Plućni tumorleti s okolnim fibroznim tkivom – suspektni karcinom: prikaz slučaja i pregled literature

Pulmonary tumorlets are small, often multiple nodular proliferations of pulmonary neuroendocrine cells. They are common incidental findings in chronic inflammatory pulmonary diseases. They can also be found in normal lung parenchyma and as one part of the continuum known as diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. In many cases, they are incidental histologic findings of no importance or clinical consequences, or they can be associated with a very slow progression of either obstructive or mixed obstructive/restrictive impairment with good prognosis. Only rarely, they metastasize to an adjacent lymph node or produce ectopic neuroendocrine products. When found during diagnostic examination, they represent a doubt to be a malignant tumor until proven otherwise, which is often impossible without biopsy or surgical removal of the adjacent lung lobe. Hereby, we present a patient with a persistent nodular lung structure after being treated for nonspecific symptoms, cough with non purulent sputum and pain among the scapulae, for a period of one month. He had otherwise normal clinical and laboratory findings, except for a mild mixed obstructive/restrictive pattern of impairment that was shown by lung spirometry. After 8 months, he underwent lobectomy of the medial lobe of the lung with partial lymphadenectomy, since the diagnostic methods applied could not define the nature of lung nodular infiltration. Histologic examination showed a few tumorlets surrounded by the fibrous tissue with a very dense lymphocyte infiltration. We present a review of the literature and emphasize the necessity to include tumorlets with adjacent fibrosis as part of the differential diagnosis of a solitary nodular lung structure.Plućni tumorleti su malene, često višestruke nodularne proliferacije plućnih neuroendokrinih stanica te su čest slučajni nalaz kod kroničnih upalnih plućnih bolesti. Također se mogu naći u normalnom plućnom parenhimu te kao jedan dio kontinuuma poznatog kao difuzna idiopatska hiperplazija plućnih neuroendokrinih stanica. U mnogim slučajevima oni su slučajni histološki nalaz bez značenja ili kliničkih posljedica, a mogu biti i povezani s vrlo sporom progresijom opstruktivnog ili miješanog opstruktivno-restriktivnog oštećenja s dobrom prognozom. Samo rijetko metastaziraju u obližnje limfne čvorove ili stvaraju ektopične neuroendokrine produkte. Nađeni tijekom dijagnostičkog pregleda, predstavljaju sumnju na maligni tumor sve dok se ne dokaže suprotno, što je često nemoguće bez biopsije ili kirurškog odstranjenja pripadajućeg plućnog režnja. Prikazuje se bolesnik s ustrajnim čvorom unutar plućnog parenhima nakon što je tijekom mjesec dana bio liječen zbog nespecifičnih simptoma – kašlja bez gnojnog iskašljaja i boli između lopatica. Ostali su klinički i laboratorijski nalazi bili uredni osim blagog miješanog opstruktivno-restriktivnog oštećenja. Nakon 8 mjeseci odstranjen je srednji režanj pluća zajedno s dijelom limfnih čvorova, jer primijenjene dijagnostičke metode nisu mogle odrediti prirodu čvoraste infiltracije pluća. Histološki pregled je pokazao nekoliko tumorleta okruženih fibroznim tkivom uz vrlo gustu infiltraciju limfocitima. U ovom članku donosimo pregled literature te prikaz slučaja koji naglašava neophodnost uključivanja tumorleta s okolnim fibroznim tkivom u diferencijalnu dijagnozu solitarne nodularne strukture u plućima

Myocardial function Depression in Severe Sepsis and Septic Shock

Depresija funkcije miokarda uobičajeni je i najvažniji dio reakcije srčano-žilnoga sustava u neprimjerenom odgovoru imunosnog sustava na infekciju, zvanom sepsa. Uz disfunkciju drugih organa još se češće poavljuje u teškoj sepsi i septičkom šoku s visokom stopom smrtnosti i do 70%. Identificirano je više čimbenika (genskih, molekularnih, staničnih, metaboličkih, jatrogenih) koji sudjeluju u nastanku, patogenezi i ishodu tog poremećaja, ali specifi čan uzrok ostaje nerazjašnjen. Potrebna su dodatna integrativna istraživanja koja bi raščlanila i omogućila razumijevanje hijerarhije različitih mehanizama koji se javljaju u kompliciranoj sepsi općenito, te u srcu u tom kontekstu. Najprominentniji oblik sa smanjenjem kontraktilnosti, ejekcijske frakcije i dilatacijom lijeve klijetke često se naziva septička kardiomiopatija. Disfunkcija miokarda u sepsi je, cjelovito gledano, karakterizirana prolaznom globalnom (sistoličkom i dijastoličkom) disfunkcijom lijeve i desne strane srca koja se javlja u uvjetima komplicirane sepse, unatoč adekvatnoj nadoknadi tekućine i vazopresora te traje 7 do 10 dana ukoliko dođe do oporavka pacijenta. Najvažniji postupak za dijagnosticiranje disfunkcije miokarda jest ehokardiografija koja uz dijagnozu omogućuje praćenje i adekvatno liječenje pacijenta. Preostaje dodatna valorizacija i nekih biokemijskih nalaza poput troponina i B-tip natriuretskog peptida koji već imaju značajnu ulogu u ranoj dijagnostici disfunkcije miokarda. Ne postoji specifično liječenje disfunkcije miokarda u sepsi već je ono sastavni dio terapijskoga pristupa samoj sepsi s komplikacijama odnosno rana antibiotska terapija uz eventualno kirurško odstranjenje infektivnoga žarišta. Simptomatska terapija predstavlja ranu i brzu nadoknadu volumena tekućine uz primjenu vazopresorne i inotropne terapije. Ciljano liječenje disfunkcije miokarda i kardioprotekcije u kompliciranoj je sepsi predmet intenzivnih istraživanja.Myocardial function depression is the common and most important part of the cardiovascular system reaction in the immune system’s unsuitable response to an infection, known as sepsis. Along with the dysfunction of other organs it is even more common in cases of severe sepsis and septic shock, and has a high mortality rate that can reach up to 70%. A number of factors that have been identified (genetic, molecular, cellular, metabolic, iatrogenic) contribute to the development, pathogenesis, and outcome of this disorder, but the specific cause remains unclear. Further integrative research is needed in order to analyze and clarify the hierarchy of various mechanisms that occur in complicated sepsis in the heart and in general. The most prominent form that includes reduced contractility, ejection fraction, and dilation of the left ventricle is often called septic cardiomyopathy. Myocardial dysfunction in sepsis is, on the whole, characterized by a temporary global (systolic and diastolic) dysfunction of the left and right sides of the heart, which occurs in complicated sepsis despite a resupply of adequate amounts of fluids and vasopressors and lasts from 7 to 10 days in case of the patient’s recovery. The most important method for diagnosing myocardial dysfunction is echocardiography, which makes possible the monitoring and suitable treatment of the patient. There is a need for additional evaluation of some biochemical results, such as troponin and B-type natriuretic peptide, which already have a significant role in early diagnosis of myocardial dysfunction. There is no specific treatment for myocardial dysfunction in sepsis. Instead, it is integrated in therapeutical approach to sepsis with complications or, in other words, an antibiotic therapy with a possible surgical removal of the infected focus. Symptomatic therapy represents an early and rapid resupply of fluids with an application of vasopressors and an inotropic therapy. A treatment aimed at myocardial dysfunction and cardioprotection in complicated sepsis is the subject of intense research