PRevalence of the Eosinophilic Phenotype Among SeveRE asthma patients in Lebanon: results of the PREPARE study.

BACKGROUND: The prevalence of eosinophilic asthma in Lebanon, one of the most severe phenotypes among severe asthma, is not known. This study aimed at determining the prevalence of the eosinophilic phenotype defined as an eosinophil count ≥ 300 cells/mm3 among severe asthma patients in Lebanon. METHODS: The Lebanese Chapter of the PREPARE study was a national, multicenter, cross-sectional observational study. Patients aged ≥ 12 years with severe asthma were identified and prospectively enrolled during clinic visits and completed the Global Initiative for Asthma (GINA) assessment of asthma control questionnaire. Patients' health characteristics were collected from medical records and blood samples were obtained for measurement of serum IgE levels and blood eosinophils count. RESULTS: Overall, 101 patients (with mean age of 46.3 ± 17.0 years and 73.27% females) with severe asthma were included and, among them, 37% had eosinophilic phenotype, 67.3% had atopic phenotype with IgE > 100 IU/mL and 25.7% patients had overlapping atopic and eosinophilic phenotypes. Close to 80% had late-onset asthma, beyond 12 years of age, and around 85% had at least one severe exacerbation in the 12 months prior to study enrolment. The majority of participants [64.4%] had uncontrolled asthma, 24.7% had partially controlled symptoms and 10.9% had controlled symptoms. 19.8% of participants were on chronic oral corticosteroids, 78.2% had short course treatment of corticosteroids and all were prescribed a combination of inhaled corticosteroids and long-acting beta-agonist. CONCLUSIONS: The majority of patients with severe asthma were uncontrolled of which 37% present with an eosinophilic phenotype, which should be taken into consideration for better management of these patients in view of the novel phenotype-specific therapeutic options.

Hepatic Hydrothorax: An Updated Review on a Challenging Disease.

Hepatic hydrothorax is a challenging complication of cirrhosis related to portal hypertension with an incidence of 5-11% and occurs most commonly in patients with decompensated disease. Diagnosis is made through thoracentesis after excluding other causes of transudative effusions. It presents with dyspnea on exertion and it is most commonly right sided. Pathophysiology is mainly related to the direct passage of fluid from the peritoneal cavity through diaphragmatic defects. In this updated literature review, we summarize the diagnosis, clinical presentation, epidemiology and pathophysiology of hepatic hydrothorax, then we discuss a common complication of hepatic hydrothorax, spontaneous bacterial pleuritis, and how to diagnose and treat this condition. Finally, we elaborate all treatment options including chest tube drainage, pleurodesis, surgical intervention, Transjugular Intrahepatic Portosystemic Shunt and the most recent evidence on indwelling pleural catheters, discussing the available data and concluding with management recommendations.

Migrating gossypiboma mimicking aspergilloma twenty years after mediastinal surgery.

A gossypiboma refers to a surgical sponge or gauze accidentally retained inside a patient during a procedure. It is more commonly encountered after abdominal surgeries. When seen in the thorax, it is usually located within the pleural cavity. We report a case of a 42-year old woman who was found to have a gossypiboma mimicking a simple aspergilloma twenty years after a left thoracotomy. The surgical gauze identified on a CT-scan of her chest appears to have migrated into her lung airways.

Traumatic Pulmonary Pseudocyst Mimicking a Congenital Cystic Lung Disease.

Traumatic pulmonary pseudocyst (TPP) is a rare entity that occurs following a trauma to the chest. It usually presents as multiple cystic lesions on thoracic imaging. It is treated conservatively and tends to completely resolve after few months. In the absence of striking signs of trauma such as rib fractures, TPP can be mistaken for other cystic lung diseases. We present a case of TPP in a 17-year-old male who was seen for mild hemoptysis after falling off a cliff. The extent of his right lower lobe cystic lesions along with the lack of major signs of trauma led to an incorrect diagnosis of congenital pulmonary airway malformation. The patient was considered for lobectomy, which he refused. Imaging of the chest repeated one and three years later showed complete resolution of the lesions.

Emergence of Mycobacterium simiae: A retrospective study from a tertiary care center in Lebanon.

