A Pregnant Woman With Hemoptysis and Diffuse Pulmonary Nodules.

CASE PRESENTATION: A 22-year-old woman who was 36 weeks pregnant presented with a 4-day history of cough, hemoptysis, and exertional dyspnea. She had no fever, night sweats, or weight loss. The review of system was otherwise negative. Her medical history was notable for a spontaneous first-trimester abortion a year ago. At that time, she had a transvaginal ultrasound scan that showed a gestational sac with no fetal movement. A post-abortion ultrasound scan revealed no residual fetal parts.

Bronchoscopic lung volume reduction with valves: What should the internist know?

Traditional therapies for emphysema such as bronchodilators and anti-inflammatory drugs have limited value due to permanent structural changes in the emphysematous lung that result in hyperinflation. Surgical lung volume reduction partially corrects hyperinflation by removing emphysematous lung and is an option in selected patients, but it carries a risk of morbidity and death. Valve therapy is a less-invasive option that involves bronchoscopic implantation of 1-way valves in emphysematous lung segments to allow air flow and mucus clearance in the direction of central airways. The authors review the rationale, evidence, and applications of valve therapy.

The Utility of Electronic Inhaler Monitoring in COPD Management: Promises and Challenges.

COPD is a common respiratory disorder that poses a major health-care burden with societal and financial ramifications. Although effective inhaled therapies are available, nonadherence is common among patients with COPD and potentially contributes to the burden of this disease. Electronic inhaler monitoring (EIM) is a novel modality that enables real-time assessment of adherence to inhaled therapy and informs the assessment of treatment effectiveness. EIM can be combined with physician feedback, automated audiovisual reminders, and text messaging to bolster adherence. Clinical studies have suggested that EIM can diagnose nonadherence, improve adherence, and predict exacerbations. Using an EIM-guided protocol has the potential to avoid treatment escalation in the nonadherent. Coupling EIM to behavioral intervention is an area of ongoing research with mixed results, with some studies showing benefit and others showing minimal or no significant change in clinical outcomes. Further investigation is necessary to understand the incremental benefits of EIM features, delineate optimal program implementation, and target patient populations that would benefit the most from monitoring.

Electronic inhaler monitoring and healthcare utilization in chronic obstructive pulmonary disease.

INTRODUCTION: The effect of electronic inhaler monitoring (EIM) on healthcare utilization in chronic obstructive pulmonary disease (COPD) has not been studied. We hypothesized that the use of EIM in conjunction with a disease management program reduces healthcare utilization in patients with COPD. METHODS: This is a retrospective pre- and post-analysis of a quality improvement project. Patients with COPD and high healthcare utilization (≥one hospitalization or emergency room visit during the year prior to enrolment) were provided with electronic monitoring devices for monitoring controller and rescue inhaler utilization for one year. Patients were contacted when alerts were triggered, indicating suboptimal adherence to controller inhaler or increased use of rescue inhalers, potentially signalling an impending exacerbation. Healthcare utilization was assessed pre- and post-monitoring, with each subject serving as his/her own control. RESULTS: Patients with COPD and high healthcare utilization (n = 39) were recruited. Mean EIM duration was 280.5 (±120.6) days. The mean age was 68.6 (±9.9) years, FEV1 (mean forced expiratory volume in one second) was 1.1 (±0.4) L, and mean Charlson Comorbidity index was 5.6 (±2.7). Average adherence was 44.4% (28.4%). Compared with the year prior to enrolment, EIM was associated with a reduction in COPD-related healthcare utilization per year (2.2 (±2.3) versus 3.4 (±3.2), p = 0.01). Although there was a reduction in all-cause healthcare utilization, this was not statistically significant (3.4 (±2.6) versus 4.7 (±4.1), p = 0.06). DISCUSSION: EIM in conjunction with a disease management program may play a role in reducing healthcare utilization in COPD patients with a history of high healthcare utilization.

Broncholithiasis: A Review.

