RESUMO
BACKGROUND: Ulcerative colitis (UC) is a chronic GI inflammatory disorder involving various extraintestinal organs, including the lungs. Although UC-related lung diseases (UC-LDs) have been widely recognized, much remains unclear. RESEARCH QUESTION: What are the incidence, characteristics, clinical course, and risk factors of UC-LD? STUDY DESIGN AND METHODS: This study retrospectively identified and classified UC-LDs by reviewing the medical records of consecutive patients with UC. The incidence, characteristics, and clinical course of each UC-LD type were investigated, and the clinical characteristics of patients with and without each UC-LD type were compared. RESULTS: Among 563 patients with UC, 28 (5.0%) developed UC-LD during a mean follow-up period of 77 months. A majority of them displayed airway disease (AD) (n = 13 [2.3%]) or organizing pneumonia (OP) (n = 10 [1.8%]); there were six cases of interstitial pneumonias other than OP (IP) (0.8%) and one of pleuritis (0.2%). All 13 patients with AD responded favorably to inhaled or systemic corticosteroids, although five experienced frequent exacerbations. Older age and a history of colectomy were identified as the risk factors for developing AD. Nine of the 10 cases of OP were possibly due to drug-induced pathogenesis. Only one case showed recurrence, and all cases of OP exhibited a favorable clinical course with discontinuation of the suspicious drug and/or initiation of corticosteroid. The clinical course of IP depended on the existence of fibrosis, and IP with fibrosis was associated with gradual deterioration. Older age was associated with the development of IP. INTERPRETATION: A nonnegligible number of patients with UC may develop UC-LD. AD, OP, and IP without fibrosis show good prognosis following steroid therapy along with the specific management for each UC-LD type, whereas IP with fibrosis shows gradual deterioration with poor prognosis. Our results provide cues to establish better management of UC-LDs.
Assuntos
Colite Ulcerativa , Pneumonia , Humanos , Estudos Retrospectivos , Colite Ulcerativa/complicações , Colite Ulcerativa/epidemiologia , Colite Ulcerativa/terapia , Colectomia/métodos , Corticosteroides/uso terapêutico , Fatores de Risco , Pneumonia/tratamento farmacológico , Progressão da Doença , FibroseRESUMO
A 59-year-old man was treated for rheumatoid arthritis (RA) for 12 years with methotrexate (MTX) and prednisolone. After MTX-associated interstitial pneumonia developed, he was treated with cyclophosphamide and prednisolone for 7 months. Arthritis worsened, and tacrolimus was added to the treatment regimen. One month later, he had fever, loss of appetite, and dyspnea on exertion. Blood tests showed pancytopenia with large, atypical lymphocytes. Computed tomography showed mild splenomegaly. Bone marrow examination demonstrated CD20-positive, EBER-positive atypical lymphocytes, and hemophagocytosis. Random skin biopsy led to the diagnosis of intravascular large B-cell lymphoma (IVLBCL). The final diagnosis was a hemophagocytic syndrome-associated variant of IVLBCL. Complete remission was achieved after seven courses of R-CHOP. However, within a month, he complained of dizziness. Magnetic resonance imaging revealed focal infarctions in the cerebellum and around the left lateral ventricle. Central nervous system relapse was suspected. Although salvage chemotherapy (CHASER), whole brain irradiation, and intrathecal injection of cytarabine and prednisolone were temporarily effective, he died. Autopsy revealed infiltration of lymphoma cells in the brain and adrenal glands. To the best of our knowledge, this is the sixth case of IVLBCL and the first case of the hemophagocytic syndrome-associated variant of IVLBCL in RA patients in the literature.
