Thoracic manifestations of paradoxical immune reconstitution inflammatory syndrome during or after antituberculous therapy in HIV-negative patients

Immune reconstitution inflammatory syndrome (IRIS) is a consequence of exaggerated and dysregulated host’s inflammatory response to invading microorganism, leading to uncontrolled inflammatory reactions. IRIS associated with tuberculosis (TB) is well recognized among human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy, but it is less common among HIV-negative patients. IRIS can manifest as a paradoxical worsening or recurring of preexisting tuberculous lesions or development of new lesions despite successful antituberculous treatment. Hence, the condition might be misdiagnosed as superimposed infections, treatment failure, or relapse of TB. This pictorial essay reviewed diagnostic criteria and various thoracic manifestations of the paradoxical form of TB-associated IRIS (TB-IRIS) that might aid in early recognition of this clinical entity among HIV-negative patients. The treatment and outcomes of TB-IRIS were also discussed

Clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment

PURPOSEWe aimed to investigate clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment.MATERIALS AND METHODSWe retrospectively reviewed the medical records, initial and follow-up chest computed tomography scans and/or radiographs for initial clinical and radiologic manifestations and outcomes following antifungal treatment of 12 immunocompetent patients diagnosed with pulmonary cryptococcosis between 1990 and 2012.RESULTSTwelve patients (age range, 21–62 years; males, eight patients [66.7%]) were included. Nine (75%) patients were symptomatic, eight of whom had disseminated infection with central nervous system involvement. Initial pulmonary abnormalities consisted of single nodules/masses (n=5), single segmental or lobar mass-like consolidation (n=3), multiple cavitary and noncavitary nodules (n=1), and multifocal consolidation plus nodules (n=3). These lesions ranged from less than 1 cm to 15 cm in greatest diameter. Distinct subpleural and lower lung predominance was observed. Seven patients (58.3%) had one or more atypical/aggressive findings, namely endobronchial obstruction (n=4), calcified (n=1) or enlarged (n=4) mediastinal/hilar lymph nodes, vascular compression (n=1), pericardial involvement (n=1), and pleural involvement (n=2). Following antifungal therapy, radiologic resolution was variable within the first six months of eight nonsurgical cases. Substantial (>75%) improvement with some residual abnormalities, bronchiectasis, cavitation, and/or fibrotic changes were frequently observed after 12–24 months of treatment (n=6).CONCLUSIONPulmonary cryptococcosis in immunocompetent patients frequently causes disseminated infection with atypical/aggressive radiologic findings that are gradually and/or incompletely resolved after treatment. The presence of nonenhanced low-attenuation areas within subpleural consolidation or mass and the absence of tree-in-bud appearance should raise concern for pulmonary cryptococcosis, particularly in patients presenting with meningitis

Unilateral postobstructive pulmonary edema following double-lumen endobronchial tube intubation

SummaryHerein, we report a male patient underwent a video-assisted thoracoscopic resection of left lower lobe intralobar bronchopulmonary sequestration that developed unilateral postobstructive pulmonary edema following double-lumen endobronchial tube intubation. Pulmonary edema subsided after receiving positive pressure ventilation at positive end-expiratory pressure of 5cm H2O and the patient was extubated 24h later. To prevent this complication, correct placement of the tube should be assessed by auscultation during intermittent ventilation of each lung and fiberoptic bronchoscope should always be performed through both tracheal and bronchial lumens after intubation

Pulmonary function abnormalities in non-splenectomized and splenectomized adult hemoglobin E/β-thalassemia patients and their correlation with pulmonary hypertension

The effect of splenectomy on pulmonary function test (PFT) and pulmonary hypertension (PH) in thalassemia remains unclear. We aimed to investigate PFT and their association with PH in patients with hemoglobin E/β-thalassemia stratified by their splenic status. Thirteen splenectomized patients (SP) and 12 non-splenectomized patients (NSP) were compared regarding to the PFT abnormalities and PH (mean pulmonary artery pressure from right-heart catheterization ≥25 mmHg or estimated systolic pulmonary artery pressure from echocardiography ≥40 mmHg). Eleven (84%) SP and 9 (75%) NSP had restrictive impairment (RI). Of these, more patients having severe RI in SP than in NSP (8 vs 2, P=0.035). FVC and PaO2 were lower in SP than in NSP (66±15% vs 77±12%, P=0.043, and 79.38±1.6 mmHg vs 98.83±6.2 mmHg, P&lt;0.001, respectively). Residual volume was higher in SP than in NSP (78±17% vs 64±15%, P=0.036). Seven (54%) SP who developed PH had a longer time interval between splenectomy and the onset of PH than those who did not (17±4.9 years vs 9.8±6.1 years, P=0.04). In conclusion, greater severity of extrapulmonary restrictive impairment and hypoxemia were more common in SP. These patients developed PH as a late complication unrelated to hypoxemia and PFT parameters. 　　因脾脏切除而对肺功能测试(PFT)以及地中海贫血症中肺动脉高压 (PH)情况造成的影响，尚不明确。我们旨在通过对血红蛋白E/β-地中海贫血症的患者进行脾脏位置的分级来探查肺功能测试(PFT)和肺动脉高压 (PH)之间的相关性。十三位脾切除患者(SP)和十二位未切除脾脏的患者(NSP)参与了有关肺功能测试(PFT)和肺动脉高压 (PH)(肺动脉高压是指从右心房导管术测量的肺动脉平均压力≥25 mmHg或者由超声心动图所估计的收缩期的肺动脉平均压力≥40 mmHg)的对比检查。十一位脾切除患者(SP)(84%)和九位未切除脾脏的患者(NSP)(75%)显现出了限制性的障碍 (RI)。毫无疑问，脾切除患者(SP)对于未切除脾脏的患者(NSP)表现出了更严重的限制性障碍(RI)(8 比2, P=0.035)。脾切除患者(SP)比未切除脾脏的患者(NSP)表现出更低的肺活量最大值及动脉氧分压值(相对应地，66±15% 比77±12%, P=0.043, 79.38±1.6 mmHg 比98.83±6.2 mmHg, P&lt;0.001)。对于余气量，SP高于NSP(对应的，78±17%比 64±15%, P=0.036)。七位(54%)SP并有 PH症状的患者显现出在首度患有肺动脉高压PH至脾切除手术之间的更长的时间间隔。综上所述，在SP群体中显现出了更严重的肺外限制性障碍以及低血氧症状。对于这类患者，患上肺动脉高压作为晚期并发症与他们在低血氧和肺功能测试的结果之间并无相关性。</p

