures for M. intracellulare or MAC. 200 strains of M. intracellulare or MAC, isolated from respiratory specimens of patients hospitalized in pulmonary wards, between 2011 and 2020, were retrospectively analyzed with GenoType NTM-DR test. 88 (44%) of strains were re-classified to M. chimaera species. Analysis of clinical data in 30 patients with positive M. chimaera isolates revealed that they were diagnosed with chronic obstructive pulmonary disease (COPD) – 27%, past tuberculosis – 20%, or interstitial lung diseases – 17%, respectively. Non-tuberculous mycobacterial lung disease (NTMLD) caused by M. chimaera has been recognized in 53% of patients, most often in those presenting with post-tuberculous lung lesions. M. chimaera was almost exclusively isolated from respiratory specimens of patients with underlying lung diseases, especially those with COPD and/or past tuberculosis. NTMLD due to M. chimaera was diagnosed predominantly in patients with past tuberculosis.

Prevalence and risk factors for latent tuberculosis in polish healthcare workers: the comparison of tuberculin skin test and interferon-gamma release assay (IGRA) performance

Background

Tuberculosis (TB) is still one of the most common infectious diseases worldwide. Health care workers (HCW) are at particular risk of the disease due to their constant exposure to TB patients or their specimens, nevertheless no specific surveillance is widely recommended in this group of professionals. Both, tuberculin skin test (TST) and interferon-gamma-release-assays (IGRAs) are widely applied to detect latent tuberculosis infection (LTBI). The aim of the present study was to evaluate the prevalence and risks of LTBI in the population of Polish HCW, to identify factors associated with LTBI, as well as to determine the rate of the discordance between the results of the two applied tests in relation to various factors in a TB endemic setting. The study participants were recruited from several health care facilities (hospitals and outpatients clinics) all over the country. Laboratory personnel included 156 persons from both TB and non-TB laboratories (118 clinical pathologists, 38 laboratory technicians), 31 medical doctors, 29 nurses (from both TB and non-TB wards and from family practices), 6 other medical employees (patients assistants). Out of examined group 88 (40%) declared constant (everyday) occupational contact with TB patients and/or contagious biologic materials, 134 (60%) reported sporadic (incidental) contact (few times a year). Administrative HCWs who were not in direct contact with patients were not included in the study group.

Material and methods

LTBI status was prospectively evaluated in 222 HCW, 204 females, 18 males, aged 40.8 ± 9 years, with tuberculin skin test (TST) and interferon gamma release assay (QuantiFERON-TB-Gold in Tube – QFT GIT).

Results

TST ≥ 10 mm was found in 58% of HCW, QFT GIT ≥ 0.35 IU/ml in 23%. Nevertheless the relative number of positive QFT GIT in HCW above 45 years of age exceeded those obtained in general population (prevalence of positive QTF test in polish adult population is around 23%). The risk of obtaining positive QFT GIT was significantly increased in the participants older than 44 years (OR = 4.95, 95%CI:2.375–10.193), in those employed > 10 years (OR = 2.726, 95%CI:1.126–6.599), and in those who reported the direct contact with tuberculous patients or infected biological materials (OR = 8.135, 95%CI:1.297–51.016). The concordance between TST and IGRA was poor (kappa 0.23), especially in younger participants, possibly due to BCG vaccination in childhood.

Conclusion

The increased risk of LTBI in Polish HCW was related to age, duration of employment and contact with infectious patients or their biological specimens. TB infection control measures in health care facilities in Poland are still insufficient. It is crucial to increase awareness about the importance of detecting and treating LTBI of HCW.

Echocardiographic signs of pulmonary hypertension in patients with newly recognized hypersensitivity pneumonitis, prevalence and clinical predictors

Background

Hypersensitivity pneumonitis (HP) is the third, according to frequency, interstitial lung disease, with the estimated incidence rate of 1–2/100,000. In HP patients, the extensive inflammatory lesions encompassing both small airways and lung parenchyma, as well as subsequent development of lung fibrosis, may result in respiratory insufficiency and secondary pulmonary hypertension (PH). The aim of the present retrospective study was to assess the prevalence of echocardiographic signs of PH and its’ clinical predictors, in newly recognized HP patients.

Methods

Consecutive HP patients, recognized in single pulmonary unit between 2005 and 2017, in whom echocardiography was performed at diagnosis, entered the present study. HP diagnosis was verified in every patient according to current diagnostic recommendations. The results of high resolution computed tomography of the chest (HRCT) were re-evaluated by two independent radiologists, blinded to clinical data. Echocardiographic signs of PH were defined as pulmonary artery systolic pressure (PASP) exceeding 36 mmHg. Regression analysis was applied to calculate PH risk, and receiver operator characteristic curves (ROC) were plotted to investigate diagnostic utility of various parameters in PH prediction.

Results

PASP exceeding 36 mmHg was noted in 26 out of 70 patients (37%)—with equal frequency among patients with fibrotic and non-fibrotic HP. Significant predictors of PH on echocardiography were: partial oxygen tension in arterialized capillary blood (PaO2) <69 mmHg, lung transfer capacity for carbon monoxide (TLCO) <42% of predicted, six minutes walking test (6MWT) distance <455 meters, and 6MWT desaturation rate >8%. In case of TLCO <42% of predicted, probability of PH on echocardiography was increased by five-fold, in case of 6MWT desaturation rate >8%—by four fold.

Conclusions

The best predictors of PASP >36 mmHg on echocardiography in HP patients at diagnosis were: TLCO <42% and 6MWT desaturation rate >8%. Neither the presence of lung fibrosis on HRCT, nor the duration of the disease or patients age, were helpful in PH prediction.