RESUMO
To comprehensively analyze the overall incidence of hospitalization for comorbidities in patients with rheumatoid arthritis (RA). We prospectively analyzed overall hospitalizations for comorbidities using the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort. The incidence of hospitalized comorbidity was calculated. Risk factors for the most frequent hospitalized comorbidities were determined by multivariate logistic regression analysis. Among 5519 RA patients contributing 5336.5 person-years of observation, 435 incidences of hospitalized comorbidity [8.15/100 person-years; 95% confidence interval (CI) 7.40-8.95] were confirmed. The most frequent cause of hospitalized comorbidity was infection (1.52/100 person-years), primarily respiratory system infection (0.77/100 person-years), followed by malignancy (1.03/100 person-years), extra-articular manifestations (0.78/100 person-years), bone fracture (0.77/100 person-years), and acute coronary syndrome (0.22/100 person-years). Death occurred in 0.34/100 person-years (95% CI 0.20-0.53), and in 94.4% of cases the cause of death was the same as that of admission. The risk factors for the most frequent cause of hospitalization, hospitalized infection, were age [odds ratio (OR) 1.03; 95% CI 1.00-1.05], serum albumin level (OR 0.30; 95% CI 0.13-0.69), and corticosteroid use (prednisone > 5 mg/day; OR 3.66; 95% CI 1.81-7.35), but not methotrexate or biological agent use. The present study determined the overall burden of hospitalized comorbidities in patients with RA. These comprehensive data on hospitalized comorbidities may provide a basis for future improvements in the treatment of RA.
Assuntos
Artrite Reumatoide/complicações , Doenças Cardiovasculares/epidemiologia , Fraturas Ósseas/epidemiologia , Hospitalização/estatística & dados numéricos , Infecções/epidemiologia , Idoso , Comorbidade , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosAssuntos
Fatores Biológicos/uso terapêutico , Pneumopatias/tratamento farmacológico , Terapia de Alvo Molecular , Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/epidemiologia , Artrite Reumatoide/imunologia , Fatores Biológicos/administração & dosagem , Fatores Biológicos/farmacologia , Comorbidade , Humanos , Japão , Pneumopatias/epidemiologia , Pneumopatias/imunologia , PrognósticoRESUMO
BACKGROUND: Birt-Hogg-Dubé (BHD) syndrome is a rare inherited autosomal genodermatosis and caused by germline mutation of the folliculin (FLCN) gene, a tumor suppressor gene of which protein product is involved in mechanistic target of rapamycin (mTOR) signaling pathway regulating cell growth and metabolism. Clinical manifestations in BHD syndrome is characterized by fibrofolliculomas of the skin, pulmonary cysts with or without spontaneous pneumothorax, and renal neoplasms. There has been no pulmonary neoplasm reported in BHD syndrome, although the condition is due to deleterious sequence variants in a tumor suppressor gene. Here we report, for the first time to our knowledge, a patient with BHD syndrome who was complicated with a clear cell "sugar" tumor (CCST) of the lung, a benign tumor belonging to perivascular epithelioid cell tumors (PEComas) with frequent causative relation to tuberous sclerosis complex 1 (TSC1) or 2 (TSC2) gene. CASE PRESENTATION: In a 38-year-old Asian woman, two well-circumscribed nodules in the left lung and multiple thin-walled, irregularly shaped cysts on the basal and medial area of the lungs were disclosed by chest roentgenogram and computer-assisted tomography (CT) during a preoperative survey for a bilateral faucial tonsillectomy. Analysis of the resected tumor showed large polygonal cells with clear cytoplasm proliferating in a solid pattern. Immunohistochemistry revealed that these tumor cells were positive for microphthalmia-transcription factor, S100, and CD1a but negative for HMB45, indicating that the tumor was a CCST. Genetic testing indicated that the patient had a germline mutation on exon 12 of the FLCN gene, i.e., insertion of 7 nucleotides (CCACCCT) (c.1347_1353dupCCACCCT). Direct sequencing of the FLCN exon 12 using genomic DNA obtained from her microdissected CCST cells clearly revealed loss of the wild-type FLCN sequence, which confirmed complete functional loss of the FLCN gene. On the other hand, no loss of heterozygosity around TCS1- or TSC2-associated genetic region was demonstrated. CONCLUSION: To our knowledge, this is the first report of CCST of the lung in a patient with BHDS, indicating that CCST should be added to the spectrum of pulmonary manifestations of BHDS.