Acute respiratory failure secondary to eosinophilic pneumonia following influenza vaccination in an elderly man with chronic obstructive pulmonary disease

Acute respiratory failure with diffuse pulmonary opacities is an unusual manifestation following influenza vaccination. We report herein a patient with chronic obstructive pulmonary disease who developed fever with worsening of respiratory symptoms and severe hypoxemia requiring ventilatory support shortly after influenza vaccination. Bronchoalveolar lavage was compatible with acute eosinophilic pneumonia. Rapid clinical improvement was observed 2 weeks after systemic corticosteroid treatment, followed by radiographic improvement at 4 weeks. No disease recurrence was observed at the 6-month follow-up

Diaphragmatic parameters by ultrasonography for predicting weaning outcomes

Abstract Background Diaphragmatic dysfunction remains the main cause of weaning difficulty or failure. Ultrasonographic measurement of diaphragmatic function can be used to predict the outcomes of weaning from mechanical ventilation. Our primary objective was to investigate the performance of various sonographic parameters of diaphragmatic function for predicting the success of weaning from mechanical ventilation. Methods We prospectively enrolled 68 adult patients requiring mechanical ventilation who were admitted to the intensive care unit from June 2013 to November 2013. The diaphragmatic inspiratory excursion, time to peak inspiratory amplitude of the diaphragm (TPIAdia), diaphragmatic thickness (DT), DT difference (DTD), and diaphragm thickening fraction (TFdi) were determined by bedside ultrasonography performed at the end of a spontaneous breathing trial. A receiver operating characteristic curve was used for analysis. Results In total, 62 patients were analyzed. The mean TPIAdia was significantly higher in the weaning success group (right, 1.27 ± 0.38 s; left, 1.14 ± 0.37 s) than in the weaning failure group (right, 0.97 ± 0.43 s; left, 0.85 ± 0.39 s) (P  0.8 s in predicting weaning success were 92, 46, 89, and 56%, respectively. The diaphragmatic inspiratory excursion, DTD, and TFdi were associated with reintubation within 48 h. The P values were 0.047, 0.021, and 0.028, and the areas under the receiver operating characteristic curve were 0.716, 0.805, and 0.784, respectively. Conclusion Among diaphragmatic parameters, TPIAdia exhibits good performance in predicting the success of weaning from mechanical ventilation. This study demonstrated a trend toward successful use of TPIAdia rather than diaphragmatic inspiratory excursion as a predictor of weaning from mechanical ventilation

Clinical Course and Outcomes among COVID-19 Patients at the Hospitel in Bangkok: A Retrospective Study

A hospitel is a hotel that has been designated as an extension of the healthcare facilities during the COVID-19 pandemic in resource-limited settings. However, the clinical course and outcomes of patients with COVID-19 admitted to this unique type of facility have never been studied. We retrospectively reviewed the medical records of adult patients with COVID-19 who were admitted to a single hospitel in Bangkok, Thailand. Risk factors with respect to chest X-ray progression and clinical progression were analyzed using a logistic regression. A total of 514 patients were recruited, with a mean (standard deviation) age of 35.6 (13.4) years, and 58.6% were women. Patients were admitted after a median (interquartile range) of 3 (2–6) days of illness and were classified with mild (12.3%), moderate (86.6%), and severe (1.1%) conditions. Favipiravir and corticosteroids were prescribed in 26.3% and 14.9% of patients, respectively. Chest X-ray progression was found in 7.6% of patients, and hospital transfer occurred in 2.9%, with no deaths. Favipiravir use (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.4–7.5, p = 0.005), nausea/vomiting after admission (OR 32.3, 95% CI 1.5–700.8, p = 0.03), and higher oxygen saturation on admission (OR 1.99; 95% CI 1.22–3.23, p = 0.005) were factors associated with chest X-ray progression. Additionally, an oxygen requirement on admission was an independent risk factor for hospital transfer (OR 904, 95% CI 113–7242, p < 0.001). In a setting where the hospitel has been proposed as an extension facility for patients with relatively non-severe COVID-19, most patients could achieve a favorable clinical outcome. However, patients who require oxygen supplementation should be closely monitored for disease progression and promptly transferred to a hospital if necessary