SARS-CoV-2 lung disease in a patient with pulmonary sarcoidosis - case report

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the recently identified cause of the current pandemic. In patients with chronic respiratory lung diseases, SARS-CoV-2 may result in significant morbidity and increased mortality. We present a case of a 69-year-old male with stage II pulmonary sarcoidosis who had been under observation for 30 months without immunosuppressive treatment. He then developed severe SARS-CoV-2 disease with typical radiological and laboratory findings. Therapy with oxygen, antibiotics, low-molecular-weight heparin in a prophylactic dose, and dexamethasone resulted in marked clinical improvement. We will discuss the rationale for corticosteroid use in both SARS-CoV-2 disease and in SARS-CoV-2 disease that is complicating comorbid sarcoidosis.

Intrapericardial recombinant tissue plasminogen activator in purulent pericarditis- case series

Background

Pericardial constriction is one of the complications of purulent pericarditis (PP). Most difficult to treat, which may develop both in early and in the late period of the disease, resulting in a very poor prognosis.

Case presentation

We present case series of 4 patients with purulent pericarditis, in whom direct intrapericardial administration of recombinant tissue plasminogen activator (r-tPA) was used.

Management of PP requires a combined surgical and medical approach. The most important is complete drainage of the effusion by subxiphoid pericardiotomy connected with complementary use of broad-spectrum antibiotics. Despite the use of broad- spectrum antibiotics, in some patients a large volume of daily drainage is still present. Constrictive pericarditis as a complication of PP is observed in majority of patients.

Intrapericardial administration of fibrinolytic agents, although not strongly recommended, can improve efficacy of antibiotic treatment especially in patients with loculation fluid and can prevent the development of constrictive pericarditis.

r-tPA was applied at a dose of 20 mg dissolved in 100 ml of normal saline in a 100 ml syringe, administered by a large pericardial drain (Pezzer drain) installed into the pericardial cavity during pericardioscopy. The tube was closed and re-opened after 24 h.

No serious complications, such as bleeding, allergy or hypotension, were noted.

Conclusion

We present case series of 4 patients with purulent pericarditis, in whom direct intrapericardial administration of recombinant tissue plasminogen activator (r-tPA), prevented the development of constrictive pericarditis, and increased efficacy of antibiotic treatment without any significant complications.

Combined Emphysema and Interstitial Lung Disease as a Rare Presentation of Pulmonary Involvement in a Patient with Chronic Visceral Acid Sphingomyelinase Deficiency (Niemann-Pick Disease Type B)

BACKGROUND Niemann-Pick disease is a rare genetic disorder caused by mutations in sphingomyelin phosphodiesterase 1 gene. It results in acid sphingomyelinase deficiency (ASMD) and sphingomyelin intracellular accumulation. Lung disease is diagnosed mostly in chronic visceral ASMD. Ground-glass opacities and smooth interlobular septal thickening are described most frequently. They are localized predominantly in the lower parts of both lungs. CASE REPORT The authors describe a rare type of lung involvement, composed of emphysema and interstitial lung disease (ILD), in a nonsmoking adult male with chronic visceral ASMD. Areas of ground-glass opacities and lung fibrosis presenting as reticulation and bronchiectasis have been described in high-resolution computed tomography of the lungs. The radiological findings were localized predominantly in the middle and lower parts of both lungs. Large air spaces of marginal emphysema, localized in the upper lobes, were also demonstrated. Foamy macrophages, staining blue with May-Grünwald-Giemsa, were found in bronchoalveolar lavage, confirming lung involvement in the course of ASMD. The course of disease was stable, with no hypoxemia at rest. Nevertheless, because of markedly decreased lung transfer for carbon monoxide and significant desaturation on exertion, further controls have been planned, with qualification for long-term oxygen therapy in case of deterioration. CONCLUSIONS We present a unique type of lung involvement, combined emphysema and ILD, in a nonsmoking adult patient with chronic visceral ASMD. On such occasion chronic obstructive pulmonary disease coexisting with ILD as well as chronic pulmonary fibrosis and emphysema syndrome should be excluded.

Can a New Scoring System Improve Prediction of Pulmonary Hypertension in Newly Recognised Interstitial Lung Diseases?

Introduction

Pulmonary hypertension (PH) is a well-recognised complication of interstitial lung diseases (ILD), which worsens prognosis and impairs exercise capacity. Echocardiography is the most widely used, non-invasive method for PH assessment. The aim of our study was to identify the factors predictive for echocardiographic signs of PH in newly recognised ILD patients.

Methods

Ninety-three consecutive patients (28F/65M) with different ILD were prospectively evaluated from January 2009 to March 2014. Pulmonary function testing, 6-min walk distance (6MWD), initial and sixth minute room air oxygen saturation, NT-proBNP and echocardiography were assessed in each patient. Echocardiographic PH probability was determined according to the 2009 ESC/ERS guidelines.

Results

In 41 patients (Group B) increased PH possibility has been diagnosed on echocardiography, in 52 patients (Group A)—low PH probability. Most pronounced differences (p ≤ 0.0005) between groups B and A concerned: age, 6MWD, room air oxygen saturation at 6 min, DLCO and TLC/DLCO index (57.6 vs 43.8 years; 478 vs 583 m; 89.1% vs 93.4%; 54.8% predicted vs 70.5% predicted and 1.86 vs 1.44; respectively). Univariate analysis showed four-fold increased probability of PH when TLC/DLCO exceeded 1.67. A scoring system incorporating age, TLC/DLCO index, 6MWD and room air oxygen saturation at 6 min provided high diagnostic utility, AUC 0.867 (95% CI 0.792–0.867).

Conclusion

ILD patients with TLC/DLCO index > 1.67 have a high likelihood of PH and should undergo further evaluation. The composite model of PH prediction, including age, 6-min walk test and TLC/DLCO was highly specific for recognition of PH on echocardiography.

Exogenous Lipoid Pneumonia Induced by Nasal Instillation of Paraffin Oil

Lipoid pneumonia is a rare pulmonary disease, classified in terms of the source of lipid exposure into two variants: exogenous and endogenous. We present a patient with exogenous lipoid pneumonia, acquired after chronic exposure to paraffin oil-containing nasal drops. The diagnosis was established by demonstration of lipid-laden macrophages in bronchoalveolar lavage, chest computed tomography results and a history of lipid exposure.