The term "broncholithiasis" is defined as the presence of calcified or ossified materials within the tracheobronchial tree. The report of the condition dates back to 300 bc when Aristotle first described a symptom of "spitting of stones." The process of calcification usually starts within either the mediastinal, hilar, or peribronchial lymph nodes. The impetus is typically initiated by a granulomatous process such as TB or histoplasmosis; however, it can also been seen following exposure to other fungal or occupational elements. The exact mechanism of the calcified material (broncholith) entering the endobronchial tree remains unknown. It is hypothesized, however, that the calcified tissues gradually erodes and/or breaks loose in the airways as a result of repetitive movements of respiration or cardiac pulsations. The broncholiths are often found in the airways without any signs of erosion, however. The most common symptoms of broncholithiasis include cough, hemoptysis, and wheezing as a result of irritation of the airways and the surrounding tissues. The diagnosis is typically suspected on chest radiographs and confirmed by using bronchoscopy. Depending on the severity of the disease, management options range from simple observation to surgical resection. Despite the potential for major complications, the overall disease prognosis is good if timely and appropriate management is provided.

Sclerosing pneumocytoma: Case report of a rare endobronchial presentation.

RATIONALE: Sclerosing pneumocytoma is a rare benign lung neoplasm seen in middle aged adults with a female predominance. Originally thought to be vascular in origin, this rare entity is now understood to be epithelial in nature. On imaging, sclerosing pneumocytoma manifests as a well circumscribed nodule or mass, often juxtapleural in location. On histopathology, sclerosing pneumocytoma is composed of cuboidal "surface cells" and round "stromal cells," both of which show nuclear staining for thyroid transcription factor-1 (TTF-1). Here we review the existing literature on sclerosing pneumocytoma and present a case of sclerosing pneumocytoma in a highly unusual endobronchial location. PATIENT CONCERNS: This case is a 43 year old woman who presented with chronic cough. DIAGNOSIS: Imaging revealed a right upper lobe nodule with an endobronchial component. INTERVENTIONS AND OUTCOMES: Endoscopic biopsy was performed, and pathologic diagnosis was confirmed. LESSONS: Although extremely rare, endobronchial presentation of sclerosing pneumocytoma is possible, and should remain on the differential for patients with endobronchial pulmonary lesions. Pathologic tissue analysis is necessary to confirm this uncommon diagnosis.

Factors Associated with Mortality in Patients with a Solid Malignancy Admitted to the Intensive Care Unit - A Prospective Observational Study.

PURPOSE: Several studies show conflicting results regarding the prognosis and predictors of the outcome of critically ill patients with a solid malignancy. This study aims to determine the outcome of critically ill patients, admitted to a hospital, with a solid malignancy and the factors associated with the outcomes. METHODS AND MATERIALS: All patients with a solid malignancy admitted to an intensive care unit (ICU) at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and six months outcomes were documented. RESULTS: There were 252 patients with a solid malignancy during the study period. Urogenital malignancies were the most common (26.3%) followed by lung cancer (23.5%). Acute respiratory failure was the most common ICU diagnosis (51.6%) followed by sepsis in 46%. ICU mortality and hospital mortality were 21.8% and 34.3%. Six months mortality was 38.4%. Using multivariate analysis, acute kidney injury, OR 2.82, 95% CI 1.50-5.32 and P=0.001, use of mechanical ventilation, OR 2.67 95% CI 1.37 - 5.19 and P=0.004 and performance status of ≥2 with OR of 3.05, 95% CI of 1.5-6.2 and P= 0.002 were associated with hospital mortality. There were no differences in outcome between African American patients (53% of all patients) and other races. CONCLUSION: This study reports encouraging survival rates in patients with a solid malignancy who are admitted to ICU. Patients with a poor baseline performance status require mechanical ventilation or develop acute renal failure have worse outcomes.

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit.