Assuntos
Síndrome de Birt-Hogg-Dubé/genética , Neoplasias Pulmonares/genética , Neoplasias de Células Epitelioides Perivasculares/genética , Adulto , Síndrome de Birt-Hogg-Dubé/patologia , DNA/química , DNA/isolamento & purificação , DNA/metabolismo , Éxons , Feminino , Mutação em Linhagem Germinativa , Humanos , Perda de Heterozigosidade , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Mutagênese Insercional , Linhagem , Neoplasias de Células Epitelioides Perivasculares/diagnóstico por imagem , Neoplasias de Células Epitelioides Perivasculares/patologia , Proteínas Proto-Oncogênicas/genética , Tomografia Computadorizada por Raios X , Proteínas Supressoras de Tumor/genéticaRESUMO
In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a well-known opportunistic infection, and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV-infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiologic features are the result of severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of PCR and serum ß-D-glucan assay for rapid and noninvasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent, and that asymptomatic carriers are at riskfor developing PCP and can serve as the reservoir for the spread of Pneumocystis by person-to-person transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients without HIV infection, although its indication and duration are still controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.
RESUMO
BACKGROUND: Tacrolimus is an immunosuppressive drug used to prevent acute rejection following organ transplantation and to treat autoimmune disease. Tacrolimus is usually prescribed in such situation at a dose of 3.0 mg/day. Pneumocystis pneumonia induced by this dose of tacrolimus has been reported in many cases; however, we encountered a rare case of Pneumocystis pneumonia induced by low-dose tacrolimus and methylprednisolone. CASE PRESENTATION: We herein report the case of an 82-year-old Asian Japanese female with rheumatoid arthritis and Pneumocystis pneumonia who was being treated with low-dose tacrolimus and low-dose methylprednisolone therapy. She was diagnosed with rheumatoid arthritis at 52 years of age and was administered oral low-dose methylprednisolone and salazosulfapyridine. Her condition had been stable under this treatment for 30 years. However, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy. However, on the 14th day of admission, she developed acute respiratory failure due to Pneumocystis pneumonia and died on the 17th day of admission in spite of adequate treatment. CONCLUSION: Our report highlights the importance of providing prompt prevention, diagnosis and treatment of Pneumocystis pneumonia in rheumatoid arthritis patients under tacrolimus and low-dose methylprednisolone therapy.
Assuntos
Artrite Reumatoide/complicações , Metilprednisolona/uso terapêutico , Pneumonia por Pneumocystis/tratamento farmacológico , Tacrolimo/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Relação Dose-Resposta a Droga , Feminino , Humanos , Metilprednisolona/administração & dosagem , Pneumonia por Pneumocystis/complicações , Tacrolimo/administração & dosagemAssuntos
Lesão Pulmonar Aguda/induzido quimicamente , Lesão Pulmonar Aguda/diagnóstico , Doenças Pulmonares Intersticiais/induzido quimicamente , Doenças Pulmonares Intersticiais/diagnóstico , Lesão Pulmonar Aguda/epidemiologia , Lesão Pulmonar Aguda/terapia , Amiodarona/efeitos adversos , Antiarrítmicos/efeitos adversos , Anti-Infecciosos/efeitos adversos , Antineoplásicos/efeitos adversos , Antirreumáticos/efeitos adversos , Biomarcadores/sangue , Testes de Provocação Brônquica , Diagnóstico por Imagem , Medicamentos de Ervas Chinesas/efeitos adversos , Testes Hematológicos , Humanos , Imunossupressores/efeitos adversos , Interferons/efeitos adversos , Japão/epidemiologia , Doenças Pulmonares Intersticiais/epidemiologia , Doenças Pulmonares Intersticiais/terapia , Ativação Linfocitária , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
INTRODUCTION: Pneumocystis jirovecii pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected adults. Although the microscopic demonstration of the organisms in respiratory specimens is still the golden standard of its diagnosis, recent advances in the diagnostic tools have been changing the situation. AREAS COVERED: Colonization of Pneumocystis is highly prevalent among the general population and could be associated with the transmission and development of PCP in immunocompromised individuals. Nested or conventional polymerase chain reaction (PCR) has a high sensitivity, detecting Pneumocystis DNA in induced sputum or oropharyngeal wash, but often produces false positives. Although quantitative real-time PCR is promising for discriminating colonization from PCP, the targeted DNA sequences and the cut-off values remain to be standardized. Serum ß-D-glucan is useful as an adjunctive tool for the diagnosis of PCP. High-resolution computed tomography, which typically shows diffuse ground-glass opacities, is informative for evaluation of immunocompromised patients with suspected PCP and normal chest radiography. EXPERT OPINION: Although these new tools have been making the diagnosis of PCP less invasive and more accurate, any one of them can not make a definitive diagnosis by itself. The diagnostic criteria based on the combination of the testing ought to be established.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/microbiologia , Humanos , Técnicas de Tipagem Micológica , Pneumonia por Pneumocystis/microbiologia , Reação em Cadeia da PolimeraseRESUMO
Rheumatoid arthritis (RA) is a common systemic disease that manifests as inflammatory arthritis of multiple joints and produces a wide variety of intrathoracic lesions, including pleural diseases, diffuse interstitial pneumonia, rheumatoid nodules, and airway disease. Patients treated for RA can have associated lung disease that commonly manifests as diffuse interstitial pneumonia, drug-induced lung injury, and infection. The purpose of this pictorial review is to illustrate the radiographic and clinical features of lung complications of acute or subacute onset in patients treated for RA and to show the computed tomography features of these complications.
