Chest CT scoring for evaluation of lung sequelae in congenital diaphragmatic hernia survivors

Objectives Data on long-term structural lung abnormalities in survivors of congenital diaphragmatic hernia (CDH) is scarce. The purpose of this study was to develop a chest computed tomography (CT) score to assess the structural lung sequelae in CDH survivors and to study the correlation between the CT scoring and clinical parameters in the neonatal period and at 1 year of follow-up. Methods A prospective, clinical follow-up program is organised for CDH survivors at the University Hospital of Leuven including a chest CT at the age of 1 year. The CT scoring used and evaluated, named CDH-CT score, was adapted from the revised Aukland score for chronic lung disease of prematurity. Results Thirty-five patients were included. All CT scans showed some pulmonary abnormalities, ranging from very mild to severe. The mean total CT score was 16 (IQR: 9-23), with the greatest contribution from the subscores for decreased attenuation (5; IQR: 2-8), subpleural linear and triangular opacities (4; IQR: 3-5), and atelectasis/consolidation (2; IQR: 1-3). Interobserver and intraobserver agreement was very good for the total score (ICC coefficient > 0.9). Total CT score correlated with number of neonatal days ventilated/on oxygen as well as with respiratory symptoms and feeding problems at 1 year of age. Conclusion The CDH-CT scoring tool has a good intraobserver and interobserver repeatability and correlates with relevant clinical parameters. This holds promise for its use in clinical follow-up and as outcome parameter in clinical interventional studies

Idiopathic pulmonary fibrosis: evaluation of progression and prognosis after the ATS/ERS/JRS/ALAT statement 2011

Objectives The prediction of usual interstitial pneumonia (UIP) progression and prognosis by the a application of HRCT criteria pattern recommended by ATS/ERS/JALAT guidelines 2011 Materials and methods Two radiologists after assessing the baseline HRCT have distributed 70 patients affected by fibrotic idiopathic interstitial pneumonia (IIP) in three groups (UIP type= group 1, possible-UIP=group 2, inconsistence UIP=group 3) on the basis of 2011 guidelines. The different abnormalities (honeycombing, reticulation, ground-glass, bronchiectasis) were visually scored at baseline and during the follow-up (total HRCT 179). Overall CT score and fibrotic score (honeycombing plus reticulation) were calculated. The progression of the abnormalities and the correlation with mortality rate were assessed (Kaplan-Mayer survival estimates). Results The inter-observed agreement was substantial or almost perfect (k=0.73-0.85). Forty-four patients were classified into group 1, 13 into group 2 and 13 into group 3. After a mean follow-up of 1386 days (DS 915), the mortality rate was significantly greater in the group 1 (18 died) versus group 2 and 3 (1 died each). In the group 1 patients whom showed at baseline a honeycombing rate greater than 25%, fibrotic score greater than 30, overall CT score greater than 45 and bronchiectasis in more than 4 lobes obtained the better prognostic value and significantly predicted mortality risk. A significant increment of fibrotic score and honeycombing rate was demonstrated in the group 1 and 3 but not in the group 2. Honeycombing progression was quantified in 3 points/year for UIP type. Conclusion In our study HRCT criteria for UIP pattern on the basis of 2011 guidelines showed high accuracy in the risk stratification of patients with idiopathic pulmonary fibrosis (IPF)

Amiodarone-Induced Pulmonary Toxicity - A Frequently Missed Complication.

IntroductionAmiodarone is often used in the suppression of tachyarrhythmias. One of the more serious adverse effects includes amiodarone pulmonary toxicity (APT). Several pulmonary diseases can manifest including interstitial pneumonitis, organizing pneumonia, acute respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary nodules or masses, and pleural effusion. Incidence of APT varies from 5-15% and is correlated to dosage, age of the patient, and preexisting lung disease.DescriptionA 56-year-old male with a past medical history of coronary artery disease and chronic obstructive pulmonary disease was admitted for a coronary artery bypass graft. Post-operatively, the patient was admitted to the ICU for ventilator management and continued to receive his home dose of amiodarone 400 mg orally twice daily, which he had been taking for the past 3 months. The patient was found to be hypoxemic with a PaO2 52 mmHg and bilateral infiltrates on chest x-ray. Patient also complained of new onset dyspnea. Physical exam found bilateral rhonchi with bibasilar crackles and subcutaneous emphysema along the left anterior chest wall. Daily chest x-rays showed worsening of bilateral interstitial infiltrates and pleural effusions. A chest high-resolution computed tomography on post-operative day 3 showed extensive and severe bilateral ground glass opacities. APT was suspected and amiodarone was discontinued. A course of oral prednisone without antibiotics was initiated, and after one week of treatment the chest film cleared, the PaO2 value normalized and dyspnea resolved.DiscussionAPT occurs via cytotoxic T cells and indirectly by immunological reaction. Typically the lungs manifest a diffuse interstitial pneumonitis with varying degrees of fibrosis. Infiltrates with a 'ground-glass' appearance appreciated on HRCT are more definitive than chest x-ray. Pulmonary nodules can be seen, frequently in the upper lobes. These are postulated to be accumulations of amiodarone in areas of previous inflammation. Those undergoing major cardiothoracic surgery are known to be predisposed to APT. Some elements require consideration: a baseline pulmonary function test (PFT) did not exist prior. APT would manifest a restrictive pattern of PFTs. In APT diffusing capacity (DLCO) is generally >20 percent from baseline. A DLCO was not done in this patient. Therefore, not every type of interstitial lung disease could be ruled out. Key features support a clinical diagnosis: (1) new dyspnea, (2) exclusion of lung infection, (3) exclusion of heart failure, (4) new radiographic features, (5) improvement with withdrawal of amiodarone. Our case illustrates consideration of APT in patients who have extensive use of amiodarone and new onset dyspnea