PURPOSE: Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome. METHODS AND MATERIALS: All patients with HM admitted to MICU at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and 6 months outcomes were documented. RESULTS: There were 130 HM patients during the study period. Acute Leukemia was the most common malignancy (31.5%) followed by Non-Hodgkin's Lymphoma (28.5%). About 12.5% patients had autologous HSCT and 51.5% had allogeneic HSCT. Sepsis was the most common ICU diagnosis (25.9%). ICU mortality and hospital mortality were 24.8% and 45.3%, respectively. Six months mortality (available on 80% of patients) was 56.7%. Hospital mortality was higher among mechanically ventilated patients (75%). Using multivariate analysis, only mechanical ventilation (OR of 19.0, CI: 3.1-117.4, P: 0.001) and allogeneic HSCT (OR of 10.9, CI: 1.8-66.9, P: 0.01) predicted hospital mortality. CONCLUSION: Overall hospital outcome of critically ill patients with HM is improving. However those who require mechanical ventilation or underwent allogeneic HSCT continue to have poor outcome.

Invasive pulmonary aspergillosis in patients with influenza infection: report of two cases and systematic review of the literature.

Superinfection or coinfections are major causes of morbidity and mortality in patients with influenza. There are limited data on invasive pulmonary aspergillosis (IPA) in this setting. We conducted a systematic review of the literature for patients with IPA following influenza infection. A total of 68 patients (two reported from our institution and 66 identified by literature review) were analyzed. The majority of patients had underlying comorbid illnesses. Overall, the mortality rate in this cohort was 47%. On multivariate analysis, H1N1 infection was associated with better outcome (odds ratio [OR]: 0.19; 95% CI: 0.05-0.67; p = 0.010), whereas corticosteroid therapy during hospitalization was associated with worse outcome (OR: 13.5; 95% CI: 3.65-49.67; p < 0.0001). In conclusion, IPA is an emerging serious infection in patients with influenza. A high index of suspicion is necessary for the timely identification and treatment of these patients.

Impact of different antimicrobial therapies on clinical and fiscal outcomes of patients with bacteremia due to vancomycin-resistant enterococci.

Vancomycin-resistant enterococci (VRE) are a growing health problem, and uncertainties exist regarding the optimal therapy for bloodstream infection due to VRE. We conducted systematic comparative evaluations of the impact of different antimicrobial therapies on the outcomes of patients with bloodstream infections due to VRE. A retrospective study from January 2008 to October 2010 was conducted at Detroit Medical Center. Unique patients with blood cultures due to VRE were included and reviewed. Three major therapeutic classes were analyzed: daptomycin, linezolid, and ß-lactams. Three multivariate models were conducted for each outcome, matching for a propensity score predicting the likelihood of receipt of one of the therapeutic classes. A total of 225 cases of bacteremia due to VRE were included, including 86 (38.2%) cases of VR Enterococcus faecalis and 139 (61.8%) of VR Enterococcus faecium. Bacteremia due to VR E. faecalis was more frequent among subjects treated with ß-lactams than among those treated with daptomycin or linezolid. The median dose of daptomycin was 6 mg/kg of body weight (range, 6 to 12 mg/kg). After controlling for propensity score and bacteremia due to VR E. faecalis, differences in mortality were nonsignificant among the treatment groups. Therapy with daptomycin was associated with higher median variable direct cost per day than that for linezolid. This large study revealed the three therapeutic classes (daptomycin, linezolid, and ß-lactams) are similarly efficacious in the treatment of bacteremia due to susceptible strains of VRE.

Lung transplantation following hematopoietic stem cell transplantation: report of two cases and systematic review of literature.

BACKGROUND: Non-infectious pulmonary complications following hematopoietic stem cell transplantation (HSCT) are major cause of morbidity and mortality with limited treatment options. Lung transplantation (LT) has been rarely reported as a treatment option for selected HSCT recipients with these problems. OBJECTIVE: Describe the outcome of HSCT recipients who underwent LT. METHODS: Two cases of LT following HSCT from our institution are presented. Cases reported in literature were identified using English language PubMed/MEDLINE with keywords hematopoietic stem cell transplantation, bone marrow transplantation, or bronchiolitis obliterans cross-referenced with lung transplantation. We extracted data on baseline characteristics and survival data following LT. RESULTS: Total of 84 patients are analyzed. Age at time of LT was median of 22 yr (range 1-66). Seventy-nine patients were recipients of allogeneic HSCT. The indications for LT were bronchiolitis obliterans syndrome (BOS; 63 patients), pulmonary fibrosis (13 patients), BOS/pulmonary fibrosis (five patients), and graft-versus-host-disease (GVHD) of lung (three patients). The median time between HSCT and LT was 52.3 months (range 6-240). The median follow-up after LT was 36 months (range 0-168). During this time, BOS was documented in 25 patients. Relapse of hematological malignancy was reported in two patients, and new malignancy developed in four patients. At the end of follow-up, 60 patients were alive and 24 patients died. The probability of survival following LT at 24 and 36 months was 0.88 (95% CI 0.78-0.93) and 0.79 (95% CI 0.67-0.87), respectively. CONCLUSION: LT is a potential therapeutic option in selected patients with severe chronic pulmonary disease following HSCT. Further studies are needed to determine the appropriate timing and the outcome of this approach.

