Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is a chronic smoking-related lung disease associated with significant mortality and morbidity. It carries an enormous economic burden on the health care system. This results in a significant social impact on affected patients and their families. In this article, we review COPD in general, critical care management of patients presenting with acute exacerbation of COPD, and methods of prevention.

Lemierre's Syndrome: A Case Series.

Lemierre's syndrome (LS) is a potentially fatal complication of oropharyngeal infection, resulting in contiguous suppurative thrombosis of the internal jugular vein (IJV) and septic emboli. It is most commonly associated with Fusobacterium necrophorum (F. necrophorum), though other pathogens have also been implicated in its pathogenesis. The incidence of LS had so significantly decreased that it was referred to as "the forgotten disease." However, cases of LS have shown a resurgence, which may be partly attributed to an overreliance on a negative group A beta-hemolytic streptococcal rapid antigen detection test (RADT), commonly referred to as "rapid strep test." Clinicians must maintain a very high index of suspicion for LS in patients with persistent sequelae from tonsillopharyngitis who have a negative RADT.

Management of the patient undergoing lung transplantation: an intensive care perspective.

The postoperative management of a patient undergoing lung transplantation involves many components of care. These components include ventilatory and hemodynamic management, immunosuppression, wound care, rehabilitation, infection control and treatment, and early detection of rejection.

One of the Largest Pancreatic Pseudocysts in the Literature: A Case Report.

The pancreatic pseudocyst is a pancreatic fluid collection which classically develops due to acute or chronic pancreatitis. A 68-year-old male with the remote history of alcohol abuse presented with abdominal pain secondary to acute pancreatitis. The first computed tomography (CT) of the abdomen showed acute necrotizing pancreatitis. He was initially treated conservatively. Repeat CT of the abdomen after two weeks revealed a peripancreatic fluid collection of 20x12x10 cm. One month later, he became septic following biliary stent placement. Repeat CT of the abdomen showed an enlarging pseudocyst of 25x20x14 cm (estimated 7000 mL of fluid). Percutaneous CT-guided cyst drainage was performed and only three liters of infected fluid could be drained which eventually grew Enterococcus faecalis. Due to lack of improvement, he underwent laparotomy with pancreatic necrosectomy, pseudocyst debridement, and cholecystectomy. The patient did well postoperatively and until one-year follow-up visit. The largest pancreatic pseudocyst in the literature (about 9500 mL) was reported in 1882. To our knowledge, this case is the second largest pseudocyst in the literature which was successfully managed by surgical resection.

Mesenchymal cystic hamartoma of the lung.

Mesenchymal cystic hamartoma, although first reported as early as 1980s, remains a very rare lung disease. There have been less than 20 cases reported to date. Mesenchymal cystic hamartoma usually has an indolent course, but it could potentially result in morbidity and mortality. Biopsy is needed to confirm the diagnosis because it is essential to rule out other possibilities including malignancy.

Oligoclonal CD4(+) T cell expansions in lung transplant recipients with obliterative bronchiolitis.

Obliterative bronchiolitis (OB) is a dreaded and frequent complication of lung transplantation with a poorly understood immunopathogenesis. To further evaluate disease mechanisms, we used T cell antigen receptor (TCR) beta-chain variable region RNase protection assays, after polymerase chain reaction amplification of TCR cDNA, to quantitate circulating CD4(+) and CD8(+) repertoires of transplant recipients with OB or no evidence of rejection (NER). All six recipients with OB had markedly abnormal CD4 expansions (2.5 +/- 0.5 expansions/recipient) attributable to oligoclonal proliferations. Only two of six recipients with NER had a single, much lesser, CD4(+) abnormality each (p < 0.01). Moreover, one of these patients developed OB shortly thereafter, and the other NER abnormality may have predated transplantation. In contrast, CD8(+) expansions were common in both recipient populations. Findings of CD4(+) expansions had 100% sensitivity and 80% specificity for the presence or imminent development of OB. These data suggest proliferations of CD4(+) T cells are important in OB pathogenesis, and these are most likely part of a major histocompatibility complex Class II-dependent process of indirect alloantigen presentation. These CD4(+) clones are likely to have facultative helper functions for the multiple and diverse immune processes that have been implicated in OB. Furthermore, the close association of CD4(+) expansions with OB raises possibilities of development of novel diagnostic and therapeutic approaches.