Importance of mediastinal granulomatous/sarcoid-like lymphadenopathy in extrathoracic malignancies.

BACKGROUND: In patients with extrathoracic malignancies (ETM), granulomatous lymph adenopathy called sarcoid-like reactions (SLR) can be seen in the regional or draining lymph nodes. We hypothesized that SLR may be a sign of imminent metastasis and investigated the clinical course and rate of recurrence in patients with ETM and granulomatous mediastinal lymphadenopathy (MLN). METHODS: In this retrospective observational study, we reviewed the medical files of patients with known ETM and who underwent EBUS-TBNA for initial staging or detection of recurrence from 2011 to 2023. Patients with granulomatous MLN were included. RESULTS: Forty-one patients (29 female) enrolled in the study. Breast and colorectal carcinomas were the most common malignancies. A total of 81 lymph nodes were sampled. The final diagnosis of patients was five sarcoidosis, one tuberculosis, one second primary, one drug reaction, and 33 SLR. Among patients with SLR, in one patient lymph nodes progressed during the follow-up and were accepted as false-negative without confirmatory biopsy. The negative predictive value (NPV) of granulomatous MLN for metastasis was 97.05%. CONCLUSION: Granulomatous MLN may be due to tuberculosis, drug reaction, sarcoidosis, or SLR in patients with ETM. SLR has a high NPV in patients with ETM. Follow-up imaging rather than confirmatory biopsy is reasonable in these patients.

A patient with widespread skin lesions presenting with massive pleural effusion.

Mycosis fungoides is the most commonly seen type of cutaneous T-cell lymphoproliferative disease. While mycosis fungoides is linked to an increased risk of developing secondary malignancies, the occurrence of B-cell-originated disease in association with it is exceedingly rare. A 66-year-old male with persistent papillomatous skin eruption was admitted due to dyspnea. Chest X-ray, positron emission tomography, and chest computed tomography revealed axillary and mediastinal lymph node enlargement and right lower pulmonary lobe infiltration along with right-sided massive pleural effusion. Histological and immunohistochemical findings of pleural biopsy and axillary lymph nodes suggested a diagnosis of pulmonary extranodal marginal zone lymphoma. Skin biopsies from the abdomen, chest, and legs revealed CD4/CD8 double-positive patch stage of mycosis fungoides. After completing six cycles of chemotherapy, complete remission of lymphoma was achieved, with the skin eruptions remaining unchanged. Herein, the authors present a unique case of concomitant diagnoses of mycosis fungoides and marginal zone B-cell lymphoma of the respiratory system to emphasize the importance of careful evaluation of each finding.

Allergic bronchopulmonary aspergillosis with endobronchial signs: Two cases.

Pulmonary aspergillosis may be classified under three categories depending on whether the patient is atopic or immunocompromised: invasive, chronic necrotizing, and allergic bronchopulmonary aspergillosis (ABPA), which is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus spp., manifesting with poorly controlled asthma. ABPA is diagnosed using major and minor criteria. Herein, we present two ABPA cases with endobronchial signs on bronchoscopy. Asthmatic 31-year-old male and 59-year-old female patients were admitted with dyspnea and bilateral rhonchi. Total IgE levels were elevated. Peripheral eosinophilia was also present. Chest computed tomography revealed consolidated areas, peribronchial micronodules, ground-glass appearance, and increased nodular densities. Bronchoscopy showed brownish-yellow membranes on the bronchial mucosa of these patients. Aspergillus spp. growth was observed in bronchial lavage culture. ABPA is a curable disease only if diagnosed correctly. Notwithstanding the large number of cases reported to date, we aimed to emphasize the importance of bronchoscopic examination in endobronchial fungal infections.

A new device for bronchoscopy for better protection.