CT imaging features of thin-walled cavitary squamous cell lung cancer

Primary lung cancer manifesting as a thin-walled solitary cavity, occurs relatively infrequently. The most common histologic type presenting such a pattern is squamous cell cancer, followed by adenocarcinoma, and finally - large cell cancer. Cavitation is typically not seen in small cell lung cancer. Entities indicating malignancy of such lesions include irregular cystic wall, wall nodule formation, nodular septa or increased standard uptake on positron emission tomography (PET). We are presenting a case of a squamous cell lung cancer manifesting on chest CT as a thin-walled septated cavity with irregular margins mimicking a cyst. The lesion was reported unchanged in a follow-up computed tomography after 3 months. A follow-up scan obtained 2 years after initial examination showed thickening of a cyst wall, solid structures within its lumen and thoracic lymph nodes enlargement.

Czynniki predysponujące do rozwoju mykobakteriozy płuc u chorych z obecnością prątków niegruźliczych w materiałach z dróg oddechowych

Wstęp: W ostatnich latach w większości krajów Europy i w Stanach Zjednoczonych jest notowany wzrost częstości zakażeń układu oddechowego prątkami niegruźliczymi. Nie ma jednak zgodności opinii na temat wpływu różnych czynników na rozwój mykobakteriozy płuc w tej grupie chorych. Celem niniejszej pracy retrospektywnej było poszukiwanie czynników ryzyka mykobakteriozy płuc, w grupie chorych, u których wyhodowano prątki niegruźlicze z dróg oddechowych. Materiał i metody: Badaną grupę stanowiło 73 chorych, 23 mężczyzn i 50 kobiet, mediana wieku wyniosła 62.2 roku, z dodatnimi wynikami posiewów plwociny/wydzieliny oskrzelowej w kierunku prątków niegruźliczych, uzyskanymi w latach 2010–2015. Wyniki: Mykobakteriozę płuc (według American Thoracic Society/Infectious Diseases Society of America) rozpoznano u 36 chorych, kolonizację dróg oddechowych—w 37 przypadkach. Mykobakteriozę rozpoznawano istotnie częściej u chorych zakażonych M. kansasii, M. abscessus i M. avium/M. intracellulare w porównaniu z chorymi zakażonymi M. xenopi, M. gordonae i M. fortuitum (p < 0.0001). Wśród chorych na mykobakteriozę, w porównaniu z grupą z kolonizacją prątkami niegruźliczymi, było istotnie więcej kobiet niż mężczyzn (p < 0.007) oraz więcej chorych z wywiadem przebytej gruźlicy płuc lub mykobakteriozy (odpowiednio 28% i 8%, p = 0.038). Wykazano, że zakażenie M. kansasii, płeć żeńska oraz przebyta gruźlica lub mykobakterioza były istotnymi czynnikami predykcyjnymi aktualnego rozpoznania mykobakteriozy płuc. Wniosek: W badanej grupie chorych ryzyko zachorowania na mykobakteriozę było istotnie większe u kobiet, osób zakażonych M. kansasii oraz z przebytą gruźlicą lub mykobakteriozą płuc w przeszłości.

Interferon Gamma Release Assays in Patients with Respiratory Isolates of Non-Tuberculous Mycobacteria - a Preliminary Study

Interferon gamma releasing assays (IGRAs) are extensively used in the diagnosis of latent tuberculosis infections. Comparing to tuberculin skin test (TST) they lack false positive results in the populations vaccinated with BCG, and in most non-tuberculous mycobacteria (NTM) infections. Nevertheless, Mycobacterium kansasii, Mycobacterium marinum, and Mycobacterium szulgai may induce positive IGRAs due to RD1 homology with Mycobacterium tuberculosis. The aim of the study was to investigate the possible influence of NTM respiratory isolates on the results of IGRAs. 39 patients (23 females and 16 males) of median age 61 years, with negative medical history concerning tuberculosis, entered the study. Identification of NTM was performed using the niacin test and molecular method GenoType CM test (Hain Lifescience). QFT-Plus was performed in 17 patients, T-SPOT-Tb - in 23 patients. Chest X-rays and a high-resolution computed tomography of the chest have been reviewed by the experienced radiologist blinded to the results of IGRAs, in search of past tuberculosis signs. Positive IGRAs results were obtained in three out of 39 patients (8%): 22% of patients with M. kansasii isolates and 18% of patients with radiological signs on HRCT that might be suggestive of past tuberculosis. Positive IGRAs correlated with radiological signs suggestive of past tuberculosis (r = 0.32, p = 0.04), and on the borderline with isolation of M. kansasii (r = 0.29, p = 0.06). These findings may suggest that a positive IGRAs result, in our material, could depend mostly on asymptomatic past Tb infection. The cross-reactivity of M. kansasii isolates with IGRAs was less probable; nevertheless, it requires further investigations.

Interferon gamma releasing assays (IGRAs) are extensively used in the diagnosis of latent tuberculosis infections. Comparing to tuberculin skin test (TST) they lack false positive results in the populations vaccinated with BCG, and in most non-tuberculous mycobacteria (NTM) infections. Nevertheless, Mycobacterium kansasii, Mycobacterium marinum, and Mycobacterium szulgai may induce positive IGRAs due to RD1 homology with Mycobacterium tuberculosis. The aim of the study was to investigate the possible influence of NTM respiratory isolates on the results of IGRAs. 39 patients (23 females and 16 males) of median age 61 years, with negative medical history concerning tuberculosis, entered the study. Identification of NTM was performed using the niacin test and molecular method GenoType CM test (Hain Lifescience). QFT-Plus was performed in 17 patients, T-SPOT-Tb – in 23 patients. Chest X-rays and a high-resolution computed tomography of the chest have been reviewed by the experienced radiologist blinded to the results of IGRAs, in search of past tuberculosis signs. Positive IGRAs results were obtained in three out of 39 patients (8%): 22% of patients with M. kansasii isolates and 18% of patients with radiological signs on HRCT that might be suggestive of past tuberculosis. Positive IGRAs correlated with radiological signs suggestive of past tuberculosis (r = 0.32, p = 0.04), and on the borderline with isolation of M. kansasii (r = 0.29, p = 0.06). These findings may suggest that a positive IGRAs result, in our material, could depend mostly on asymptomatic past Tb infection. The cross-reactivity of M. kansasii isolates with IGRAs was less probable; nevertheless, it requires further investigations.