Risk factors for and epidemiology of community-onset vancomycin-resistant Enterococcus faecalis in southeast Michigan.

BACKGROUND: Given the known link between vancomycin-resistant Enterococcus faecalis (VREF) and vancomycin-resistant Staphylococcus aureus (VRSA), the recent increase in prevalence of VREF in southeast Michigan has raised concerns about the presence of a large "community" reservoir of VREF. Efforts to control its spread face some important challenges. METHODS: Patients with clinical isolates of community-onset (CO) VREF (cases) were compared with matched uninfected controls (study 1) and patients with hospital-onset (HO) VREF (study 2). Here, CO was defined as a hospital stay of ≤2 days before VRE isolation. RESULTS: Independent predictors for the isolation of CO-VREF compared with uninfected controls were nonhome residence; chronic skin ulcers; previous invasive procedures/surgery; exposure to cephalosporin, penicillin, and/or vancomycin; immunosuppressive status; and the presence of indwelling devices. Independent predictors for isolation of CO-VREF compared with HO-VREF included no stay in an intensive care unit in the previous 3 months and recent hospitalization. VREF isolation from wounds and aminoglycoside exposure were inversely associated with isolation of CO-VREF. CONCLUSIONS: Health care-related exposures and antimicrobial exposures are risk factors for the isolation of CO-VREF. Regional infection control practices are imperative in controlling CO-VREF, in addition to the emergence and spread of VRSA.

Epidemiology and risk factors for isolation of Escherichia coli producing CTX-M-type extended-spectrum ß-lactamase in a large U.S. Medical Center.

A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum ß-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially bla(CTX-M-15) type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.

Epidemiology of vancomycin-resistant Enterococcus faecalis: a case-case-control study.

Although much is known about vancomycin-resistant (VR) Enterococcus faecium, little is known about the epidemiology of VR Enterococcus faecalis. The predilection of VR E. faecalis to transfer the vancomycin resistance determinant to Staphylococcus aureus is much greater than that of VR E. faecium. The epidemiology of VR E. faecalis has important implications regarding the emergence of vancomycin-resistant S. aureus (VRSA); 8 of 13 reported VRSA cases have been from Michigan. A retrospective case-case-control study was conducted at the Detroit Medical Center, located in southeastern Michigan. Unique patients with VR E. faecalis infection were matched to patients with strains of vancomycin-susceptible (VS) E. faecalis and to uninfected controls at a 1:1:1 ratio. Five hundred thirty-two VR E. faecalis cases were identified and were matched to 532 VS E. faecalis cases and 532 uninfected controls. The overall mean age of the study cohort (n = 1,596) was 63.0 ± 17.4 years, and 747 (46.8%) individuals were male. Independent predictors for the isolation of VR E. faecalis (but not VS E. faecalis) compared to uninfected controls were an age of ≥65 years, nonhome residence, diabetes mellitus, peripheral vascular disease, exposure to cephalosporins and fluoroquinolones in the prior 3 months, and immunosuppressive status. Invasive procedures and/or surgery, chronic skin ulcers, and indwelling devices were risk factors for both VR E. faecalis and VS E. faecalis isolation. Cephalosporin and fluoroquinolone exposures were unique, independent predictors for isolation of VR E. faecalis. A majority of case patients had VR E. faecalis present at the time of admission. Control of VR E. faecalis, and ultimately VRSA, will likely require regional efforts focusing on infection prevention and antimicrobial stewardship.