BACKGROUND: During the COVID-19 pandemic, the risk of transmission of SARS-CoV-2 has not been precisely known in bronchoscopy procedures. We have designed a cabinet device called Ankara University Bronchoscopy Cabinet (Aubrocab®) to protect healthcare. We aimed to evaluate preventing effect of Aubrocab® on aerosol spreading by measuring the particles in the bronchoscopy suite. METHODS: The patients were categorized into two groups as those who underwent bronchoscopy with and without Aubrocab®. We measured PM 0.5 levels before and after bronchoscopy in the bronchoscopy suite. RESULTS: A total of 82 patients, 62 of whom underwent bronchoscopy with Aubrocab®, were enrolled in the study. The PM 0.5 level measured before bronchoscopy was similar in both groups, whereas the PM 0.5 level measured after bronchoscopy was lower in the Aubrocab® group (42,603 ± 8,632 vs. 50,377 ± 10,487, p = 0.001). The percent of particle change (50.76 ± 19.91 vs 67.15 ± 24.24, p = 0.003) and the difference of the particle numbers between pre and postprocedure (13,638 ± 4,292 and 19,501 ± 5,891, p < 0.001) were lower in the Aubrocab® group. DISCUSSION: Our institution developed a barrier device named Aubrocab® which was shown to prevent excessive aerosol release in addition to routine precautions during bronchoscopy procedures.

Evaluation of lung cancer biomarkers profile for the decision of targeted therapy in EBUS-TBNA cytological samples.

BACKGROUND: Guidelines recommend performing biomarker tests for epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), BRAF and ROS proto-oncogene-1(ROS1) genes and protein expression of programmed death ligand-1(PD-L1) in patients with non-small lung cell carcinoma (NSCLC). Studies reported that endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) can provide sufficient material for cancer biomarker analyses, but there are still concerns about the subject. AIM: The purpose of the study was to assess the adequacy of EBUS-TBNA for testing lung cancer biomarkers. METHODS: We retrospectively reviewed patients with NSCLC whose EBUS-TBNA was analysed for EGFR, ALK, ROS-1, BRAF and PD-L1 expression between December 2011 and December 2020. RESULTS: A total of 394 patients were enrolled in the study. EGFR mutation and ALK fusion were the most common studied biomarkers. EBUS-TBNA adequacy rate for biomarker tests was found 99.0% for EGFR, 99.1 for ALK, 97.2% for ROS1, 100% for BRAF and 99.3% for PD-L1 testing. Multivariate analysis revealed the histological type, history of treatment for NSCL, size, or 18-fluorodeoxyglucose uptake of sampled lesion did not show any association with TBNA adequacy for biomarker testing. CONCLUSION: EBUS-TBNA can provide adequate material for biomarker testing for EGFR, ALK, ROS-1, BRAF and PD-L1 expression.

Is endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) reliable and safe procedure in geriatric patients?

BACKGROUND: Even though studies have indicated the usefulness and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), elderly patient data are limited due to the small sample sizes. AIM: We aimed to evaluate usage and safety of EBUS-TBNA in elderly population. METHODS: This single-center retrospective study was conducted with patients who underwent an EBUS-TBNA procedure between September 2011 and December 2019. The patients were categorized into two groups: those aged 65 years or older (elderly group) and those younger than 65 years (younger group). RESULTS: 2444 patient data, 1069 of which were in the elderly group, were analyzed. The cytological examination of EBUS-TBNA identified specimen adequacy in 96.8% of patients. One hundred and thirty patients (5.3%) experienced complications, with similar complication rates recorded in both the elderly and younger groups (5.4% vs 5.2%, p: 0.836). Logistic regression analyses revealed that age, and presence of hypertension, diabetes mellitus, coronary artery disease and malignancy are associated significantly with complication-related EBUS-TBNA. For the lymph nodes with a final diagnosis of malignancy, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EBUS-TBNA revealed a diagnostic performance in excess of 90% except for metastasis and lymphoma. CONCLUSION: EBUS-TBNA can be considered a safe and effective technique in patients aged 65 years and over.

Additive effect of dabigatran and high-dose aspirin in the development of haemorrhagic pleural effusion in a patient with tuberculous pleuritis.