Wpływ skojarzonego leczenia cisplatyną podawaną doosierdziowo oraz kolchicyną doustnie na poprawę wyników leczenia wysięku osierdziowego w przebiegu raka nerki z przerzutami

Wstęp: Wysięk do worka osierdziowego o etiologii nowotworowej (NPE) stanowi częstą przyczynę zachorowalności i umieralności u chorych onkologicznych. Często przebiega w postaci tamponady serca wymagającej pilnego odbarczenia: perikardiocentezy lub perikardiotomii wraz z drenażem płynu. Pomimo dużej skuteczności tych zabiegów, nawrót płynu w osierdziu występuje u 30–60% pacjentów. Cisplatyna podawana doosierdziowo jest skuteczną i uznaną metodą przeciwdziałania ponownemu gromadzeniu się płynu w osierdziu w przebiegu raka płuc i raka piersi. Natomiast jej efektywność w leczeniu tamponady serca u chorych na raka nerki pozostaje nieznana. Opis przypadku: Przedstawiono przypadek 82-letniego mężczyzny chorego na raka nerki, który został przyjęty na oddział intensywnej terapii z powodu zagrażającej tamponady serca. W trybie pilnym wykonano zabieg perikardiotomii podmostkowej i ewakuowano z osierdzia 1000 ml krwistego płynu. Na wewnętrznej powierzchni osierdzia zauważono kilka różowych guzków, które pobrano do badania histopatologicznego, gdzie stwierdzono komórki raka jasnokomórkowego nerki. W związku z utrzymującymi się dużymi drenażami z osierdzia zdecydowano o konieczności zastosowania cisplatyny doosierdziowo. Ponadto już w pierwszej dobie po zabiegu chory otrzymał kolchicynę doustnie w dawce 0,5 mg dziennie. Nie zaobserwowano skutków niepożądanych terapii. Pacjent zmarł po 12 miesiącach z powodu progresji nowotworu i wyniszczenia. Nie odnotowano nawrotu wysięku do worka osierdziowego. Wnioski: Jest to pierwszy opis przypadku prezentujący długotrwałą skuteczność w prewencji nawrotu płynu w osierdziu po doosierdziowym podaniu cisplatny w połączeniu z doustną kolchicyną w leczeniu NPE w przebiegu jasnokomórkowego raka nerki z przerzutami.

Factors predisposing to non-tuberculous mycobacterial lung disease in the patients with respiratory isolates of non-tuberculous mycobacteria

INTRODUCTION

An increasing incidence rate of respiratory isolates of non-tuberculous mycobacteria (NTM) has been noted recently in most European countries as well as in the US. Despite many publications, there is no consensus concerning the importance of different factors in promoting NTM lung disease (NTMLD). The aim of the present retrospective study was to analyse patients with positive NTM respiratory isolates in search of factors predisposing to NTMLD.

MATERIAL AND METHODS

73 patients, 23 males, 50 females, median age 62.2 years, in whom NTM have been cultured from respiratory specimen (sputum and/or bronchial washings), in the period 2010-2015, entered the study.

RESULTS

NTMLD (according to ATS/IDSA) has been recognised in 36 patients, airways colonisation by NTM - in 37 patients. NTMLD was diagnosed more often in the patients infected with M. kansasii, M. abscessus and M. avium/M. intracellulare comparing to those infected with M.xenopi, M. gordonae and M. fortuitum (p < 0.0001). The proportion of females to males was significantly higher in the NTMLD group comparing to the colonisation group (p < 0.007). Previous tuberculosis or mycobacteriosis were noted significantly more frequently in the group of patients with NTMLD comparing to the colonisation group (28% vs 8%, p = 0.038). Univariate regression analysis revealed M. kansasii, female gender, and previous tuberculosis or mycobacteriosis as significant predictors of NTMLD.

CONCLUSIONS

The risk factors of NTMLD recognition in the presented group of patients were the following: female gender, M. kansasii isolation, as well as past tuberculosis or mycobacteriosis.

Respiratory system involvement in inflammatory bowel diseases

Inflammatory bowel diseases are systemic disorders that can manifest in any location. The problem of respiratory system involvement is very important form clinical point of view. In the article we try to systematize the current knowledge on this topic.

Choroba zarostowa żył płucnych: patogeneza, czynniki ryzyka, cechy kliniczne i algorytm diagnostyczny—Aktualny stan wiedzy

Choroba zarostowa żył płucnych (PVOD) i hemangiomatoza włośniczek płucnych (PCH) należą do rzadkich schorzeń—szacowana częstość występowania wynosi mniej niż jeden przypadek na milion mieszkańców. W PVOD/PCH patologia dotyczy małych żyłek—przedprzegrodowych i przegrodowych, włośniczek oraz tętniczek zaprzegrodowych i małych tętniczek płucnych. W klasyfikacji nadciśnienia płucnego (PH) według ERS/ESC z 2015 roku PVOD/PCH tworzy podgrupę 1’. Dane z niedawnych analiz wskazują jednak, że PVOD/PCH może być w rzeczywistości częstsze, z powodu błędnej kwalifikacji tych chorych do grupy 1. Problem ten może dotyczyć przypadków rozpoznanych jako tętnicze nadciśnienie płucne (PAH) występujące w przebiegu twardziny, spowodowane lekami, związane z zakażeniem wirusem HIV oraz około 10% pacjentów z idiopatycznym PAH (IPAH). Ostatnio zidentyfikowano dwuallelowe mutacje genu EIF2AK4 w dziedzicznej postaci PVOD/PCH i w 9% przypadków bez rodzinnego występowania choroby. Udowodniono ponadto zależność między zawodowym narażeniem na rozpuszczalniki organiczne a PVOD/PCH. Niniejszy przegląd jest próbą podsumowania aktualnych danych na temat patogenezy, czynników ryzyka, cech klinicznych i algorytmu diagnostycznego PVOD/PCH.