OBJECTIVE: The objective of this study is to describe the clinical significance of Mycobacterium simiae at a major tertiary care center in Lebanon. METHODS: This is a retrospective study of patients with positive cultures for M. simiae isolated between 2004 and 2016 at the American University of Beirut Medical Center. RESULTS: This study included 103 M. simiae isolates recovered from 51 patients. Their mean age was 62.7 years. The majority were males and smokers. Specimens were mostly from respiratory sources (97%). Common comorbidities included chronic lung disease (such as chronic obstructive pulmonary disease), solid tumor, systemic disease, and diabetes mellitus. Productive cough and dyspnea were the most common symptoms. Frequent radiographic findings were infiltrates and nodules on chest X-ray and nodules, infiltrates, and bronchiectasis on chest computed tomography scan. Among 18 tested isolates, 5.8% were resistant to clarithromycin, 11.7% to amikacin, and 70-100% to other antimicrobials. Out of 13 patients receiving early treatment, 5 noted improvement, one had recurrence of symptoms, two received alternative diagnosis, and five died. Two of those deaths were related to M. simiae. Common treatment regimens included clarithromycin in different combinations with trimethoprim-sulfamethoxazole, moxifloxacin, and amikacin. Moreover, clofazimine was used in only two patients whose isolates were resistant to all but one agent. Duration of treatment ranged from 6-24 months. CONCLUSION: In Lebanon, M. simiae is increasingly encountered with true infection rates of at least 47%. Furthermore, the prevalence of multidrug resistance among the Lebanese M. simiae isolates is very high limiting the treatment options.

Indolent lung opacity: Ten years follow-up of pulmonary inflammatory pseudo-tumor.

Inflammatory pseudotumor (IPT) has always been considered a diagnostic challenge. Its rarity and resemblance to other more common pathological entities imposes that neither clinical nor radiological characteristics can lead to a definitive diagnosis. The surgical excision of the lesion is the ultimate approach for accurate diagnosis and cure. Moreover the true nature of IPT, its origin as a neoplastic entity or an over-reactive inflammatory reaction to an unknown trigger, has been a long debated matter. Surgery remains the treatment of choice. IPT is mostly an indolent disease with minimal morbidity and mortality. Local invasion and metastasis predict a poor prognosis. We hereby present a unique case of pulmonary IPT that was surgically excised, but recurred contralaterally, shortly thereafter. Despite no medical or surgical treatment for ten years, the lesion has remained stable in size, with neither symptoms nor extra-pulmonary manifestations.

Phonatory Symptoms and Acoustic Findings in Patients with Asthma: A Cross-Sectional Controlled Study.

To investigate the prevalence of phonatory symptoms, perceptual, acoustic and aerodynamic findings in patients with asthma compared to a control group. This study is a cross-sectional study. A total of 50 subjects, 31 asthmatic and 19 control subjects matched according to age and gender were enrolled in this study. All subjects were asked about the presence or absence of dysphonia, vocal fatigue, phonatory effort, cough, dyspnea, and respiratory failure. Perceptual evaluation, acoustic analysis and aerodynamic measurements were also performed. Patient's self assessment using the Voice Handicap Index 10 was reported. The mean age of patients was 43.5 years with a female to male ratio of 2:1. There was a statistically significant difference in the prevalence of dysphonia between the two groups (32.3 vs. 5.3%, p value 0.025) with a non-significant higher prevalence of vocal fatigue and phonatory effort. The overall grade of dysphonia was significantly higher in asthmatics compared to controls (p value 0.002). Patients with asthma had also significantly higher degree of asthenia and straining (p value of 0.04 and 0.008, respectively) with borderline significant difference with respect to roughness. There was no significant difference in the means of any of the acoustic parameters between patients and controls except for Shimmer, which was higher in the asthmatic group (p value of 0.037). There was also no significant difference in the Maximum phonation time between the two groups. Dysphonia is significantly more prevalent in patients with asthma compared to controls.

Laryngopharyngeal symptoms in patients with asthma: a cross-sectional controlled study.

OBJECTIVE: To examine the frequency and severity of laryngopharyngeal symptoms in asthmatic patients. The role of laryngopharyngeal reflux disease as a co-morbid disease to asthma has not been previously reported. SUBJECTS AND METHOD: Seventy-two subjects, 36 asthmatics and 36 controls were included in this study. Demographic data included age, gender, status of asthma, use of steroid inhalers, smoking and history of allergy. Pulmonary function test was reported in 13 subjects. The evaluation consisted of filling the Reflux Symptom Index (RSI) described by Belafsky et al. The total score, frequency and average score of each laryngopharyngeal symptom was computed in both groups. RESULTS: The mean age of patients was 46.61 ± 17.59 years with a female to male ratio of 2.3:1. Twenty patients were using steroid inhalers. Close to one third were smokers (30.6%) and 55.6% had allergic rhinitis. Thirty-six percent had controlled asthma vs 64% were uncontrolled. The mean of the total RSI was significantly higher in patients compared with controls (12.03 ± 8.3 vs 6.64 ± 6.08, P value < 0.05). In the asthmatic group, 15 subjects had a positive RSI compared with only 4 in the control group (P value of 0.003). There was a significant difference in the prevalence and means of four laryngopharyngeal symptoms in patients vs controls. CONCLUSION: Laryngopharyngeal reflux disease is more prevalent and more severe in patients with asthma vs controls.

