Hematologic neoplasms: interpreting lung findings in chest computed tomography.

Lung disease is very common in patients with hematologic neoplasms and varies in function of the underlying disease and its treatment. Lung involvement is associated with high morbidity and mortality, so it requires early appropriate treatment. Chest computed tomography (CT) and the analysis of biologic specimens are the first line diagnostic tools in these patients, and sometimes invasive methods are necessary. Interpreting the images requires an analysis of the clinical context, which is often complex. Starting from the knowledge about the differential diagnosis of lung findings that radiologists acquire during training, this article aims to explain the key clinical and radiological aspects that make it possible to orient the diagnosis correctly and to understand the current role of CT in the treatment strategy for this group of patients.

[Changes in spirometric parameters and arterial oxygen saturation during a mountain ascent to over 3000 meters]. / Cambios espirométricos y en la saturación arterial de oxígeno durante la ascensión a una montaña de más de 3.000 metros.

OBJECTIVE: To ascertain whether climbing a mountain over 3000 meters high produces any alterations in ventilation, whether such alterations are modified by acclimatization, and whether they correlate with changes in arterial oxygen saturation (SaO2) or the development of acute mountain sickness (AMS). SUBJECTS AND METHODS: The following parameters were measured in 8 unacclimatized mountaineers who climbed Aneto (3404 m) and spent 3 days at the summit: forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), airway response to inhaled terbutaline, SaO2, and the symptoms of AMS. RESULTS: At the summit, mean (SD) FEV1 declined by 12.3% (5.7%) and mean FVC by 7.6% (6.7%) while the ratio of FEV1 to FVC remained normal. The means for both parameters were higher on the following day. No airway response to bronchodilator treatment was observed. The restriction disappeared entirely on descent. At the peak, SaO2 increased progressively as the climbers became acclimatized. During the ascent, FEV1 correlated with SaO2 (r=0.79). One participant who suffered from AMS had a ratio of FEV1 to FVC less than 70% and the worst SaO2 during the 3 days on the summit. Obstruction preceded the AMS symptoms, did not respond to bronchodilator treatment, and disappeared when the climber descended. CONCLUSIONS: The mountaineers who climbed over 3000 meters presented restriction that correlated with hypoxemia. This restriction did not respond to bronchodilator treatment, improved with acclimatization, and disappeared on descent. One person with AMS presented obstruction that did not respond to terbutaline and disappeared on descent.

Maximal static respiratory pressures in children and adolescents.

This study was designed to establish reference values of maximal static respiratory pressures in children and adolescents in our community, and compare them with previous studies. Participants were recruited from three schools (randomly chosen from those located in the metropolitan area of the city of Valencia) after appropriate consent. None of the participants had a previous history of pulmonary, cardiac, and/or skeletal abnormalities, and all of them had normal spirometry. Forced spirometry (Spirotrac III, Vitalograph) and maximal inspiratory (P(ImaxRV)) and expiratory (P(EmaxTLC)) pressure values (Sibelmed 163) were obtained by the same investigator, following national guidelines (SEPAR 1990).We studied 392 subjects (185 males, 207 females) whose ages ranged from 8-17 years. The reproducibility of measurements was investigated in a subgroup of 88 participants (randomly selected from the total sample, and stratified for age and gender) by means of the intraclass correlation coefficient (P(EmaxTLC), 0.98; P(ImaxRV), 0.95). P(EmaxTLC) and P(ImaxRV) values were significantly different between males and females (P < 0.0001) and were normally distributed. A stepwise, linear multiple regression model was built in each gender group (male/female) for the prediction of P(ImaxRV) and P(EmaxTLC) values. Independent variables (weight, height, and age) and their potential interactions were forced to enter the model in order to maximize the square of the multiple correlation coefficient of the resultant equation. This model turned out to be applicable (homoscedasticity, independence, and normality requirements) for P(ImaxRV) (in males and females) and for P(EmaxTLC) (in males but not in females). Variables included in the model were age and the product of weight and height. Their predictive power ranged between 0.21-0.51. In conclusion, P(ImaxRV) and P(EmaxTLC) values increase with age from 8 until 17 years. In all age groups, values were higher in males than in females. Weight, height, and age are included in the predictive equations for P(ImaxRV) (in males and females) and P(EmaxTLC) (in males). Their predictive value is similar to that reported by other authors and ranges between 0.21-0.51. This model is not suitable for the prediction of P(EmaxTLC) in females; the observed mean and range should be used instead.

Respiratory disorders in common variable immunodeficiency.