Intrapericardial cisplatin combined with oral colchicine resulted in long term control of malignant pericardial effusion in the course of metastatic renal cancer

Background Neoplastic pericardial effusion (NPE) represents a common cause of morbidity and mortality in patient with cancer. NPE presents frequently as cardiac tamponade, requiring urgent pericardiocentesis or pericardiotomy, with subsequent pericardial fluid drainage. Despite high effectiveness of such procedures, the recurrence of effusion is noted in 30- 60% of patients. Intrapericardial therapy with cisplatin was found to be effective in NPE due to lung and breast cancer. Its role in cardiac tamponade due to renal cancer is unknown. Case presentation We presented 82-year-old man with renal cancer who was admitted to the Intensive Care Unit because of threatening pericardial tamponade due to NPE . Urgent subxiphoid pericardiotomy was performed with subsequent evacuation of 1000ml of bloody fluid. On the inner surface of the pericardium several pink nodules were found. Histological examination revealed carcinoma clarocellulare. In view of the persistent high drainage of the pericardium, intrapericardial cisplatin therapy was performed. The first day after surgery colchicine 0.5 mg/day/po was also introduced. No side effects of this treatment were observed. The patient died 12- month later due to cancer progression and cachexia. No recurrence of pericardial effusion was observed. Conclusion This is the first case study demonstrating long-term efficacy and safety of intrapericardial cisplatin combined with oral colchicine in NPE due to metastatic renal cell carcinoma.

Mykobakterioza Płuc u Chorego na Przewlekłą Obturacyjną Chorobę płuc i Rozstrzenie Oskrzeli, Przebiegająca z Obrazem Radiologicznym Guza Płuca

Mykobakteriozy to choroby wywoływane przez prątki niegruźlicze (NTM, nontuberculous mycobacteria), zwane również prątkami atypowymi. Prątki niegruźlicze występują powszechnie w środowisku, głównie w glebie i wodzie. Mogą kolonizować drogi oddechowe, przewód pokarmowy i układ moczowo-płciowy człowieka, nie wywołując objawów choroby. Do zachorowania dochodzi przede wszystkim w grupach ryzyka, między innymi u chorych na przewlekłe choroby płuc oraz z obniżoną odpornością. W ostatnich latach obserwuje się zwiększenie liczby przypadków mykobakteriozy u chorych na przewlekłą obturacyjną chorobę płuc (POChP), szczególnie w przypadku stosowania długotrwałej steroidoterapii wziewnej. W pracy opisano przypadek mykobakteriozy wywołanej przez Mycobacterium avium u chorego na POChP i rozstrzenie oskrzeli, u którego obraz kliniczny i radiologiczny sugerowały obecność guza płuca.

The Role of Carcinoembryonic Antigen (CEA) and Neuron-Specific Enolase (NSE) Evaluation in Pericardial Fluid for the Recognition of Malignant Pericarditis

This study was designed to assess the value of tumor marker evaluation in pericardial fluid for the recognition of malignant pericarditis. Thirty-six patients with signs and symptoms of large pericardial effusion entered the study. Pericardiocentesis with pericardial fluid drainage was performed in all of them. CEA and NSE levels were evaluated in the pericardial fluid and compared to pericardial fluid cytology. The median CEA value in malignant effusions was 80 ng/ml (range 0-305 ng/ml) and in non-malignant ones 1.26 ng/ml (range 0.2-18.4 ng/ml), p<0.01. The sensitivity of CEA elevation above 5 ng/ml for the recognition of malignant pericarditis was 73% and the specificity was 90%.

Pericardial fluid cytology was positive in 22 of 26 patients with malignant pericarditis (85%). CEA exceeding 5 ng/ml or positive cytology were seen in 96% of the patients with malignant pericarditis. The median NSE value in malignant pericardial effusions was 41.8 μg/l (range 2-172 μg/l) and in non-malignant ones 5.85 μg/l (range 1-83.9 μg/l), p<0.3. For the differential diagnosis of large pericardial effusions we would recommend simultaneous cytologic examination of pericardial fluid and CEA assessment. NSE measurement in hemorrhagic pericardial fluid is of limited value.

The Clinical Value of Cyfra 21-1 Estimation for Lung Cancer Patients

Cytokeratin-19, one of the cytoskeletal proteins, is expressed both in bronchial epithelium and in lung cancer cells. The aim of our study was to establish the value of serum cytokeratin-19 soluble fragment (Cyfra 21-1) measurement in lung cancer patients. Cyfra 21-1 levels were estimated in 35 patients (pts) with benign lung diseases and in 116 lung cancer patients: 55 pts with squamous cell lung cancer, 38 pts with small cell lung cancer and 23 pts with adenocarcinoma. The cutoff level was set at 4 ng/ml with a specificity of 94% and a sensitivity of 40%. Elevated Cyfra 21-1 values were found in 44% of squamous cell lung cancer, 39% of adenocarcinoma and 34% of small cell lung cancer pts (the difference was not significant). In squamous cell lung cancer and in adenocarcinoma elevated Cyfra 21-1 values were observed more often in patients with advanced disease than in patients with limited disease. There was no significant correlation between the initial Cyfra 21-1 level and the response to chemotherapy. Cyfra 21-1 was hot a prognostic indicator, although in operable squamous cell lung cancer the proportion of survivors in the second year of observation was higher among the patients with normal preoperative Cyfra 21-1 levels.

Neuron-Specific Enolase in Non-Neoplastic Lung Diseases, a Marker of Hypoxemia?