Pulmonary Embolism in a Sarcoidosis Patient Double Heterozygous for Methylenetetrahydrofolate Reductase Gene Polymorphisms and Factor V Leiden and Homozygous for the D-Allele of Angiotensin Converting Enzyme Gene.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology and pathogenesis. It presents in patients younger than 40 years of age. The lungs are the most commonly affected organ. Till the present day, there is no single specific test that will accurately diagnose sarcoidosis; as a result, the diagnosis of sarcoidosis relies on a combination of clinical, radiologic, and histologic findings. Patients with sarcoidosis have been found to have an increased risk of pulmonary embolism compared to the normal population. MTHFR and factor V Leiden mutations have been reported to increase the risk of thrombosis in patients. We hereby present a case of a middle aged man with sarcoidosis who developed a right main pulmonary embolism and was found to be double heterozygous for methylenetetrahydrofolate reductase gene polymorphisms and factor V Leiden and homozygous for the D-allele of the angiotensin converting enzyme gene.

The growing epidemic of water pipe smoking: health effects and future needs.

Water pipe smoking (WPS), an old method of tobacco smoking, is re-gaining widespread popularity all over the world and among various populations. Smoking machine studies have shown that the water pipe (WP) mainstream smoke (MSS) contains a wide array of chemical substances, many of which are highly toxic and carcinogenic for humans. The concentrations of some substances exceed those present in MSS of cigarettes. Despite being of low grade, current evidence indicates that WPS is associated with different adverse health effects, not only on the respiratory system but also on the cardiovascular, hematological, and reproductive systems, including pregnancy outcomes. In addition, association between WPS and malignancies, such as lung, oral and nasopharyngeal cancer, has been suggested in different studies and systematic reviews. Despite its long standing history, WPS research still harbors a lot of deficiencies. The magnitude of toxicants and carcinogen exposures, effects on human health, as well as the addiction and dependence potentials associated with WPS need to be studied in well-designed prospective trials. Unfortunately, many of the tobacco control and clean indoor policies have exempted water pipes. World wide awareness among the public, smokers, and policymakers about the potential health effects of WPS is urgently required. Furthermore, stringent policies and laws that control and ban WPS in public places, similar to those applied on cigarettes smoking need to be implemented.

Effect of heliox- and air-driven nebulized bronchodilator therapy on lung function in patients with asthma.

BACKGROUND: This study compares the effect of heliox-driven to that of air-driven bronchodilator therapy on the pulmonary function test (PFT) in patients with different levels of asthma severity. METHODS: One-hundred thirty-two participants were included in the study. Participants underwent spirometry twice with bronchodilator testing on two consecutive days. Air-driven nebulization was used one day and heliox-driven nebulization the other day in random order crossover design. After a baseline PFT, each participant received 2.5 mg of albuterol sulfate nebulized with the randomized driving gas. Post bronchodilator PFT was repeated after 30 min. The next day, the exact same protocol was repeated, except that the other driving gas was used to nebulize the drug. Participants were subgrouped and analyzed according to their baseline FEV(1) on day 1: Group I, FEV(1) ≥80 %; Group II, 80 % > FEV(1) > 50 %; Group III, FEV(1) ≤50 %. The proportion of participants with greater than 12 % and 200-mL increases from their baseline FEV(1) and the changes from baseline in PFT variables were compared between heliox-driven versus air-driven bronchodilation therapy. RESULTS: The proportion of participants with >12 % and 200-mL increases from their baseline FEV(1) with air- or heliox-driven bronchodilation was not different with respect to the proportion of participants with baseline FEV(1) ≥80 % (20 vs. 18 %, respectively) and 80 % > FEV(1) > 50 % (36 vs. 43 %, respectively), but it was significantly greater with heliox-driven bronchodilation in participants with FEV(1) ≤50 % (43 vs. 73 %, respectively; p = 0.01). Changes from baseline FVC, FEV(1), FEV(1)/FVC, FEF(25-75) %, FEF(max), FEF(25) %, FEF(50) %, and FEF(75) % were significantly larger with heliox-driven versus air-driven bronchodilation in participants with baseline FEV(1) ≤50 %. CONCLUSION: Improvements in PFT variables are more frequent and profound with heliox-driven compared to air-driven bronchodilator therapy only in asthmatic patients with baseline FEV(1) ≤50 %.