Tuberculous pleuritis can rarely cause haemorrhagic pleural effusion. Dabigatran etexilate can have an additive effect on increasing the risk of haemorrhage. Aspirin cannot cause major haemorrhage, but in the elderly it can cause gastrointestinal bleeding via ulceration of the gastrointestinal mucosa. We report here the case of a 77-year-old male who presented to the hospital with a 2-month history of progressive dyspnoea. He had been taking dabigatran etexilate (220 mg) and high-dose acetylsalicylic acid (aspirin; 300 mg) daily for chronic atrial fibrillation. A chest X-ray revealed a moderately sized right pleural effusion confirmed by a computed tomography scan, which also showed bronchiectasis of both lungs. Dabigatran was discontinued and aspirin was decreased to the minimal therapeutic dose of 100 mg before thoracentesis was performed. Lymphocyte-predominant (50%) haemorrhagic fluid of 500 ml was drained, positive for acid-fast bacilli smear and polymerase chain reaction of Mycobacterium tuberculosis. A chest tube was placed and an additional 1250 ml of haemorrhagic exudate drained out. We treated the patient with a routine regimen of antituberculous medication and the infection resolved without complications other than the bronchiectasis present before treatment. We think that the combination of dabigatran etexilate and high doses of aspirin increased the risk of pleural haemorrhage in this patient with tuberculous pleuritis.

A Very Rare Adverse Effect of Clozapine, Clozapine-induced Interstitial Lung Disease: Case Report and Literature Review.

Clozapine is the gold-standard antipsychotic agent for treatment-resistant schizophrenia. Yet with all its clinical efficacy, there are numerous adverse effects associated with clozapine. Although many, such as leucopenia and agranulocytosis, are well established, there is little published material on the drug's rare adverse effects. Among these, very little is known about clozapine-induced interstitial lung disease. Here we present such a case. We focus on its clinical aspects and discuss its relationship to the extant literature.

Flexible bronchoscopy and mechanical ventilation in managing Mounier-Kuhn syndrome: a case report / Broncoscopia flexível e ventilação mecânica no tratamento da síndrome de Mounier-Kuhn: relato de caso

ABSTRACT CONTEXT: Mounier-Kuhn syndrome is a rare congenital condition with distinct dilatation and diverticulation of the tracheal wall. The symptoms may vary and the treatment usually consists of support. CASE REPORT: The patient was a 60-year-old male with recurrent hospital admission. He was admitted in this case due to dyspnea, cough and sputum production. An arterial blood sample revealed decompensated respiratory acidosis with moderate hypoxemia. A chest computed tomography (CT) scan showed dilatation of the trachea and bronchi, tracheal diverticula and bronchiectasis. Flexible bronchoscopy was performed, which revealed enlarged airways with expiratory collapse. Furthermore, orifices of tracheal diverticulosis were also detected. Non-invasive positive pressure ventilation (NPPV) was added, along with long-term oxygen therapy. At control visits, the patient's clinical and laboratory findings were found to have improved. CONCLUSION: Flexible bronchoscopy can be advocated for establishing the diagnosis and non-invasive mechanical ventilation can be used with a high success rate, for clinical wellbeing in Mounier-Kuhn syndrome.

RESUMO CONTEXTO: A síndrome de Mounier-Kuhn é uma condição congênita rara com dilatação e diverticulação distintas da parede traqueal. Os sintomas podem ser variáveis ​e o tratamento geralmente é de suporte. RELATO DE CASO: Paciente do sexo masculino, de 60 anos, com internação hospitalar recorrente, foi internado neste caso devido a dispneia, tosse e produção de expectoração. A amostra de sangue arterial revelou acidose respiratória descompensada, com hipoxemia moderada. A tomografia computadorizada de tórax mostrou dilatação da traqueia e brônquios, divertículos traqueais e bronquiectasias. Realizou-se broncoscopia flexível, que revelou aumento das vias aéreas com colapso expiratório. Além disso, também foram detectados orifícios de diverticulose traqueal. Foi adicionada ventilação com pressão positiva não invasiva (NPPV) juntamente com a oxigenoterapia a longo prazo. Foram verificadas melhoras dos resultados clínicos e laboratoriais do doente nas visitas de controle. CONCLUSÃO: A broncoscopia flexível pode ser defendida para estabelecer o diagnóstico, e a ventilação mecânica não invasiva pode ser utilizada com alta taxa de sucesso, para bem-estar clínico, na síndrome de Mounier-Kuhn.