Assuntos
Artrite Reumatoide/complicações , Artrite Reumatoide/diagnóstico por imagem , Pneumopatias/complicações , Pneumopatias/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Doença Aguda , Antirreumáticos/efeitos adversos , Antirreumáticos/uso terapêutico , Pneumonia em Organização Criptogênica/complicações , Pneumonia em Organização Criptogênica/diagnóstico por imagem , Humanos , Infecções/complicações , Infecções/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Doenças Pulmonares Intersticiais/complicações , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Lesão Pulmonar/induzido quimicamente , Lesão Pulmonar/diagnóstico por imagemRESUMO
OBJECTIVES: To investigate the clinical characteristics and risk factors of Pneumocystis jirovecii pneumonia (PCP) in rheumatoid arthritis (RA) patients treated with adalimumab. METHODS: We conducted a multicenter, retrospective, case-control study to compare RA patients treated with adalimumab with and without PCP. Data from 17 RA patients who were diagnosed with PCP and from 89 RA patients who did not develop PCP during adalimumab treatment were collected. RESULTS: For the PCP patients, the median age was 68 years old, with a median RA disease duration of eight years. The median length of time from the first adalimumab injection to the development of PCP was 12 weeks. At the onset of PCP, the median dosages of prednisolone and methotrexate were 5.0 mg/day and 8.0 mg/week, respectively. The patients with PCP were significantly older (p < 0.05) and had more structural changes (p < 0.05) than the patients without PCP. Computed tomography of the chest revealed ground-glass opacity without interlobular septal boundaries in the majority of the patients with PCP. Three PCP patients died. CONCLUSIONS: PCP may occur early in the course of adalimumab therapy in patients with RA. Careful monitoring, early diagnosis, and proper management are mandatory to secure a good prognosis for these patients.
Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/complicações , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Adalimumab , Idoso , Anticorpos Monoclonais Humanizados/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Estudos de Casos e Controles , Quimioterapia Combinada , Feminino , Humanos , Masculino , Metotrexato/efeitos adversos , Metotrexato/uso terapêutico , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/etiologia , Prednisolona/efeitos adversos , Prednisolona/uso terapêutico , Estudos Retrospectivos , Fatores de RiscoRESUMO
In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a well-known opportunistic infection, and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiologic features are the result of severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of PCR and serum ß-D-glucan assay for rapid and noninvasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent, and that asymptomatic carriers are at risk for developing PCP and can serve as the reservoir for the spread of Pneumocystis by person-to-person transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients without HIV infection, although its indication and duration are still controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.