Neuron-specific enolase (NSE) is a glycolytic enzyme localized within neuronal and neuroendocrine tissues. Serum NSE is widely used as a marker of neuroendocrine tumors. Moderate serum NSE elevation has been reported in some patients with benign lung diseases. We decided to investigate whether the elevation of serum NSE in non-neoplastic lung diseases is connected with hypoxemia and to what extent the recovery of sufficient ventilation with a respirator may influence NSE concentrations. Serum NSE was estimated by means of radioimmunoassay in 83 patients with various non-neoplastic lung diseases. Serum NSE exceeding 12.5 μg/L was significantly more frequent in patients with marked hypoxemia (PaO2<6.67 kPa; p=0.03) than in others. The median NSE value in the group of patients without respiratory failure (Ro) was 7.2 μg/L (10% >12.5 μg/L), in the group of patients with respiratory failure not requiring mechanical ventilation (Rf) it was 8.5 μg/L (24%>12.5 μg/L), and in the group of patients with respiratory failure requiring mechanical ventilation (Rfv) 13.1 μg/L (60%>12.5 μg/L). The differences between the Rfv group and the other two groups (Rf and Ro) were significant (p=0.049 and p=0.0004, respectively). During successful mechanical ventilation elevated serum NSE decreased to values below the cutoff in 8/10 patients. We conclude that serum NSE elevation is a frequent event in patients with terminal hypoxemia in the course of benign lung diseases. Normalization of serum NSE is observed in the majority of patients during the first week of mechanical ventilation.

Nadciśnienie Płucne w Przebiegu Sarkoidozy Leczone Sildenafilem

Rozwój nadciśnienia płucnego w przebiegu sarkoidozy (SAPH) istotnie pogarsza rokowanie. Niestety, nie ma metody leczenia o udokumentowanym korzystnym działaniu w tej postaci nadciśnienia płucnego. Duże zainteresowanie w tym zakresie budzą leki stosowane w terapii tętniczego nadciśnienia płucnego (PAH). W prezentowanej pracy przedstawiono opis przypadku chorej na sarkoidozę powikłaną ciężkim nadciśnieniem płucnym, która była leczona sildenafilem. Obserwowano istotną, choć zaledwie przejściową poprawę stanu czynnościowego. Pacjentka zmarła z powodu stopniowo postępującej niewydolności krążenia i oddychania, w trakcie oczekiwania na przeszczepienie płuc.

Nadciśnienie Płucne w Przebiegu śródmiąższowych Chorób Płuc—Czy Leczenie Ukierunkowane na PAH Przynosi Korzyści?

Nadciśnienie płucne (PH) jest rozpoznawane u 40–50% chorych w końcowym stadium rozsianych śródmiąższowych chorób płuc (DPLD) i wiąże się ze znacznym pogorszeniem rokowania. Najnowsze wytyczne Europejskiego Towarzystwa Chorób Płuc i Europejskiego Towarzystwa Kardiologicznego zalecają w tej grupie chorych najbardziej optymalne leczenie DPLD oraz przewlekłą tlenoterapię u chorych z PaO2 poniżej 60 mm Hg. Leki stosowane w tętniczym nadciśnieniu płucnym (PAH) nie są rekomendowane chorym na PH-DPLD, ze względu na ryzyko zwiększenia przecieku krwi nieutlenowanej w płucach i w konsekwencji, pogorszenia hipoksemii. Jednak leczenie ukierunkowane na PAH może przynosić korzyść w wybranych sytuacjach klinicznych. Autorzy obecnej pracy próbują znaleźć odpowiedź na kilka ważnych pytań: czy terapia ukierunkowana na PAH może przynieść korzyści w PH-DPLD, kto powinien być poddany terapii ukierunkowanej na PAH, jaka grupa leków jest najbardziej obiecująca, w jaki sposób należy oceniać wyniki leczenia?

Diagnostic Utility of Cyfra 21-1 and Cea Assays in Pericardial Fluid for the Recognition of Neoplastic Pericarditis

A positive cytology result in pericardial fluid is the gold standard for recognition of malignant pericardial effusion. Unfortunately, in 30–50% of patients with malignant pericardial effusion cytological examination of the pericardial fluid is negative. Tumor marker assessment in pericardial fluid may help to recognize malignant pericardial effusion. The aim of our study was to estimate the value of CYFRA 21-1 and CEA measurement in pericardial fluid for the recognition of malignant pericardial effusion. To our knowledge this is the first study on CYFRA 21-1 assessment in pericardial effusion. The examined group consisted of 50 patients with malignant pericardial effusion and 34 patients with non-malignant pericardial effusion. Median CEA concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 80 ng/mL (0–317) and 0.5 ng/mL (0–18.4), respectively (p<0.001). Median CYFRA 21-1 concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 260 ng/mL (5.3–10080) and 22.4 ng/mL (1.87–317.6), respectively (p<0.001). The optimal cutoff value for CYFRA 21-1 in pericardial effusion was 100 ng/mL. CYFRA 21-1 >100 ng/mL or CEA >5 ng/mL were found in 14/15 patients with malignant pericardial effusion and negative pericardial fluid cytology. We therefore strongly recommend the use of CYFRA 21-1 and/or CEA in addition to pericardial fluid cytology for the recognition of malignant pericardial effusion.

Sarcoidosis-associated pulmonary hypertension treated with sildenafil - a case report

Development of sarcoidosis-associated pulmonary hypertension (SAPH) significantly worsens prognosis in sarcoidosis patients. Unfortunately, there is no treatment of proven benefit for this condition. Medications used for treatment of pulmonary arterial hypertension are of great interest in this respect. Here, we report a case of a patient with severe SAPH treated with sildenafil. A significant, but only temporary improvement in functional status was observed, and the patient died of gradually progressing heart and respiratory failure while awaiting for lung transplantation.

Pulmonary hypertension in diffuse parenchymal lung diseases - is there any benefit of PAH-specific therapy?

