Pulmonary tuberculosis in patients with chronic renal failure at Zagazig University Hospitals

The incidence of active TB and attendant mortality is increased in patients with impaired cellular immunity, such as HIV infected patients, solid organ and stem cell transplant recipients and patients with end-stage renal failure. The relative risk for TB varies with the type of immunodeficiency and mortality rates may be as high as 75%. End-stage renal disease (ESRD) and particularly uraemia is a known contributor to immunosuppression. The aim of this work: The aim of this work was to evaluate the increasing risk of pulmonary tuberculosis among patients with chronic renal failure and the impact of hemodialysis. Patients and methods: This study was carried at both Nephrology Unit and Chest Department, Zagazig University Hospitals during the period from April 2012 to Jan 2013. The study included a total number of 140 patients with chronic renal failure (92 males and 48 females), with mean age of 49 ± 6.4 years. Patients were classified to three groups: Group 1: Included 40 Patients with chronic renal failure and not on dialysis. Group 2: Included 50 Patients with chronic renal failure and on regular hemodialysis three sittings per week for less than 1 year. Group 3: Included 50 Patients with chronic renal failure and on regular hemodialysis three sittings per week for more than 1 year. All patients were subjected to: history taking and medical evaluation including general and local examinations, routine laboratory investigations, Plain chest X-ray; Posteroanterior and lateral views for all patients, Sputum Ziehl–Neelsen staining and Sputum induction in patients who had chest X-ray suspecting pulmonary TB without expectoration and Tuberculin skin testing. Selected cases were subjected to fiberoptic bronchoscopy to obtain BAL for ZN staining. Results: 16 patients (11.4%) proved to have pulmonary tuberculosis by +ve ZN stain for acid fast bacilli in either sputum or BAL, 28 patients (20%) were suspected to have pulmonary tuberculosis by radiological suspension and −ve sputum ZN for acid fast bacilli, 6 patients (4.3%) proved to have extra-pulmonary TB while 90 patients (64.3%) were free from tuberculosis. There were no significant differences among different groups as regards infection by TB. Conclusion: Patients with chronic renal failure are at increased risk for pulmonary and extra pulmonary tuberculosis and should be screened routinely and carefully for early detection of TB infection

Usefulness of pigtail catheter in pleurodesis of malignant pleural effusion

The management of patients with malignant pleural effusion (MPE) remains problematic. Various modalities are available in the management of MPE. However, optimal treatment is still controversial and there is no universal standard approach. Management options include observation, thoracentesis, indwelling pleural catheter (IPC) or chest tube placement and pleurodesis. The aim of the study: To evaluate the efficacy, safety and tolerability of pigtail catheters in comparison to intercostal tubes in pleurodesis of malignant pleural effusions. Patients and methods: This study was carried out at Chest Department, Zagazig University Hospitals during the period from January 2012 to September 2013. The study included 100 patients (39 males and 61 females with a mean age of 61.8 ± 11.3 years) with pleural effusion of malignant etiology. Patients were classified into two groups Group I: included 50 patients 18 males and 32 females with a mean age of 63.8 years who were subjected to pigtail catheter drainage then pleurodesis. Group II: included 50 patients 21 males and 29 females with a mean age of 61.8 years who were subjected to tube thoracotomy drainage then pleurodesis. Results: As regards pleurodesis outcome, there was a high frequency of success in group I (33 patients, 66%) when compared with group II (27 patients, 54%). However, the difference is not statistically significant. As regards pleurodesis complications the higher frequency of complications was in group II (22 patients, 44%) when compared with group I (43 patients, 86%). These differences were statistically significant (P < 0.05). Conclusion: Pigtail catheters could be considered a safe, easy, tolerable and effective alternative method in comparison to the traditional intercostal tubes in pleurodesis of malignant pleural effusions

Serum levels of Interleukin-33 and its soluble receptor ST2 in asthmatic patients