Assuntos
Imunossupressores/uso terapêutico , Pneumocystis carinii/isolamento & purificação , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/microbiologia , Doenças Transmissíveis Emergentes/tratamento farmacológico , Doenças Transmissíveis Emergentes/imunologia , Doenças Transmissíveis Emergentes/microbiologia , Infecções por HIV/imunologia , Infecções por HIV/microbiologia , Humanos , Imunocompetência , Pneumonia por Pneumocystis/imunologiaRESUMO
PURPOSE: To clarify the long-term effect of immunotherapy, the effect of adoptive activated T lymphocyte immunotherapy on advanced lung cancer was evaluated in terms of survival time. In addition, the performance status of cancer patients under immunotherapy was examined. EXPERIMENTAL DESIGN: Over 5 × 10(9) alpha-beta T lymphocytes cultured ex vivo with an immobilized anti-CD3 antibody and interleukin-2 were injected intravenously into patients, once every 2 weeks for 3 months or longer. Follow-up of these patients was carried out using clinical records and by telephone interview questionnaire. Patients undergoing immunotherapy in immunotherapy clinics and those undergoing other anticancer therapies without immunotherapy in seven hospitals in Tokyo were enrolled in this study. Data were analyzed by a third-party statistician. Performance status was studied on another series of various cancer patients who underwent immunotherapy. RESULTS: The overall median survival time of the patients with the best supportive care, which was obtained using Kaplan-Meier's model, was 5.6 months, and those with immunotherapy alone, chemotherapy alone, and immuno-chemotherapy were 12.5, 15.7, and 20.8 months, respectively. Using Cox' proportional hazard model, we examined the possible factors on survival time by univariate analysis. Then, the patients were stratified by gender and histological type for multivariate analysis. Significantly low hazard ratios were observed for immunotherapy and radiotherapy in males with squamous cancer; for chemotherapy and radiotherapy in male with adenocarcinoma; and for immunotherapy in females with adenocarcinoma. Addition of immunotherapy to chemotherapy resulted in a statistically significant decrease in hazard ratio in females with adenocarcinoma. Studies on the performance status (PS), determined according to the European Cooperative Oncology Group criteria, revealed a continuous high level of PS under immunotherapy until around 2 months before death, in contrast to the gradual increase of tumor marker level. CONCLUSIONS: The effectiveness of immunotherapy on advanced lung cancer is limited but may extend life span under certain conditions. Immunotherapy itself provided no clinical benefit by itself as compared with chemotherapy, but a significant additive effect of immunotherapy on chemotherapy was observed in females with adenocarcinoma. Moreover, immunotherapy can maintain good quality of life of the patients until near the time of death.
Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/terapia , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/terapia , Imunoterapia Adotiva/métodos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/terapia , Ativação Linfocitária/efeitos dos fármacos , Linfócitos T/transplante , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/imunologia , Adenocarcinoma de Pulmão , Idoso , Anticorpos Neutralizantes/farmacologia , Complexo CD3/imunologia , Carcinoma de Células Escamosas/imunologia , Células Cultivadas , Estudos de Coortes , Terapia Combinada/métodos , Terapia Combinada/estatística & dados numéricos , Feminino , Humanos , Imunoterapia Adotiva/estatística & dados numéricos , Interleucina-2/farmacologia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/imunologia , Ativação Linfocitária/imunologia , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Linfócitos T/efeitos dos fármacos , Resultado do TratamentoRESUMO
In 1998, a 51-year-old woman was diagnosed with Mycobacterium avium infection on the basis of chest radiographic findings, positive smear test results, and positive results of polymerase chain reaction (PCR) specific for Mycobacterium avium DNA in bronchial lavage fluid. Antimycobacterial therapy was administered for 11 months, and the chest radiographic findings improved. In 2001, re-treatment was performed because radiographic findings indicated exacerbation of disease and poor response. After 2005, the patient remained both smear and culture positive for mycobacterium. However, the precise species could not be identified using PCR and DNA-DNA hybridization, and her left lung lesions gradually worsened. The culture isolate was subjected to DNA analysis with PCR amplification and sequence analysis; this ultimately revealed the presence of Mycobacterium lentiflavum. Combination antimicrobial therapy was administered for 10 months. The patient's symptoms were alleviated, and the radiographic appearance remained stable.