Disseminated mycobacterium tuberculosis: Pulmonary and musculoskeletal infections in a previously healthy man.

UNLABELLED: Chest wall masses are an uncommon result of Mycobacterium tuberculosis (MTB) infection especially in immune-competent patients. Herein, we report a case of 47-year-old previously healthy man who presented with an anterior chest wall mass, along with a swelling of the left fourth finger. MTB was recovered from the patient's sputum and from the aspirate of the chest wall mass. Four anti-tuberculous drugs for 2 months then 2 drugs for 7 months resulted in complete resolution of both masses with no need for surgical resection. CONCLUSION: MTB can present in disseminated form in a healthy man and treated with quadruple anti-tuberculous medications without surgical intervention.

[Tobacco: its control is urgently needed].

Smoking is a chronic disease that kills five million yearly. Nicotine is responsible for the addictive part. Smoking is quite neglected, due to its predominance in poor and underdeveloped countries. Available smoking cessation programs have a limited role to play. Fighting tobacco dependence requires a multidisciplinary approach involving awareness campaigns, enforcing no smoking laws in public places, raising taxes and careful watching of our kids not to get addicted.

Severe hemophagocytic syndrome developing after treatment initiation for disseminated Mycobacterium tuberculosis: case report and literature review.

We describe a case of a young male with disseminated tuberculosis and severe secondary hemophagocytic syndrome. He presented with symptoms of tuberculosis and Mycobacterium tuberculosis was diagnosed. Later, while on anti-tuberculous treatment, he developed pancytopenia and bone marrow aspirate showed large macrophages with increased phagocytosis of mature and immature blood elements typical of hemophagocytic syndrome.

Metabolic and respiratory variables during pressure support versus synchronized intermittent mandatory ventilation.

BACKGROUND: Mechanically ventilated patients interact and respond differently to different modes of ventilatory support. OBJECTIVES: To assess changes in metabolic and respiratory variables during equivalent changes with either pressure support ventilation (PSV) or volume-cycled synchronized intermittent mandatory ventilation (SIMV) in non-tracheostomized patients without known obstructive pulmonary disease receiving short-term mechanical ventilation in the intensive care unit. METHODS: Fourteen patients receiving volume-cycled SIMV at 12 breaths/min (SIMV(100%)) were included in the study. The PSV level (PSV(100%)) resulting in a minute volume and respiratory rate equivalent to that during SIMV(100%) was determined for each patient. Then each patient underwent trials at 66% and 33% of initial ventilator support with volume-cycled SIMV (SIMV(66%) and SIMV(33%)) and PSV (PSV(66%) and PSV(33%)) in random order. At the end of each trial, oxygen consumption ((.)VO2), carbon dioxide production ((.)VCO2), measured energy expenditures (MEE), peak inspiratory flow, total respiratory frequency, tidal volume, minute ventilation, occlusion pressure (P(0.1)) and inspiratory duty cycle (T(i)/T(tot)) were measured. RESULTS: There were smaller changes in (.)VO2, (.)VCO2 and MEE when equivalent changes were applied with PSV (15.7 +/- 4.4; 12.5 +/- 2.2 and 15 +/- 3.5%) compared with volume-cycled SIMV (32.7 +/- 7.7; 23 +/- 5.2 and 30.7 +/- 6.8%; p < 0.05). P(0.1) and T(i)/T(tot) were significantly smaller during PSV (2.64 +/- 0.28 and 0.38 +/- 0.03 cm H(2)O) than volume-cycled SIMV (4.01 +/- 0.21 and 0.43 +/- 0.02 cm H2O; p < 0.05). CONCLUSIONS: Changes in the level of PSV resulted in smaller changes in metabolic and respiratory variables compared with equivalent changes in the level of volume-cycled SIMV support. PSV may be more suitable for progressive respiratory muscle reloading.

Familial idiopathic pulmonary fibrosis in three Lebanese siblings. Case report with long-term follow-up.

This is the first report of a familial cluster of idiopathic pulmonary fibrosis (IPF) in Lebanon. This rare variant of IPF has an autosomal dominant mode of inheritance with variable expressivity, and is commonly associated with a mutation of the surfactant protein C gene. The patients are younger at diagnosis but have otherwise identical clinical, radiological, and histological features as the more common non-familial cases. IPF is an invariably fatal disease with no effective treatment. Lung transplantation remains the only chance for more prolonged survival and must be considered in young patients.