Bochdalek hernia masquerading as pleural effusion in a young adult.

Bochdalek hernia (BH) is a congenital diaphragmatic hernia which rarely presents in adulthood. We report on a 25-year-old man admitted with 3-year recurrent and self-limiting abdominal pain and vomiting. Chest radiograph showed left pleural opacity which shifted position in the decubitus film suggesting pleural effusion. Before attempting drainage, point-of-care (POC) thoracic ultrasound (TUS) demonstrated features of intrathoracic gastrointestinal content above the left hemi-diaphragm. Computed tomography of the thorax confirmed a large left BH. Acute recurrent symptoms 3 months post-discharge was associated with BH enlargement and early bowel ischemia, which was successfully managed by emergency surgery. This case illustrates the importance of pre-procedural imaging with POC-TUS before pleural procedures in all cases of suspected or apparent pleural effusion, and of prompt surgical treatment of symptomatic BH despite clinical stabilization.

Prevalence, risk factors, and recurrence risk of persistent air leak in patients with secondary spontaneous pneumothorax.

Background: Persistent air leak (PAL) is common in secondary spontaneous pneumothorax (SSP), with risk factors only been determined for post-pulmonary resection PAL. Information about its risk factors and long-term outcome is, however, necessary to enable selection of treatment modalities for elderly SSP patients with comorbid conditions. Methods: A retrospective observational study was performed on chest drain-treated SSP patients from 2009 to 2018. The risk factors, long-term recurrent pneumothorax, and mortality rates of those with and without PAL were evaluated. Results: Of 180 non-surgical SSP patients, PAL prevalence for >2 days and >7 days were 81.1% and 43.3%, respectively. Bulla was associated with PAL >7 days (OR: 2.32; P: 0.027) and serum albumin negatively associated (OR: 0.94; P: 0.028). PAL resulted in longer hospitalization in the index episode (P: <0.01). PAL >7 days was associated with a higher pneumothorax recurrence rate in three months (HR: 2.65; P: 0.041), one year (HR: 2.50; P: 0.040) and two-year post-discharge (HR: 2.40; P: 0.029). Patients treated with medical pleurodesis were significantly older (P: <0.01), had higher Charlson Co-morbidity index scores (P: <0.01), and 77.8% of those who had PAL >7 days were considered unfit for surgery. Of these, pneumothorax had not recurred in 69.4% after two years (HR: 0.47; P: 0.044). Conclusion: Bulla was positively associated with PAL over seven days in SSP patients while albumin was negatively associated. PAL over seven days increased future recurrent pneumothorax risks, while elderly SSP patients unfit for surgery had acceptable recurrence rates after medical pleurodesis.

Variability of the prevalence of undiagnosed airflow obstruction in smokers using different diagnostic criteria.

PURPOSES: To estimate the prevalence of undiagnosed airflow obstruction (AFO) in Hong Kong smokers with no previous diagnosis of respiratory disease, and to assess its variability when applying different prediction equations and diagnostic criteria. METHODS: A multicenter, population-based, cross-sectional prevalence study was performed in smokers aged 20 to 80 years. Three different criteria (fixed 70% [Global Initiative for Chronic Obstructive Lung Disease and British Thoracic Society], fixed 75%, and European Respiratory Society [ERS]) were applied to define a lower limit of normal (LLN) of the FEV(1)/FVC ratio to compare with the Hong Kong Chinese reference equation (criterion 1), which had used a distribution-free method to obtain the lower fifth percentile of FEV(1)/FVC ratio as the LLN. RESULTS: In 525 male patients, using criterion 1 (local internal prediction equation) and defining AFO as FEV(1)/FVC less than LLN, the overall prevalence of AFO was 13.7%: 8.3% in age > or = 20 to 40 years, 14.0% in age > or = 40 to 60 years, and 17.8% in age > or = 60 to 80 years. When the local internal prediction equation was used as the comparison reference, the fixed-ratio methods tended to miss AFO in younger age groups and overdiagnose AFO in old age, while the ERS criteria, which uses an almost lower fifth percentile-equivalent method, showed less of such a trend but still only showed moderate agreement with criterion 1. CONCLUSIONS: Undiagnosed AFO was prevalent in Hong Kong smokers. Estimated prevalence rates were highly affected by the criteria used to define AFO. The predicted lower fifth percentile values calculated from a local reference equation as the LLN of FEV(1)/FVC ratio should be used for the diagnosis of AFO.

Pseudallescheria boydii or Aspergillus fumigatus in a lady with an unresolving lung infiltrate, and a literature review.