Assuntos
Infecções por Mycobacterium não Tuberculosas/microbiologia , Mycobacterium/genética , Tuberculose Pulmonar/microbiologia , DNA Bacteriano/análise , Feminino , Humanos , Pessoa de Meia-Idade , Mycobacterium/isolamento & purificação , Reação em Cadeia da PolimeraseRESUMO
OBJECTIVE: This study was performed to evaluate the radiological features of and therapeutic responses to pulmonary disease caused by nontuberculous mycobacteria (NTM) in the setting of biological therapy for rheumatoid arthritis (RA). METHODS: We conducted a retrospective chart review of 13 patients from multiple centers who had developed pulmonary NTM disease during biological therapy for RA, including infliximab, etanercept, adalimumab, and tocilizumab. RESULTS: Most cases were asymptomatic or resulted in only common-cold-like symptoms. Abnormalities in computed tomography (CT) imaging were protean and frequently overlapped. The most predominant pattern was nodular/bronchiectatic disease (six cases), followed by alveolar infiltrate (three cases), cavitary disease (two cases), and pulmonary nodules (two cases). In most cases, pulmonary NTM disease had spread from a preexisting lesion; in particular, bronchial/bronchiolar abnormalities. In three cases, one or more nodular lesions with or without calcification were a focus of disease. Following the discontinuation of biological agents, most patients responded to anti-NTM therapy. Two patients showed no exacerbation in the absence of any anti-NTM therapy. In one patient, restarting tocilizumab therapy while continuing to receive adequate anti-NTM therapy produced a favorable outcome. In two other patients with a previous history of pulmonary NTM disease, introducing biological therapy led to recurrence, but anti-NTM therapy was effective in these patients. CONCLUSION: CT abnormalities of pulmonary NTM disease in RA patients receiving biological therapy were variable, but were not unique to this clinical setting. NTM disease can spread from preexisting structural abnormalities, even if they are minute. Contrary to our expectations, the therapeutic outcomes of pulmonary NTM disease were favorable in these patients.
Assuntos
Anticorpos Monoclonais/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/tratamento farmacológico , Infecções por Mycobacterium não Tuberculosas/induzido quimicamente , Adalimumab , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/efeitos adversos , Artrite Reumatoide/complicações , Artrite Reumatoide/diagnóstico por imagem , Etanercepte , Feminino , Humanos , Imunoglobulina G/efeitos adversos , Infliximab , Masculino , Pessoa de Meia-Idade , Infecções por Mycobacterium não Tuberculosas/complicações , Infecções por Mycobacterium não Tuberculosas/diagnóstico por imagem , Radiografia Torácica , Receptores do Fator de Necrose Tumoral , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: Acute-onset diffuse interstitial lung disease (AoDILD) in patients with rheumatoid arthritis (RA) has been a serious concern, especially for those under treatment with biological agents which may affect the presentation and outcome of AoDILD, including Pneumocystis pneumonia (PCP). Therefore, we conducted a retrospective, multi-center study of AoDILD in RA patients receiving biological agents. METHODS: Patients who developed AoDILD while receiving biological agents (infliximab, etanercept, adalimumab and tocilizumab) were enrolled in the study. Definite PCP was defined as patients who showed either P. jirovecii organisms in their respiratory samples by microscopic examination, or positive tests for both P. jirovicii DNA-PCR with respiratory samples and an elevated serum 1,3-ß-D-glucan level above the cut-off value. Probable PCP was defined as either a positive test for P. jirovicii PCR or an elevated serum ß-D-glucan level. Chest HRCT findings were evaluated and scored by two board-certified radiologists. RESULTS: The final diagnoses for 26 patients examined were definite PCP for 13 patients, probable PCP for 11, and methotrexate-associated pneumonitis in 2 patients. Definite and probable PCP cases were clinically indistinguishable. Generalized, diffuse ground-glass opacity (GGO) is the characteristic HRCT finding in patients with definite or probable PCP, which was different from our previous findings in RA patients, mostly without biologics, showing GGO distributed in a panlobular or multilobular manner. The clinical outcome was favorable by treatment with trimethoprim-sulfamethoxazole and glucocorticoids. CONCLUSION: The possibility of PCP should be intensively investigated in RA patients developing AoDILD while receiving biological agents.