Flexible bronchoscopy and mechanical ventilation in managing Mounier-Kuhn syndrome: a case report.

CONTEXT: Mounier-Kuhn syndrome is a rare congenital condition with distinct dilatation and diverticulation of the tracheal wall. The symptoms may vary and the treatment usually consists of support. CASE REPORT: The patient was a 60-year-old male with recurrent hospital admission. He was admitted in this case due to dyspnea, cough and sputum production. An arterial blood sample revealed decompensated respiratory acidosis with moderate hypoxemia. A chest computed tomography (CT) scan showed dilatation of the trachea and bronchi, tracheal diverticula and bronchiectasis. Flexible bronchoscopy was performed, which revealed enlarged airways with expiratory collapse. Furthermore, orifices of tracheal diverticulosis were also detected. Non-invasive positive pressure ventilation (NPPV) was added, along with long-term oxygen therapy. At control visits, the patient's clinical and laboratory findings were found to have improved. CONCLUSION: Flexible bronchoscopy can be advocated for establishing the diagnosis and non-invasive mechanical ventilation can be used with a high success rate, for clinical wellbeing in Mounier-Kuhn syndrome.

Alpha-1 Antitrypsin Levels and Polymorphisms in Interstitial Lung Diseases.

BACKGROUND/AIM: Alpha-1 antitrypsin deficiency may be a potential predisposing factor for interstitial lung fibrosis. We investigated alpha-1 antitrypsin levels and its polymorphisms in patients with interstitial lung disease. MATERIALS AND METHODS: A total of 103 interstitial lung disease patients were compared. RESULTS: The mean alpha-1 antitrypsin level in idiopathic interstitial pneumonia patients was 1.67 ± 0.33 g/L, and it was 1.54 ± 0.37 g/L in patients with nonidiopathic interstitial pneumonia (P = 0.13). Low alpha-1 antitrypsin levels were more frequently observed in nonidiopathic interstitial pneumonia patients compared with idiopathic interstitial pneumonia, but the difference was not statistically significant (8.9% vs. 0%, respectively, P = 0.4). In 100 patients, the normal PiMM genotype was detected, while abnormal ones (PiMZ, n = 2, 1.9%; PiMS, n = 1, 0.97%) were determined in three cases. When the frequency of alpha-1 antitrypsin polymorphism in interstitial lung disease patients was compared with the data of the healthy population, no significant difference was detected for the PiMZ and PiMS variants (P = 0.15 and P = 0.44, respectively). CONCLUSION: Lower levels of serum alpha-1 antitrypsin were more frequent in nonidiopathic interstitial pneumonia patients than idiopathic interstitial pneumonia without an increase in genetic polymorphism. The difference was not statistically significant.

Concurrent central nervous system and endobronchial tuberculosis mimicking a metastatic lung cancer.

BACKGROUND AND AIMS: Early diagnosis and treatment of central nervous system tuberculosis are important because of high mortality and morbidity. Airways must be carefully evaluated in differential diagnosis. METHODS: We present a rare case of intracranial-endobronchial tuberculosis mimicking lung cancer with brain metastasis. RESULTS: A vegetative mass lesion, confirmed as necrotic granulomatous inflammation, originating from the entrance of the right upper lobe entry, was coagulated and extracted by argon plasma coagulation and cryotherapy to prevent permanent upper lobe atelectasis. Mycobacterium tuberculosis complex was detected in bronchoscopic material. A four-drug initial anti-tuberculous treatment regimen was given in 2 months. The upper lobe atelectasis was resolved at the fourth month of therapy despite upper lobar bronchus patency. The patient was doing well and completed the two-drug maintenance therapy of 7 months with complete resolution. CONCLUSION: In such cases, tissue diagnosis should be achieved as early as possible and anti-tuberculous treatment was commenced along with advanced interventional techniques.

Neutrophilic Alveolitis and High Serum Pro-Brain Natriuretic Peptide Level may be Indicators of Pulmonary Functional Impairment in Connective Tissue Disorders.