A 53-year-old lady with blood-stained sputum and pleuritic pain had a lingular opacity on CXR which failed to resolve. A bronchial aspirate and transbronchial biopsy revealed features of bronchocentric granulomatosis with dichotomous branching hyphae suggestive of Aspergillus infection. However, subsequent fungal culture grew Pseudallescheria boydii. This case demonstrates the similarity of clinical and histological features caused by these two fungi. This appears to be the first reported case of pulmonary pseudallescheria with a bronchocentric granulomatous response.

Coronary plaque instability in severe acute respiratory syndrome.

In his second week of severe acute respiratory syndrome (SARS) illness, a patient developed an unusually complicated course of acute coronary syndrome. One day after initial stabilization of a non-ST-elevated anterior myocardial infarction (MI), he sustained an ST-elevated anterior MI. Eight hours after emergency coronary intervention to the culprit lesion, he developed another ST-elevated MI in the inferior territory. Acute inflammation and cytokine storm in the immunopathological phase of SARS may play a role in coronary plaque instability. Physicians should be alert to this potentially fatal complication and adopt appropriate vigilant and aggressive management strategies.

Preparedness of the cardiac catheterization laboratory for severe acute respiratory syndrome (SARS) and other epidemics.

Severe acute respiratory syndrome (SARS) is a highly contagious disease that has led to large hospital and community outbreaks, necessitating stringent infection control in its management. Among 90 SARS patients in our institution in the 2003 outbreak, 2 underwent cardiac catheterization. We report the personal respiratory protection and environmental control measures implemented to minimize the risk of droplets spread during these procedures, including re-engineering of the ventilation system of the cardiac catheterization laboratory (CCL). The report highlights the importance of collaboration of CCL personnel with relevant hospital engineering and management teams to develop a contingency infection control plan to prepare for future outbreaks of SARS or other epidemics.

Altered exercise gas exchange as related to microalbuminuria in type 2 diabetic patients.

STUDY OBJECTIVE: Microalbuminuria in diabetes mellitus is a risk factor for cardiovascular disease. We hypothesized that microalbuminuria in type 2 diabetic patients is related to impaired cardiopulmonary function during exercise, and that the severity of impairment is correlated with the degree of microalbuminuria. DESIGN: Twenty of each of the following categories of subjects performed symptom-limited cardiopulmonary exercise testing on a cycle ergometer: (1) type 2 diabetic patients with normoalbuminuria (daily urinary albumin excretion [UAE] < 30 mg/d); (2) type 2 diabetic patients with microalbuminuria (daily UAE, 30 to 300 mg/d); and (3) normal control subjects. MEASUREMENTS AND RESULTS: Oxygen consumption (VO(2)) of patients with microalbuminuria was lower than that of control subjects at anaerobic threshold (AT) [p < 0.001], and was lower than both control subjects (p < 0.001) and patients with normoalbuminuria (p = 0.015) at peak exercise. There was a progressive worsening in gas exchange efficiency at the lungs, as measured by minute ventilation (VE)/carbon dioxide production (VCO(2)) at AT or DeltaVE/DeltaVCO(2) slope, (p = 0.006 and p = 0.019, respectively) going from control subjects to patients with normoalbuminuria and then to patients with microalbuminuria. Left ventricular ejection fractions and BP were similar in patients with normoalbuminuria and microalbuminuria. More patients with microalbuminuria (n = 9) than with normoalbuminuria (n = 2) demonstrated diastolic dysfunction (p = 0.013). These 11 patients had lower peak VO(2) values (p = 0.001) and higher daily UAE (p = 0.028). An inverse linear relationship was found between peak VO(2) and log(10) daily UAE (r = - 0.57, r(2) = 0.29, p < 0.001). CONCLUSIONS: Abnormalities reflecting reduced oxygen transport and impaired gas exchange efficiency were found during exercise, and were especially profound in patients with microalbuminuria. These changes could be secondary to pulmonary microangiopathy and myocardial interstitial changes. Increases in capillary permeability to proteins may take place in the myocardium as they do in the kidneys, and contribute to impaired myocardial distensibility and hence diastolic dysfunction.

Management of Critically Ill Patients with Severe Acute Respiratory Syndrome (SARS).