Pulmonary hypertension (PH) is diagnosed in 40-50% of the patients with end-stage diffuse parenchymal lung diseases (DPLD), and it is associated with significant worsening of life expectancy. Latest ERS/ESC guidelines recommend best available treatment of DPLD, and long-term oxygen therapy in the patients with PaO2 less than 60 mm Hg. Pulmonary arterial hypertension (PAH)-targeted drugs are not recommended in PH-DPLD patients, due to the risk of increasing the ventilation-perfusion mismatch, and consequently worsening of hypoxaemia. Nevertheless, PAH-oriented treatment may be beneficial to selected groups of patients. The authors try to find the answer to several important questions: is there any benefit of PAH-specific therapy in PH-DPLD, who should be the candidate for PAH-specific therapy, what class of drugs is most promising, and what outcome measures should be employed?

Zajęcie układu oddechowego w przebiegu nieswoistych zapaleń jelit

Nieswoiste zapalenia jelit to choroby systemowe z możliwością manifestacji w praktycznie każdej lokalizacji. Zagadnienie zajęcia układu oddechowego jest bardzo ważne z klinicznego punktu widzenia. W artykule próbujemy usystematyzować dotychczasową wiedzę na ten temat.

Low DLCO in idiopathic pulmonary arterial hypertension - clinical correlates and prognostic significance

INTRODUCTION

Decreased diffusing capacity of the lung for carbon monoxide (DLCO) is observed in some idiopathic pulmonary arterial hypertension (IPAH) patients, but its clinical significance is uncertain. We aimed to assess clinical correlates and prognostic significance of low DLCO in IPAH patients.

MATERIAL AND METHODS

In the group of 65 IPAH patients the cut off value for low DLCO was set up based on histogram as < 55% of predicted value. Demographic data, exercise capacity, lung function tests, hemodynamic parameters and survival of the patients were compared depending on DLCO value.

RESULTS

Low DLCO was found in 18% of the patients, and it was associated with male sex, older age, worse functional status and exercise capacity, and higher prevalence of coronary artery disease. Low DLCO carried a 4-fold increase of death risk in 5-year perspective.

CONCLUSIONS

Low DLCO was a marker of worse functional capacity and increased risk of death in studied IPAH patients.

The value of the new scoring system for predicting neoplastic pericarditis in the patients with large pericardial effusion

PURPOSE

Early recognition of neoplastic pericarditis (npe) is crucial for the planning of subsequent therapy. The aim of the present study was to construct the scoring system assessing the probability of npe, in the patients requiring pericardial fluid (pf) drainage due to large pericardial effusion.

METHODS

One hundred forty-six patients, 74 males and 72 females, entered the study. Npe based on positive pf cytology and/or pericardial biopsy specimen was recognised in 66 patients, non-npe in 80. Original scoring system was constructed based on parameters with the highest diagnostic value: mediastinal lymphadenopathy on chest CT scan, increased concentration of tumour markers (cytokeratin 19 fragments-Cyfra 21-1 and carcinoembryonic antigen-CEA) in pf, bloody character of pf, signs of imminent cardiac tamponade on echocardiography and tachycardia exceeding 90 beats/min on ECG. Each parameter was scored with positive or negative points depending on the positive and negative predictive values (PPV, NPV).

RESULTS

The area under curve (AUC) for the scoring system was 0.926 (95%CI 0.852-0.963) and it was higher than AUC for Cyfra 21-1 0.789 (95%CI 0.684-0.893) or CEA 0.758 (95%CI 0.652-0.864). The score optimally discriminating between npe and non-npe was 0 points (sensitivity 0.84, specificity 0.91, PPV 0.9, NPV 0.85).

CONCLUSION

Despite chest CT and tumour marker evaluation in pericardial fluid were good discriminators between npe and non-npe, the applied scoring system further improved the predicting of neoplastic disease in the studied population.

[Hypersensitivity pneumonitis: Diagnostic criteria, treatment, prognosis and prevention]

Hypersensitivity pneumonitis (HP) is caused by inhalation of environmental antigens. Farmers and bird keepers are most frequently affected by this desease. The HP diagnosis is based on clinical symptoms (cough, dyspnea) in a person exposed to environmental antigens, and the presence of characteristic changes in high resolution chest computed tomography (HRCT) (bilateral, mosaic, ground glass opacities in the middle and lower lung zones, ill-defined centrilobular nodules and the sign of air-trapping on expiration). This type of HRCT pattern is most frequently found in the patients with subacute HP. Bronchioloalveolar lavage fluid (BALF) examination is helpful in establishing the HP diagnosis, when the increased total number of cells, with the predominance of T lymphocytes (> 50%), and the increased number of neutrophils (> 3%) and mastocytes (> 1%) are found. The presence of specific serum precipitins increases the likelihood of HP. In case of atypical clinical presentation, lung biopsy is recommended. The diagnostic criterion of HP is the presence of ill-defined non-necrotising granulomas, after excluding other granulomatous lung diseases. The prevention and treatment of HP is based on the elimination of the antigen from the environment. Corticosteroids may contribute to the improvement in the acute and sub-acute form of the disease but their long term effectiveness is uncertain. The prognosis of HP patients is generally perceived as good, especially in those patients in whom antigen avoidance is possible. Nevertheless, in some patients progressive pulmonary fibrosis and development of severe respiratory insufficiency is observed. Med Pr 2016;67(4):517-527.

Non-tuberculous mycobacterial lung disease (NT MLD ) in patients with chronic thromboembolic pulmonary hypertension and idiopathic pulmonary arterial hypertension

INTRODUCTION

Non-tuberculous mycobacterial lung diseases (NTMLD) occur rarely and are diagnosed mainly in patients belonging to risk groups. Pulmonary hypertension (PH) has not been recognised as a risk factor for NTMLD yet. The aim of the study was to analyse the clinical course and predisposing factors of NTMLD recognised in our centre between 2002 and 2012 in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and idiopathic pulmonary arterial hypertension (IPAH).