OBJECTIVES: This study aims to assess the role of several diagnostic tests and tools, immune markers, and the association between serum pro-brain natriuretic peptide levels and other parameters in patients with collagen tissue disorders with pulmonary involvement. PATIENTS AND METHODS: In this prospective study, 62 patients (17 males, 45 females; mean age 58.1±13.6 years; range 24 to 87 years) with pulmonary involvement of connective tissue disorders were evaluated using several functional parameters (six-minute walking test, serum pro-brain natriuretic peptide, echocardiographic measurement of the pulmonary pressure, respiratory functional parameters, and blood pressure measurement), bronchoalveolar lavage differential cytology and/or flow cytometric analysis. RESULTS: Duration of disease was 7.6 years. Diagnoses included rheumatoid arthritis (38.7%), scleroderma (38.7%), primary Sjögren's syndrome (16.1%), mixed collagen tissue disorder (4.8%), and systemic lupus erythematosus (1.6%). Pulmonary hypertension was present in 38.7% of the patients with the highest incidence of rheumatoid arthritis showing reduced respiratory functions, partial oxygen pressure, and six-minute walk distance, as well as increased serum pro-brain natriuretic peptide and neutrophilic alveolitis. CONCLUSION: High serum pro-brain natriuretic peptide levels and neutrophilic alveolitis may provide diagnostic clues for a possible diagnosis of pulmonary hypertension and impaired respiratory functions.

Electromagnetic navigation-guided TBNA vs conventional TBNA in the diagnosis of mediastinal lymphadenopathy.

OBJECTIVES: Conventional transbronchial needle aspiration (C-TBNA) is a safe method for the diagnosis of hilar and mediastinal lymphadenopathy (MLN). However, diagnostic yield of this technique varies considerably. Electromagnetic navigation bronchoscopy (ENB) is a new technology to increase the diagnostic yield of flexible bronchoscopy for the peripheral lung lesions and MLN. The aim of this prospective study was to compare the diagnostic and sampling success of ENB-guided TBNA (ENB-TBNA) in comparison with C-TBNA while dealing with MLN. METHODS: Consecutive patients with MLN were randomized into two groups - C-TBNA and ENB-TBNA - using a computer-based number shuffling system to avoid recruitment bias. Procedures were performed in usual fashion, published previously. RESULTS: Ninety-four cases (M/F: 45/49) with a total of 145 stations of MLN were enrolled in the study. In 44 patients, 81 stations were sampled by ENB-TBNA, and in 50 patients 64 stations by C-TBNA. The mean size of MLN in study subjects was 17.56 ± 6.25 mm. The sampling success was significantly higher in ENB-TBNA group (82.7%) compared with C-TBNA group (51.6%) (P < 0.005). Defined by histopathological result, the diagnostic yield in ENB-TBNA was 72.8%, and 42.2% with C-TBNA (P < 0.005). For subcarinal localization, sampling or diagnostic success was higher in ENB-TBNA than that of C-TBNA (P < 0.05). Based on the size of the MLN ≤15 mm or >15 mm, the sampling success of ENB-TBNA was also significantly higher than C-TBNA in both subgroups (P < 0.005 and P < 0.005, respectively). No serious complication was observed. CONCLUSION: In this study comparing ENB-TBNA and C-TBNA, the sampling and diagnostic success of ENB-TBNA was found to be superior while dealing with MLN, in all categories studied.

Tuberculosis preventive treatment in a single medical center and evaluation of the results.

The aim of the present study was to evaluate the application of tuberculosis preventive treatment (TB-PT). Demographic data, indications and results for cases that received TB-PT at the Ankara Tuberculosis Control Dispensary No. 7 between 2008 and 2011 were retrospectively evaluated. The 'Prevention with Drugs' registry at the dispensary was used. A total of 463 cases received TB-PT, with the indications including close contact with an active TB case (44%), positive tuberculin skin test (TST) in a child <15 years-old (25%) and immunosuppressive therapy (31%). The immunosuppressed group (n=144) were administered steroids (10%) or tumor necrosis factor (TNF)-α inhibitors (90%). Indications of TST conversion and sequela lesions were not observed among the cases. The male/female ratio was 106/98 for cases with TB close contact, 61/54 for TST-positive cases and 85/59 for immunosuppressed cases. The mean ages of these groups were 9±5.7, 9.5±3.8 and 38±14.9 years, respectively. TB-PT was completed in 364 cases (78.6%), and the rate of discontinuation due to adverse effects was 1% for TB close contact and 2% for TST-positive cases, but 5% for immunosuppressed cases. While the percentage of TB close contact cases receiving TB-PT decreased during the four-year study period, the percentage of cases with immunosuppression (in particular patients using TNF-α inhibitors) increased. Among the studied cases, only two subjects developed active TB. The first case involved a 1.5-year-old female that had close contact exposure to TB from a parent, while the other case involved a 14-year-old TST-positive male (induration size,16 mm). In conclusion, patients receiving TB-PT should be monitored and/or followed-up carefully to control any side-effects from the treatment and development of active TB.