An unusual presentation of a case of human psittacosis

Background: Chlamydia psittaci is a gram-negative, obligate intracellular organism. Birds are the main reservoir, but also non-avian domestic animals and humans can be infected. In humans it mostly causes respiratory infections due to occupational exposure with varying severity. Sensitive and specific diagnostic tests are needed to define psittacosis in humans as these tests also allow rapid tracing of the animal source. However, diagnosis in humans is often based on time-consuming culture techniques and antibody detection assays as in many countries, the existing molecular diagnostic tests for psittacosis are not reimbursed by the public health insurance. Case presentation: An 82-year old female was referred to the hospital with a non-productive cough since four weeks and since one week fever up to 39 degrees C, myalgia, generalized skin rash, acral edema and generalized weakness under treatment with moxifloxacin. Blood analysis showed signs of inflammation with mild eosinophilia. Chest CT showed multiple peripheral ground glass opacities with consolidation in both lungs. Pulmonary function testing only showed a mild decrease in diffusion capacity. Viral and bacterial serology were negative. As the patient kept a pet parakeet for over ten years, a nested PCR for C. psittaci was performed on a nasopharyngeal swab of the patient and on feces of the parakeet. Both returned positive for the same genotype. Genotyping was performed by a genotype-specific real-time PCR. The patient fully recovered after a ten-day course of azithromycin. Conclusion: Due to non-specific signs during psittacosis, early detection of the infection and differentiation from hypersensitivity pneumonitis can be challenging. Culture and antibody titers for C. psittaci have a lower sensitivity than PCR-testing due to several factors. We present a case of human psittacosis (presenting as pneumonia) with diagnosis based on clinical findings confirmed by means of nested PCR. This case suggests the added value of PCR in suspect cases despite negative serology. Our current paper underlines the need for a broader implementation of PCR for early diagnosis of human psittacosis and thus early initiation of correct antibiotic treatment with reduction of morbidity and mortality

Evaluation of diffuse lung diseases by high resolution computed tomography of chest

Background: Diffuse lung diseases describe a heterogeneous group of disorders of the lower respiratory tract characterized by inflammation and derangement of the interstitium and loss of functional alveolar units. The disease is not restricted to the interstitium only, as it involves epithelial, endothelial and mesenchymal cells with the disease process extending into the alveoli, acini and bronchioles. Thus, the entire pulmonary parenchyma is involved. The objective of the study was to evaluate diffuse lung diseases by high resolution computed tomography of chest.Methods: A cross-sectional observational study was done in 30 patients. Adult patients of either sex of age group 18 and above showing reticular opacities on chest X-ray and those patients who were incidentally diagnosed as cases of diffuse lung diseases on HRCT chest were included in present study.Results: Reticular opacities were the most common roentgenographic finding followed by reticulonodular opacities. On HRCT, intra and interlobular septal thickening was the most common finding in Idiopathic interstitial pneumonia (usual interstitial pneumonia).Conclusions: High resolution computed tomography (HRCT) is superior to the plain chest X-ray for early detection and confirmation of suspected diffuse lung diseases. In addition, HRCT allows better assessment of the extent and distribution of disease, and it is especially useful in the investigation of patients with a normal chest radiograph. Coexisting disease is often best recognized on HRCT scanning

Imaging of Pulmonary Infection

The spectrum of organisms known to cause respiratory infections is broad and constantly increasing as new pathogens are identified, and an increasing number of patients have impaired immunity due to disease or medications. The radiographic manifestations of a given organism may be variable depending on the immunologic status of the patient and the presence of pre- or coexisting lung disease. Moreover, the clinical data and radiographic findings often fail to lead to a definitive diagnosis of pneumonia because there are an extensive number of noninfectious processes associated with febrile pneumonitis. This chapter describes and illustrates the characteristic imaging manifestations of the most common community- acquired pneumonias, nosocomial pneumonias, and the various infections seen in both immunocompetent and immunocompromised patients

A case of lung injury resembling diffuse pulmonary hemorrhage after the first administration of alemtuzumab in a patient with multiple sclerosis. Role of the HRCT

Diffuse pulmonary hemorrhage (DPH) is an uncommon, acute condition characterized by a variable combination of hemoptysis, dyspnoea, anemia, hypoxernia, and an initial nonspecific imaging features such as diffuse and bilateral ground glass pulmonary opacities that can be induced by different causes. DPH is a rare manifestation of adverse drug reactions. We report here the case of a 25-year-old woman that has been admitted to our pulmonary clinic for the onset of chest pain, cough and haemoptysis, started one week after her first treatment with alemtuzumab for multiple sclerosis. Computed tomography (CT) scan of the chest at the admission showed diffuse and bilateral ground glass pulmonary opacities. Her symptoms resolved completely without any treatment, after the interruption of alemtuzumab, and a CT scan of the chest performed one month later showed total disappearance of the pulmonary opacities

COVID‐19 in Tuberculosis patients: a report of three cases

The clinical features and treatment of pulmonary tuberculosis patients with COVID‐19 is unclear and understudied. Here, three pulmonary tuberculosis patients with COVID‐19 infection were prospectively followed from hospital admission to discharge. We provide information and experience with treatment of pulmonary tuberculosis cases with confirmed COVID‐19 infection