MATERIAL AND METHODS

Thirteen patients (10 - CTEPH, 3 - IPAH) entered the study. PH was recognised during right heart catheterisation. Median value of mean pulmonary artery pressure (mPAP) was 49 mm Hg (39-65 mm Hg). NTMLD was diagnosed according to ATS guidelines (2007).

RESULTS

M. kansasii was the most frequent pathogen. Most patients complained of the exaggeration of dyspnoea and productive cough. Computed tomography of the chest with angiography revealed infiltrations with cavitation in seven patients and cavities surrounded by micronodules in six patients. In all CTEPH patients, NTMLD developed in the hypoperfused lung areas. No parenchymal abnormalities preceded the development of NTMLD. After diagnosis all of the patients received antituberculous treatment; in 12/13 improvement was achieved. By the end of March 2014 seven patients died due to right heart insufficiency, no deaths due to NTMLD were noted.

CONCLUSIONS

NTMLD should be suspected in patients with CTEPH or IPAH, presenting with productive cough and a new pulmonary infiltrate with cavitation. In patients with CTEPH, special attention should be paid to a new cavitary lesions without accompanying thrombus in the artery supplying the area. High mPAP (CTEPH/IPAH) and hypoperfusion (CTEPH) are predisposing to NTMLD.

Guzki środkowej części zrazika w tomografii komputerowej płuc o wysokiej rozdzielczości u chorych na IPAH—Wstępne korelacje kliniczno-radiologiczne

Wstęp: Zmiany miąższowe w tomografii komputerowej płuc o wysokiej rozdzielczości (TKWR) obserwowane są u niektórych chorych na idiopatyczne tętnicze nadciśnienie płucne (IPAH), pomimo że nie mają oni śródmiąższowej choroby płuc. Najczęściej opisuje się: słabo odgraniczone guzki środkowej części zrazika (CN, centrilobular nodules) albo ogniskowe zacienienia typu matowej szyby (FGGO, focal ground glass opacities). Nie wiadomo czy obecność tych zmian wskazuje na odmienny typ IPAH czy też na zarostową chorobę żył płucnych (PVOD, pulmonary venoocclusive disease). Celem pracy była ocena częstości występowania i znaczenia klinicznego zmian miąższowych w płucach stwierdzanych w TKWR u chorych na IPAH. Materiał i metody: Do badania zakwalifikowano 52 chorych na IPAH (38 kobiet, 14 mężczyzn, średni wiek 41 ± 15 lat). Wszystkie dostępne badania TKWR zostały poddane retrospektywnej analizie doświadczonego radiologa, nieposiadającego wiedzy na temat danych klinicznych. Wyniki: U 10 chorych (19%) stwierdzono CN, u 12(23%) FGGO. U badanych chorych nie występowały cechy PVOD, takie jak powiększenie węzłów chłonnych czy też pogrubienie przegród międzyzrazikowych. Wykazano, że chorzy z CN w porównaniu z pozostałymi byli istotnie młodsi (średnie wieku wynosiły 31 lat oraz 43.5 roku, p = 0.02), nie posiadali drożnego otworu owalnego (0% oraz 43%, p = 0.03), mieli istotnie wyższe średnie ciśnienie w prawym przedsionku (12.5 mm Hg oraz 7.94 mm Hg, p = 0.01). Nie wykazano jednak istotnych różnic dotyczących rokowania. Wnioski: Chorzy na IPAH, u których stwierdzono w TKWR guzki środkowej części zrazika, charakteryzowali się nieobecnością PFO, młodszym wiekiem i wyższym ciśnieniem w prawym przedsionku w porównaniu z pozostałymi chorymi.

Prognostic value of serum C-reactive protein (CRP) and cytokeratin 19 fragments (Cyfra 21-1) but not carcinoembryonic antigen (CEA) in surgically treated patients with non-small cell lung cancer

INTRODUCTION

The aim of the study was to assess the prognostic value of cytokeratin 19 fragments (Cyfra 21-1), carcinoembryonic antigen (CEA) and C-reactive protein (CRP) in surgically treated NSCLC patients.

MATERIAL AND METHODS

50 NSCLC patients (25 adenocarcinoma, 21 squamous cell and 4 adenosquamous), clinical stages I and II, age 42-89 years, entered the study. CEA, Cyfra 21-1 and CRP concentrations were measured in serum taken before surgery, CEA and Cyfra 21-1 in 50 patients, CRP - in 46 patients. The survival was calculated from the date of surgical treatment until death or until the end of the observation time. The results were expressed as medians (95%CI).

RESULTS

Cyfra 21-1 concentration was 2.1 (0.7-14.5) ng/mL. Survival time in the patients with Cyfra 21-1 ≤ 2 ng/mL, and > 2 ng/ /mL was 79 (14.85-88.2) and 29 (5.7-87.6) months, (p < 0.026). CEA concentration was 2.68 (0.87-72.7) ng/mL, significantly higher in adenocarcinoma than in squamous cell lung cancer - 4.38 ng/mL (1.67-41.35) vs. 2.2 ng/mL (1.0-6.1), p = 0.002. CRP concentration was 5.45 (0-122.6) mg/L. Significant dependence was found between CRP and pathological tumour size (pT). Median CRP values in pT1, pT2 and pT3+4 tumours were: 2.8 mg/L, 6.9 mg/L and 23.5 mg/L, respectively. Survival time of the patients with CRP ≤ 10 mg/L and CRP > 10 mg/L was 79 (14.85-88.2) and 29.5 (5.7-87.6) months, respectively (p = 0.045). CRP > 10 mg/L and Cyfra 21-1 > 2 ng/mL were the only significant preoperative prognostic indicators (HR 2.08 and 2.04, respectively). Among the postoperative parameters, pathological stage of disease (p-stage) and pT were the significant prognostic indicators (HR 2.1 and 2.42, respectively).

CONCLUSIONS

In the present study, concerning surgically treated NSCLC patients, preoperative CRP > 10 mg/L and Cyfra 21-1 > 2 ng/mL were the only negative prognostic indicators, while pT and p-stage were significant postoperative prognostic indicators.