Common variable immunodeficiency (CVID) is a heterogeneous immunodeficiency syndrome characterized by hypogammaglobulinemia, recurrent bacterial infections, and various immunologic abnormalities. The clinical presentation is generally that of recurrent pyogenic sinopulmonary infections. Our objectives were to study the prevalence of lung involvement and the response to intravenous immunoglobulin replacement therapy in 19 patients with CVID. Nineteen patients (12 men) with a mean age (SD) of 33.1 (17.1) years had a previous diagnosis of CVID and were treated with intravenous immunoglobulin replacement. All patients underwent complete pulmonary function tests and high-resolution computed tomography (HRCT) examination. Bronchiectasis was diagnosed in 11 (58%) patients and eight (42%) were multi-lobar bronchiectasis. Chronic airflow limitation (CAL) was present in 10 (53%) patients and a restrictive pattern was seen in one case. Eleven patients (58%) presented a decrease in single-breath carbon monoxide diffusing capacity of the lung (DL(CO)). Before intravenous immunoglobulin replacement therapy (INIRT), 84% of patients had suffered from at least one episode of pneumonia. Episodes of lower respiratory tract infection decreased significantly from 0.28 per patient and year before replacement therapy to 0.16 per patient and year after treatment. The mean duration of replacement therapy was 7.5 years. In conclusion lung involvement was frequent in patients with CVID. Long-term administration of intravenous gammaglobulin resulted in a substantial reduction of pneumonic episodes.

[Cough-inducing capsaicin challenge test in a healthy population]. / Test de provocación tusígena con capsaicina: resultados en una población sana.

OBJECTIVE: Cough-inducing agents are used to study the cough reflex in both pharmacological and physiological research. Clinical use of cough challenge testing as a tool in diagnostic algorithms has been limited by the lack of either uniform methodology or reference values for healthy subjects. The objective of this study was to determine the cough threshold for capsaicin in a sample of healthy subjects, while also evaluating the influence of age, sex and smoking. We also assessed the reliability and repeatability of the test. MATERIAL AND METHODS: Ninety-two healthy subjects were enrolled and given a capsaicin challenge test using concentrations from 0.49 to 500mg. The concentrations of capsaicin that triggered two and five coughs, C2 and C5 respectively, were recorded. The test was repeated three days later in a sub-sample of 30 subjects. RESULTS: No subject showed clinical or functional signs of bronchoconstriction. The mean values obtained for the study population were log C2:1.5 +/- 0.69 mM. and log C5: 2.1 +/- 0.4 microM. The geometric means were 31.6 and 134.8 microM for C2 and C5, respectively. No significant differences were found for sex or smoking; however age was significantly related to log C5 (r: -0.27, p < 0.05). Repeatability of the capsaicin test was high, with intra-class correlation coefficients and 95% confidence intervals of 0.75 (0.53-0.87) and 0.88 (0.76-0.97)for C2 and C5, respectively. CONCLUSION: The capsaicin challenge test was safe and easy to administer,gave reproducible results and allowed us to obtain reference values for a healthy population in our community.

[Triiodothyronine intoxication. A clinical and phamacokinetic study]. / Intoxicación por triyodotironina. Estudio clínico y farmacocinético.

A woman, thyroidectomised because of a thyroid papillary carcinoma, interrupted temporarily her levothyroxine intake in order to be subjected to an extension study five weeks later. To minimise her symptoms for the first three weeks, a treatment was prescribed consisting of one 25 micro g-capsule of triiodothyronine every 8 hours. Nine days later she complained of abdominal pain, nausea, vomiting, fever of 40 degrees C and chest discomfort. A serum total triiodothyronine of 575.2 nmol/l was measured by chemoluminiscent immunoassay eleven hours after the intake of the latest capsule (normal level: 1.1-2.9 nmol/l). Along the following ten days the patient suffered from delirium, agitation, tachycardia, hypertension, constipation and later diarrhoea, but neither arrythmias nor axillary temperature over 38 degrees C. Fifty-nine measurements of the serum total triiodothyronine were performed in order to determine the kinetics of elimination of this drug. We estimate that the maximal serum concentration after the intake of the latest capsule could be 794.3 nmol/l, i.e. 397 times higher than the mean normal value. The elimination half-life was 24 hours 40 minutes. The charcoal haemoperfusion had no impact on the velocity of elimination. The concentration of triiodothyronine became normal 200 hours after the intake of the latest capsule, but the clinical manifestations still lasted three days more. The pharmacokinetic data suggest that this intoxication could be due to the intake of capsules containing 5 mg of triiodothyronine, i.e. a dose 200 times higher than that prescribed by her physician.