Assuntos
Artrite Reumatoide/complicações , Artrite Reumatoide/terapia , Produtos Biológicos/efeitos adversos , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/etiologia , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais/efeitos adversos , Antirreumáticos/efeitos adversos , Feminino , Humanos , Japão , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Doenças Pulmonares Intersticiais/terapia , Masculino , Pessoa de Meia-Idade , Pneumonia por Pneumocystis/diagnóstico por imagem , Pneumonia por Pneumocystis/terapia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
PURPOSE: To elucidate the clinical and radiological features of tuberculous pneumonia in patients with pulmonary emphysema. MATERIAL AND METHOD: Three emphysematous cases diagnosed with tuberculous pneumonia are clinically and radiologically reviewed. RESULT: Case 1 was a 62-year-old male with an infiltrate in the right upper lobe. A CT scan showed diffuse emphysema and a nonsegmental infiltrate without typical signs of bronchogenic spread. Sputum was negative for acid-fast bacilli. The infiltrate showed a nonsegmental spread unresponsive to antibiotics. Mycobacterium tuberculosis grew from a needle biopsy specimen five weeks after admission. The infiltrate disappeared with antituberculous treatment. Case 2 was an 82-year-old male, who presented with seven weeks of low-grade fever followed by high fever and lobar pneumonia in the right upper lobe. Sputum was positive for acid-fast bacilli on smear and tuberculosis PCR, leading to a diagnosis of tuberculous pneumonia. Case 3 was a 57-year-old male who had a history of dry cough lasting for one month. CT findings included a diffuse emphysematous change and a left upper lobe infiltrate, indistinguishable from bacterial pneumonia. His bronchoalveolar lavage was positive for tuberculosis PCR, which led to a diagnosis of tuberculous pneumonia. CONCLUSION: Tuberculous pneumonia in emphysematous patients can be nonsegmental, lacks bronchogenic spread, is indistinguishable from bacterial pneumonia, and clinically shows a poor inflammatory reaction, which is distinct from classical "caseous pneumonia.
Assuntos
Pneumonia Bacteriana/diagnóstico por imagem , Enfisema Pulmonar/complicações , Tuberculose Pulmonar/diagnóstico por imagem , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/complicações , Pneumonia Bacteriana/microbiologia , Radiografia , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/microbiologiaRESUMO
BACKGROUND: The clinical features of pneumocystis pneumonia (PCP) differ according to the predisposing factors responsible for immunosuppression. Although PCP in patients with acquired immunodeficiency syndrome (AIDS) has been extensively described, its characteristics in non-AIDS patients, such as those with malignancies, are not thoroughly documented. STUDY OBJECTIVE: To characterize and compare the clinical and imaging features of PCP in patients with malignancies with those in AIDS patients. DESIGN: A multi-center retrospective study. PATIENTS AND MEASUREMENTS: We evaluated the clinical and radiological features of PCP in 21 patients with malignancies and in 17 with AIDS. Clinical presentation, serum markers, oxygenation, CT findings, and outcome were examined. RESULTS: The patients with malignancies showed shorter durations of symptoms before PCP was diagnosed. The levels of serum markers and the oxygenation index did not differ. CT showed diffuse or widespread ground-glass opacity (GGO) in all of the patients evaluated. None of the AIDS patients demonstrated consolidation, whereas half of the patients with malignancy showed consolidation along with GGO. The extent of GGO scored on CT images was significantly greater in the AIDS patients. No correlation was observed between the CT findings and other clinical parameters. All of the AIDS patients recovered from PCP, whereas six patients with malignancies died within a month after the onset of PCP. CONCLUSION: The characteristics of the CT images differed between the patient groups with different underlying disorders, although it remains to be determined whether CT findings are associated with other clinical features or are predictive of the outcome of PCP.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Neoplasias/complicações , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/etiologia , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico por imagem , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Adulto , Anti-Infecciosos/uso terapêutico , Biomarcadores/sangue , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Pneumonia por Pneumocystis/diagnóstico por imagem , Pneumonia por Pneumocystis/tratamento farmacológico , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Combinação Trimetoprima e Sulfametoxazol/uso terapêuticoRESUMO
Pleuropulmonary paragonimiasis is a food-borne parasitic disease caused by the lung fluke Paragonimus westermani or other species of Paragonimus, which is endemic in Southeast Asia. It presents mainly pleural effusion or intrapulmonary nodules with respiratory symptoms. However, here we describe an exceedingly rare case of Paragonimus westermani with a mass in the pleural cavity. A 47-year-old man, who had presented with chest pain nine months earlier, was found to have right pleural effusion on detection survey computed tomography. He had a history of asbestos exposure and river fishing as a hobby and was confirmed to have Paragonimus westermani by immunodiagnosis. Because of a high level of hyaluronic acid in pleural effusion, he underwent a thoracoscopic examination. The pleura of the thoracic wall thickened greatly and showed no malignant lesion on biopsy. A white mass measuring 8 cm in diameter showed in the pleural cavity, which partially connected with the diaphragm and pulmonary pleura of the lower lobe. The postoperative pathological examination reported that the intrathoracic mass was a lesion that contained necrotic tissue enveloped with a fibrin capsule, which was thought to be formed by paragonimus.