Pulmonary arterial hypertension and systemic sclerosis relation: a single centre experience.

AIM: In systemic sclerosis (SSc), this single-centre study aimed to define the frequency and association of pulmonary arterial hypertension (PAH), occurring either alone in SSc-PAH or together with interstitial lung disease (ILD-PH). MATERIAL-METHODS: SSc cases between the years 1990-2011 were reviewed, retrospectively. Patients' clinical, laboratory findings, Modified Rodnan Skin Score and Medsger score, 6-minute walk distance (6MWD), carbon monoxide diffusion test (DLCO), echocardiography, thorax HRCT, and right heart catheterisation findings were recorded. RESULTS: One hundred and forty-one cases (F/M:124/17, diffuse cutaneous SSc (DcSSc)/limited cutaneous SSc (LcSSc): 84/57) were included in the study with the mean age of 52.70±15.17 years and disease duration of 107.07±99.44 months. PaO2, FEV1 and FVC were lower in DcSSc (p<0.05) as compared to LcSSc, but DLCO and 6MWD did not differ significantly, between the two forms. Ground glass opacity (64.7%) and interlobular septal thickening (58.8%) were the most frequent findings on HRCT of such subjects. PAH was detected in 34 subjects (24.1%). Seven of them had SSc associated PAH (SSc-PAH) and 27 ILD-PH. Both frequencies were similar between DcSSc and LcSSc. Mean sPAP was higher in SSc-PAH. CONCLUSION: PAH was observed in approximately one fourth of patients; therefore advanced cardio-pulmonary investigation should be routinely performed in the SSc patients' management.

Rapid on-site evaluation and low registration error enhance the success of electromagnetic navigation bronchoscopy.

BACKGROUND: Electromagnetic navigation bronchoscopy (EMN) is a novel technology which allows localizing peripheral lung lesions and mediastinal lymph nodes for sampling and thus increasing diagnostic yield of Flexible Bronchoscopy. OBJECTIVES: A prospective study was conducted to investigate the diagnostic yield of EMN with lower average fiducial target registration error (AFTRE) and rapid on-site evaluation (ROSE). METHODS: Consecutive patients with peripheral lung lesion (PL) or enlarged mediastinal lymph node (MLN) which could not be diagnosed by conventional techniques and/or if the patients were not suitable for such interventions were included. The navigation procedure was continued once registration error was reached below/equal to the absolute value of 5 mm. ROSE was performed by an expert cytopathologist. RESULTS: A total of 76 patients; 22 having only PLs, 41 having only MLNs, and 13 having both PLs and MLNs together were enrolled. Thirty-two of 35 PLs (91.4%) and 85 of 102 MLNs (83.3%) were successfully sampled. Overall diagnostic yield was 89.5%. PLs and MLNs were further grouped according to their size (PLs: <20 mm vs ≥20 mm, MLNs: <15 mm vs ≥15 mm). The sampling yield was independent of size for both PL and MLN (P = 1.00, P = 0.38). In diagnostic EMN cases, mean AFTRE was 4.33 ± 0.71 mm, whereas it was 5.16 ± 0.05 mm (P = 0.008) in nondiagnostics. The total duration of procedure was 36.17 ± 9.13 min. Pneumothorax was observed in three patients (3.9%). CONCLUSION: EMN with low AFTRE in combination with ROSE is a reliable method with high sampling and/or diagnostic rate in PLs and MLNs.