[The value of pulse oximetry during the performance of a forced spirometry maneuver]. / Valor de la pulsioximetría durante la realización de la maniobra de espirometría forzada.

Given that forced spirometry is the main routine exploration in any laboratory of pulmonary functional assessment, we have analyzed the behaviour of O2 arterial saturation (SaO2) during such maneuver in patients with airflow chronic obstruction (AFCO), in order to verify any potential alterations. We have studied three groups of patients: Group A, control, 17 healthy subjects; group B, 18 patients with AFCO and initial saturation higher than 90%; group C, 15 patients with AFCO and saturation equal to or lower than 90%. Total duration of the maneuver was significantly higher in groups B and C compared with the control group (p < 0.001). In groups A and B, we did not observed any significant reductions in SaO2 with respect to the initial value, although we did observed such differences in group C (p < 0.001). None of the patients presented a subjective clinical disorder, although the absence of both complexity and risk suggest the convenience of including the oximetry as an additional parameter when conducting a forced spirometry in patients with AFCO and respiratory failure.

[Cardiac tamponade caused by aortic pseudoaneurysm with fistula in the right ventricle]. / Taponamiento cardíaco por pseudoaneurisma aórtico fistulizado a ventrículo derecho.

A 69-year-old woman, with an aortic replacement valve for rheumatic aortic insufficiency suffered a sudden cardiac tamponade caused by a ruptured pseudoaneurysm of the ascending aorta which had its origin in the suture of the aorta performed 10 years earlier. The cardiac tamponade presented as syncope, absent central pulse, and respiratory failure. Hemodynamic variables recovered with early detection and start of cardiopulmonary resuscitation maneuvers. After fluids were replaced and following catecholamine treatment, a transesophageal echocardiogram revealed a pseudoaneurysm and continuous flow between the aorta and the right ventricle. The aneurysm and an unusual right ventricular fistula were repaired surgically through an emergency exploratory sternotomy. Cardiovascular recovery was satisfactory although hospital discharge was delayed because of pulmonary complications leading to severe hypoxia, pleural effusion, and pneumonia, with tracheal aspirate and bronchoalveolar lavage cultures positive for Pseudomonas aeruginosa, Acinetobacter spp, and Aspergillus flavus. We stress that immediate start of cardiopulmonary resuscitation prevented multiorgan failure and allowed for satisfactory recovery from surgery in spite of the presence of risk factors for mortality.

[Arterial oxygen saturation during ascent of a mountain higher than 8,000 meters]. / Saturación arterial de oxígeno durante la ascensión a una montaña de más de 8.000 metros.

BACKGROUND: Arterial oxygen saturation (SaO2) diminishes with altitude. AIM: To know the values of SaO2 in healthy mountaineers during the ascent of a mountain higher than 8,000 metres. METHOD: On occasion of an expedition to Gasher brum II (8,035 m), SaO2 at rest was measured by pulse oxymetry during the approach march, in the base camp (on day one and one month later), in camps II and III, during the assault at 7,500 m and on the summit. RESULTS: During the approach march, the SaO2 in Paiju (3,365 m) was 92.9 +/- 1.4% and in Gore II (4,250 m) 85.0 +/- 4.3%. In the base camp (5,200 m) it was 78.4 +/- 9.5% on the first day and 87.4 +/- 3.0% one month later (p < 0.007). In camp II (6,500 m) it was 72.7 +/- 6.7%. In camp III (7,000 m) it was 68.0 +/- 9.3% (recorded on 21 asymptomatic climbers). At this altitude a SaO2 of 40% was recorded during sleep in an asymptomatic subject, apparently without apnoeic crises. During the assault at 7,500 m, SaO2 was 60.5 +/- 13.5% (measured on 4 climbers). On the summit (8,035 m) the SaO2 of two subjects was 84% and 88%, respectively. CONCLUSION: During expeditions to mountains higher than 8,000 metres, mountaineers have extremely low values of SaO2, similar to those of patients with severe respiratory failure. SaO2 increases progressively with acclimatization. SaO2 on the summit could have been relatively high, probably because of hyperventilation.

Effects of air pollution and weather conditions on asthma exacerbation.

