Lung volume reduction can be effective in appropriately selected patients with severe emphysema and is associated with reduced breathlessness and improved survival. Spontaneous resolution of ...emphysematous bullae can also sometimes occur.
We report a case of severe smoking-related emphysema in a 60-year-old patient, who presented in October 2013 with a right upper lobe acute community-acquired pneumonia on the background of previously undocumented emphysema. The patient improved following treatment with co-amoxiclav and serial radiology showed progressive cicatricial retraction. Nine months later there had been a major functional improvement characterized by a complete normalization of the patient's ventilatory parameters, specifically a 45% improvement in FEV
. In the literature, the average FEV1 improvement obtained by surgical or endoscopic lung volume reduction techniques does not exceed 28%.
Rarely, emphysematous bullae resolve following infections. Further studies of the mechanisms involved in these natural regressions may be of interest in the development of new therapeutics.
The new 2018 international guidelines for diagnosing usual interstitial pneumonia (UIP)/idiopathic pulmonary fibrosis (IPF) by CT scan split the old pattern possible UIP (2011 IPF guidelines) into ...two new patterns: probable UIP and indeterminate for UIP. However, the proportions and prognoses of these new CT-scan patterns are not clear.
We used a monocentric retrospective cohort of 322 patients suspected of having IPF (University Hospital of Rennes; Competence Center for Rare Lung Diseases; 1 January 2012-31 December 2017). All patients initially diagnosed by CT scan as possible UIP were included. The chest CT-scans were then reclassified according to the new 2018 international guidelines by 3 observers. These data were then subjected to survival analysis with multivariate Cox regression using a composite endpoint of death, lung transplantation, a decline of≥10% in forced vital capacity (FVC), or hospitalization.
Of the 89 possible UIP patients included, 74 (83%) were reclassified as probable UIP and 15 (17%) as indeterminate for UIP. Probable UIP patients were more likely to meet the composite endpoint (56/74 75.7% vs. 5/15 33% patients; HR IC 95% =3.12 1.24; 7.83, P=0.015). Multivariate analysis indicated that the probable UIP pattern was associated with significantly increased risk of reaching the composite endpoint (HR 95% CI=2.851.00; 8.10, P=0.049).
The majority of possible UIP diagnoses corresponded to probable UIP, which was associated with a significantly worse prognosis than indeterminate for UIP. This distinction between these two CT patterns emphasizes the relevance of the new international guidelines for the diagnosis of IPF.
The purpose of this investigation was to characterize the management and prognosis of severe
Pneumocystis jirovecii
pneumonia (PJP) in human immunodeficiency virus (HIV)-negative patients. An ...observational cohort study of HIV-negative adults with PJP documented by bronchoalveolar lavage (BAL) through Gomori–Grocott staining or immunofluorescence, admitted to one intensive care unit (ICU) for acute respiratory failure, was undertaken. From 1990 to 2010, 70 patients (24 females, 46 males) were included, with a mean age of 58.6 ± 18.3 years. The mean Simplified Acute Physiology Score (SAPS)-II was 36.9 ± 20.4. Underlying conditions included hematologic malignancies (
n
= 21), vasculitis (
n
= 13), and solid tumors (
n
= 13). Most patients were receiving systemic corticosteroids (
n
= 63) and cytotoxic drugs (
n
= 51). Not a single patient received trimethoprim–sulfamethoxazole as PJP prophylaxis. Endotracheal intubation (ETI) was required in 42 patients (60.0 %), including 38 with acute respiratory distress syndrome (ARDS). In-ICU mortality was 52.9 % overall, reaching 80.9 % and 86.8 %, respectively, for patients who required ETI and for patients with ARDS. In the univariate analysis, in-ICU mortality was associated with SAPS-II (
p
= 0.0131), ARDS (
p
< 0.0001), shock (
p
< 0.0001), and herpes simplex virus (HSV) or cytomegalovirus (CMV) on BAL (
p
= 0.0031). In the multivariate analysis, only ARDS was associated with in-ICU mortality (odds ratio OR 23.4 4.5–121.9,
p
< 0.0001). PJP in non-HIV patients remains a serious disease with high in-hospital mortality. Pulmonary co-infection with HSV or CMV may contribute to fatal outcome.
Nocardiosis is an infectious disease with wide range of clinical features, which can eventually lead to death. The agent responsible belongs to the genus Nocardia that includes about fifty different ...species. Nocardiosis occurs mainly in immunocompromised hosts. We report here three cases of disseminated nocardiosis misdiagnosed initially as cerebral metastatic lung cancer. These patients, including two immunocompetent hosts, presented with both pulmonary and cerebral lesions. In all three patients, the diagnosis was based on magnetic resonance imaging with diffusion sequence, apparent diffusion coefficient reconstruction and neurosurgical cerebral biopsies. Treatment with an appropriate antibiotic regimen was prolonged for several months. Progress was favorable with full resolution of the neurological symptoms and the radiological abnormalities. These three cases emphasize the diagnostic challenge of nocardiosis, especially in disseminated disease.
There are no French guidelines for the management of complicated parapneumonic effusions. A national observational study was carried out to assess the main features of current clinical practice for ...this condition.