Interleukin-33 is a member of IL-1 family of cytokines and binds to two receptors: ST2 (IL-1-R1) and IL-1 receptor accessory protein (IL-1RAP). There are two isoforms of ST2 proteins: ST2L, a transmembrane form, and a soluble ST2 (sST2), a secreted form, that can serve as a decoy receptor of IL-33. The IL-33/ST2 signaling pathway activates airway eosinophils that exacerbate airway inflammation. The aim of this study was to analyze the serum level of IL-33 and its receptor sST2 in patients with bronchial asthma to assess if the serum level of IL-33 and/or sST2 may be a marker of the disease severity and potential therapeutic targets. Patients and methods: This study was carried out at the Microbiology & Immunology and Chest departements, Faculty of Medicine, Zagazig University Hospitals during the period from December 2012 to September 2013. The study included 30 patients diagnosed as bronchial asthma according to GINA 2012. Patients were classified into two groups: Group I: included 15 patients 8 males and 7 females with a mean age 36.2 ± 15.8 during exacerbation of bronchial asthma. Group 2: included 15 patients 8 male and 7 female with mean age 37.3 ± 12.8. They were stable asthmatic patients and the last exacerbation was one month ago. There were 30 normal healthy persons as a control group. All patients were subjected to, full medical history, general and local examination, Plain chest X-ray PA and lateral views, pulmonary function tests, Liver and kidney function tests, intradermal skin test, skin prick test, measurement of serum levels of IL-33 (WEKA MED), IL-33 Receptor (soluble ST2) (OmniKine) and total IgE (IMMUNOSPEC) by enzyme linked immunosorbent technique using commercial kits. Results: There was a highly significant increase in the serum level of IL-33 in both groups of patients (p1 < 0.001) with the highest level 960 ± 336 ng/ml in group 1 followed by 732.2 ± 68.3 ng/ml in group 2 while the normal control group serum level was 174 ± 41 ng/ml. As regards serum level of sST2, there was a highly significant increase in its level in both groups of patients (p1 < 0.001) with the highest level 96.8 ± 25 μg/ml in group 1 followed by 83.3 ± 5.3 μg/ml in group 2 while the normal control group serum level was 33.9 ± 9.6 μg/ml. In acute exacerbated patients there was significant −ve correlation between FEV1 and serum level of both total IgE and IL-33 and in stable asthmatic patients there was high significant +ve correlation between PEFR variability and serum level of sST2. Conclusion: The serum levels of IL-33 and its receptor sST2 were markedly elevated in patients with bronchial asthma and this supports the concept of sST2 and Interleukin-33 as a therapeutic target in asthma

Diagnostic utility of soluble triggering receptor expression on myeloid cells-1 in complicated parapneumonic pleural effusion

Background: The differentiation between complicated parapneumonic effusions (CPPE) or empyema, which require chest tube drainage, and uncomplicated parapneumonic effusions (UCPPE), which respond to antibiotic therapy alone, is sometimes unclear. Delay in diagnosis results in substantial delay in the commencement of treatment and may contribute to the high mortality of this infection. The aim of the study: Evaluation of the utility of soluble triggering receptor expression on myeloid cells-1 (sTREM-1) as an early marker in the diagnosis and management of complicated parapneumonic effusions and empyema. Patients and methods: This study included 58 patients who were diagnosed as having PPE and admitted to the Chest Department, Zagazig University Hospitals during the period from March 2012 to March 2013. Patients were diagnosed PPE if they had a pleural effusion and showed one or more clinical manifestations typical of pneumonia, including acute febrile illness, sputum production, chest pain, leukocytosis and infiltrate(s) on chest X-ray. They were divided into two groups. Group (1): Complicated parapneumonic effusion (22 patients), according to at least one of the following criteria on pleural fluid examination: macroscopic pus, presence of organisms on Gram-stain or culture, fluid pH < 7.2 with normal peripheral blood pH, or fluid glucose concentrations <40 mg/dL. Group (2): Uncomplicated parapneumonic effusion (36 patients), according to the following criteria: pleural effusion associated with a non purulent pleural fluid, negative fluid microbiological studies; fluid pH > 7.2 with normal peripheral blood pH and fluid glucose >40 mg/dL. Exclusion criteria: A history of pleural disease or any underlying disease that could potentially cause pleural effusions, such as tuberculosis, malignancy, heart failure, systemic lupus erythematosus and chronic renal failure, were excluded. Pleural fluid samples were examined for level of sTREM-1, pH, LDH and glucose. The sTREM-1 levels were expressed as pg/mL. Microbiological studies included: Gram and Ziehl–Neelsen stains and cultures on conventional media for aerobic and anaerobic micro-organisms in the pleural fluid samples. Results: The median sTREM-1 level in pleural fluid was significantly higher in the bacterial PPE (688 ± 398 pg/mL) than in the non-bacterial PPE (45 ± 79 pg/mL). The cut-off value of pleural fluid sTREM-1 for diagnosis of bacterial PPE was 130 pg/mL with 93% sensitivity and 92% specificity, while it was 7.237 for pleural fluid pH with 91% sensitivity and 96% specificity and 640 mg/L for pleural fluid glucose with 92% sensitivity and 86% specificity and 800 IU/L for pleural fluid LDH with 81% sensitivity and 90% specificity. In conclusion: Combination of classical criteria with pleural fluid sTREM-1 could be useful in discrimination between nonpurulent complicated and non complicated parapneumonic pleural effusions and hence early pleural drainage in patients with complicated parapneumonic effusions which may affect disease outcome