BACKGROUND: Meteorological conditions and a high concentration of air pollutants have been associated with increased respiratory morbidity. However, few studies have examined the association between asthma exacerbation and air pollution. OBJECTIVES: In the present study, the possible relationship of the concentration of black smoke and SO2 in the air, the local weather conditions and emergency room visits for asthma is investigated. METHODS: The weekly total of emergency room admissions for asthmatic adults during a 1-year period was recorded together with daily metereological conditions (average temperature, humidity, rainfall, wind speed and barometric pressure) and average weekly levels of daily pollutant concentrations (black smoke and SO2). The relationship was assessed by stepwise regression linear models and analysis of variance. The analysis took into account season and metereological variables. RESULTS: Both air pollutants correlated significantly with emergency room admissions for asthma (SO2 [r = 0. 32], black smoke [r = 0.35]); however, multiple regression analysis showed that black smoke was the only significant predictor of weekly visits. There were approximately 3.5 admissions a week per SD of change (34.6 microg.m-3). There were no significant correlations between weekly emergency room visits and the weather variables. Analysis of the data stratified by season and weather conditions demonstrated that the association of black smoke with asthma exacerbation was more pronounced in autumn (r = 0.67) or when temperatures were higher than average. CONCLUSION: In our city, a high concentration of certain air pollutants is indeed associated with an increase in the number of hospital emergency room admissions for asthma.

[Risk factors for lung toxicity in pediatric cancer survivors]. / Factores de riesgo para toxicidad pulmonar en supervivientes de cáncer pediátrico.

OBJECTIVE: Our objectives were to determine the prevalence of alterations in lung function among pediatric cancer survivors with known risk factors and to establish clinical and imaging correlations, as well as to establish follow-up criteria. PATIENTS AND METHODS: Cancer survivors diagnosed at the Pediatric Oncology Unit between 1971 and 1997 who fulfilled at least one of the following criteria were eligible: 1) primary lung or thoracic wall neoplasm; 2) lung metastasis at diagnosis or later, or; 3) irradiation of mediastinum and/or lung fields. Assessment included respiratory symptomatology questionnaire, physical examination, forced spirometry, static lung volumes, maximal static respiratory pressures, single breath CO diffusing capacity, pulse oximetry and imaging studies. RESULTS: Thirty-five (14 females and 21 males) out of 41 survivors were assessed. Mean age at diagnosis, evaluation and follow-up were 9 (1-14), 18 (10-28) and 9 (3-27) years, respectively. The diagnoses included pleuropulmonary blastoma (1), chest wall Ewing's sarcoma (1), Hodgkin's disease (18), nephroblastoma (7), yolk-sac tumor (2), acute leukemia2), non-Hodgkin's lymphoma (1), rhabdomyosarcoma (1), coriocarcinoma of the ovary (1) and osteosarcoma (1). Thirteen patients presented lung metastasis at diagnosis or later. All were administered chemotherapy. Irradiated fields were the mediastinum (dose 20-56 Gy) in 20 cases, the lung (8-30 Gy) in 6 and the spine (24 Gy) in one. Eight underwent thoracotomy. Fourteen percent were dyspneic when walking at the same rate as a person of the same sex and age (grade 2). Twenty percent had a restrictive ventilatory disorder, but none were obstructive. The presence of dyspnea had sensitivity, specificity, positive predictive values and negative predictive value for the diagnosis of restrictive ventilatory disorder of 67%, 96%, 80% and 93%, respectively. Lung irradiation was associated with an increased risk for the development of restrictive disease. Excluding those who received lung irradiation, survivors under 6 years of age at diagnosis obtained lower spirometric values, lung volumes and DLCO values than survivors aged 6 years or older at diagnosis. There were no differences in pulmonary function values between survivors who received mediastinum irradiation and those who did not. The cumulative dose of cyclophosphamide significantly correlated with FVC, FEV1 and FRC. Pulse oximetry values were > or = 95% in all survivors. Maximal static respiratory pressures were within normal limits in all but one survivors whose other pulmonary function results were normal. Thirty-two percent (11 out of 34) had KCO (diffusing capacity adjusted to alveolar volume) values lower than 80% of reference values. Two survivors of nephroblastoma with pulmonary metastasis and who underwent lung irradiation had radiological signs of lung fibrosis. CONCLUSIONS: Pediatric cancer survivors who were administered intensive chemotherapy and/or lung irradiation are eligible for follow-up of lung function. Those diagnosed before 6 years of age and/or with moderate dyspnea are at high risk of having pulmonary restrictive disease. Imaging studies (chest X-ray) have a low sensitivity that prevents their use as a screening method in the follow-up of cancer survivors.