A questionnaire was sent by email to the 1500 members of the Société de Pneumologie de Langue Française (SPLF) between 15th November and 15th December 2012.
There were 92 responders, i.e. a response rate of 6%. Of these, 87 physicians mentioned that they were involved in the management of patients with complicated parapneumonic effusions with a median number of cases of 10 per year (IQR: 5-20). Chest tube drainage was the main approach used for pleural fluid aspiration (n=51/87), followed by repeated thoracentesis (n=29/87) and early surgery (1/87). Five physicians answered both chest tube drainage or repeated thoracentesis and one physician either chest tube drainage or early surgery. Pleural fibrinolytics were never used by 20% of physicians, only in case of loculations by 70% and by 10% of respondents in all cases. Only 3 physicians combined fibrinolytics with DNAse. A double antibiotic dose was used by one third of physicians. All the physicians used respiratory physiotherapy during hospitalization and to aid recovery. Follow-up practices were heterogeneous.
The management of complicated parapneumonic effusions varies significantly in France. National guidelines may be helpful to define best practice and aid in its implementation.
Auto-immune pulmonary alveolar proteinosis is a rare disorder characterized by the accumulation of surfactant proteins in the alveoli.
We report a case of a 41-year-old smoker, presenting initially ...with acute respiratory failure. Whole lung lavages were effective initially but only for a few weeks. GM-CSF subcutaneous injections were not effective, and then plasmapheresis were tried.
This is the fifth report of the use of this treatment in auto-immune pulmonary alveolar proteinosis. Plasmapheresis was not effective in our patient.
Objectif Analyser les caractéristiques virologiques et les complications des syndromes grippaux chez les diabétiques en période hivernale. Patients et Méthodes Étude conduite dans 6 hôpitaux ...(Montpellier, Lyon, Cochin, Bichat, Limoges, Rennes) au cours de 3 saisons grippales (2012-2013, 2013-2014 et 2014-2015), sur 1 451 adultes hospitalisés avec syndrome grippal récent (début ≤ 7 jours), associant un signe respiratoire (toux, dys-pnée) et un signe systémique (fièvre, céphalées, malaise, myalgies). Les virus respiratoires étaient recherchés par RT-PCR sur prélèvement naso-pharyngé ou LBA (Centre National de Référence, Lyon). La vaccination anti-grippale, la présence d'un diabète, les comorbidités, les complications en cours d'hospitalisation (insuffisance rénale, cardiaque, respiratoire, pneumonie, décès) et la durée moyenne de séjour (DMS) étaient enregistrées. Les facteurs de risque de complications ont été étudiés par régression logistique multivariée ajustée sur âge, sexe, infection grippale, vaccination, diabète et antécédents de pathologies rénale, cardiaque ou respiratoire. Résultats Les hospitalisations ont eu lieu dans des services de maladies respiratoires, médecine interne, MIT et réanimation. Un diabète était présent chez 368 sujets (non traités : 15 %, ADO : 41 %, insuline : 27 %, mixte : 17 %). Les diabétiques étaient plus âgés (71 ± 15 vs 65 ± 20 ans, P < 0,001) et présentaient plus souvent un antécédent de pathologie rénale (18 % vs 8 %, P < 0,00001) ou cardiaque (19 % vs 11 %, P < 0,001). Leur couverture vaccinale était meilleure (60 % vs 46 %). Les données virologiques étaient comparables : grippe 38,9 % (76,1 % type A) vs 39,2 % ; (74,1 % type A) ; autres virus respiratoires : 17,0 % vs 19,9 %. La DMS était un peu plus élevée chez les diabétiques (9,1 ± 9 vs 8,9 ± 11, P = 0,015), avec une tendance à un risque de décès plus élevé (6,25 % vs 3,97 %, P 0,07). En analyse multivariée, le diabète était un facteur de risque de complications à type d'insuffisance rénale (OR : 1,66, IC 95 % : 1,10-2,52) mais pas d'insuffisance cardiaque, respiratoire ou de décès. Les complications n'étaient pas modi-fiées par les résultats virologiques. Conclusions Le diabète est un facteur de risque de complications rénales chez les patients hospitalisés avec syndrome grippal.
Airway-centered interstitial fibrosis (ACIF) is a distinct type of lung interstitial fibrosis characterized by lesions centered on the airways. Several cases reported in the literature showed little ...to no effect of corticosteroids and a high mortality rate in the absence of lung transplantation. No other efficient approach is described for the treatment of this type of fibrosis. We report for the first time the case of a 44-year-old patient diagnosed with ACIF on surgical lung biopsy and stabilized with clarithromycin after failure of systemic corticosteroids. We need to confirm this benefit in other patients to ascertain the anti-inflammatory effect of macrolides, which are far less harmful compared to corticosteroids or immunosuppressant drugs.
Patients with autoimmune pulmonary alveolar proteinosis received inhaled molgramostim or matching placebo for 24 weeks. Patients receiving molgramostim had greater improvement in pulmonary gas ...transfer and alleviation of symptoms than those receiving placebo.
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