Severe acute respiratory syndrome (SARS) is frequently complicated with acute respiratory failure. In this article, we aim to focus on the management of the subgroup of SARS patients who are critically ill. Most SARS patients would require high flow oxygen supplementation, 20-30% required intensive care unit (ICU) or high dependency care, and 13-26% developed acute respiratory distress syndrome (ARDS). In some of these patients, the clinical course can progress relentlessly to septic shock and/or multiple organ dysfunction syndrome (MODS). The management of critically ill SARS patients requires timely institution of pharmacotherapy where applicable and supportive treatment (oxygen therapy, noninvasive and invasive ventilation). Superimposed bacterial and other opportunistic infections are common, especially in those treated with mechanical ventilation. Subcutaneous emphysema, pneumothoraces and pneumomediastinum may arise spontaneously or as a result of positive ventilatory assistance. Older age is a consistently a poor prognostic factor. Appropriate use of personal protection equipment and adherence to infection control measures is mandatory for effective infection control. Much of the knowledge about the clinical aspects of SARS is based on retrospective observational data and randomized-controlled trials are required for confirmation. Physicians and scientists all over the world should collaborate to study this condition which may potentially threaten human existence.

Corticosteroid treatment of severe acute respiratory syndrome in Hong Kong.

BACKGROUND: The patterns of corticosteroids usage in severe acute respiratory syndrome (SARS) and associated treatment outcomes in Hong Kong were studied. METHOD: Patients> or =18 years old who either had not received corticosteroid or had taken corticosteroids within 14 days from symptom onset were included. Patients receiving corticosteroids beyond 15 days or other investigational treatment within 21 days from symptom onset were excluded. Of 1313 eligible patients, 1287 with major corticosteroid dosage-type combinations were analysed. RESULTS: Crude death rate was lower among 1188 steroid-treated patients compared to 99 patients in Group No Steroid (17.0% vs. 28.3%). Among four corticosteroid groups studied, mortality was lowest in the low-dose oral prednisolone (Group P) and high-dose methylprednisolone (Group MP) groups. On multivariate analysis of the corticosteroid groups, independent factors related to death were: corticosteroid group, older age, co-morbidity, worse chest X-ray score, worse respiratory status at Days 8-10 and higher admission white cell count. Again Groups P and MP had significantly lower adjusted odds ratios for death and lower bacterial and fungal culture rates. Despite worse chest X-ray scores and higher cumulative corticosteroid dosages in Group MP compared to Group P, fewer patients required rescue pulsed corticosteroid. Patients on hydrocortisone (Group HC) had the highest positive culture rates. CONCLUSION: We speculate that corticosteroid with higher in-vitro inflammatory potency administered at timing and dosages commensurate with disease severity may be conducive to better outcome from SARS as a consequence of more effective control of immunopathological lung damage.

Outcome of coronavirus-associated severe acute respiratory syndrome using a standard treatment protocol.

OBJECTIVE: There is so far no consensus on the optimal treatment strategy for the coronavirus-associated severe acute respiratory syndrome (SARS). We aimed to analyse the outcomes of a standard treatment strategy comprising antibiotics, a combination of ribavirin, a 3-week step-down course of corticosteroids, and the possibility of pulsed methylprednisolone rescue in the event of deterioration. METHODOLOGY: This was a prospective cohort study performed at a major public-funded hospital in Hong Kong. Eighty-eight World Health Organisation/Centers for Disease Control and Prevention probable cases of SARS (97% laboratory-confirmed) were treated with a standard protocol previously reported. Seventy-one patients treated de novo were analysed in detail with regard to time to clinical stabilization after combination treatment, requirement of additional therapy (pulsed methylprednisolone; assisted ventilation); and final outcomes (recovery, mortality). RESULTS: The mean age was 42. Twenty-one patients (24%) had comorbidities. Three of 71 treated de novo recovered with antibiotics alone. The remaining 68 received combination treatment at a mean of 5.8 days after symptom onset, of whom 30 subsequently required pulsed methylprednisolone rescue (independent predictors: older age and higher LDH) and 18 required assisted ventilation (independent predictors: older age, higher oxygen requirement and creatinine level). Their median time to clinical stabilization was 8.0 days after combination treatment (independent predictor for longer time to stabilization: median age of 41 or above). Common complications were hyperglycaemia (58%), pneumo-mediastinum/thoraces (13%), psychiatric manifestations (7%) and ventilator-associated pneumonia (2%). One patient (1%) died of SARS-related respiratory failure. All-cause mortality was 3.4%, occurring in patients aged > 65 years only. None of the discharged survivors required continuation of oxygen therapy. CONCLUSIONS: This standard treatment protocol resulted in overall satisfactory outcomes. Randomized controlled trial is suggested to confirm its efficacy.