Chest radiography for predicting the cause of febrile illness among inpatients in Moshi, Tanzania.

AIM: To describe chest radiographic abnormalities and assess their usefulness for predicting causes of fever in a resource-limited setting. MATERIALS AND METHODS: Febrile patients were enrolled in Moshi, Tanzania, and chest radiographs were evaluated by radiologists in Tanzania and the United States. Radiologists were blinded to the results of extensive laboratory evaluations to determine the cause of fever. RESULTS: Of 870 febrile patients, 515 (59.2%) had a chest radiograph available; including 268 (66.5%) of the adolescents and adults, the remainder were infants and children. One hundred and nineteen (44.4%) adults and 51 (20.6%) children were human immunodeficiency virus (HIV)-infected. Among adults, radiographic abnormalities were present in 139 (51.9%), including 77 (28.7%) with homogeneous and heterogeneous lung opacities, 26 (9.7%) with lung nodules, 25 (9.3%) with pleural effusion, 23 (8.6%) with cardiomegaly, and 13 (4.9%) with lymphadenopathy. Among children, radiographic abnormalities were present in 87 (35.2%), including 76 (30.8%) with homogeneous and heterogeneous lung opacities and six (2.4%) with lymphadenopathy. Among adolescents and adults, the presence of opacities was predictive of Streptococcus pneumoniae and Coxiella burnetii, whereas the presence of pulmonary nodules was predictive of Histoplasma capsulatum and Cryptococcus neoformans. CONCLUSIONS: Chest radiograph abnormalities among febrile inpatients are common in northern Tanzania. Chest radiography is a useful adjunct for establishing an aetiologic diagnosis of febrile illness and may provide useful information for patient management, in particular for pneumococcal disease, Q fever, and fungal infections.

The value of end-of-treatment chest radiograph in predicting pulmonary tuberculosis relapse.

SETTING: Patients with cavitary pulmonary tuberculosis (TB) on baseline chest radiograph (CXR) who remain culture-positive after 8 weeks of treatment are at high risk of relapse. The role of end-of-treatment (EOT) CXR in predicting relapse is unclear. OBJECTIVE: To determine whether EOT CXR independently predicts TB relapse. DESIGN: We conducted a secondary analysis of a randomized trial of intermittent treatment using rifapentine in the continuation phase of TB treatment among 1004 human immunodeficiency virus seronegative adults with culture-proven pulmonary TB. RESULTS: Relapse occurred in 17.3% of subjects with persistent cavity on EOT CXR, in 7.6% of subjects with a cavity that resolved by EOT, and 2.5% (P=0.002 for trend) of subjects who never had a cavity. In multivariable analysis, patients with persistent cavity on EOT CXR were significantly more likely to relapse than patients with no cavity on baseline or 2-month CXR (hazard ratio [HR] 4.22, 95%CI 2.00-8.91), and were more likely to relapse than subjects whose early cavity had resolved by EOT CXR (HR 1.92, 95%CI 1.09-3.39). CONCLUSION: A persistent cavity after 6 months of TB treatment was independently associated with disease relapse after controlling for other variables. EOT CXR may help predict those likely to relapse.

Kaposi's sarcoma involving the lung in patients with the acquired immunodeficiency syndrome.

To determine the distinguishing features of pulmonary Kaposi's sarcoma (KS) in patients with the acquired immunodeficiency syndrome (AIDS), we compared three groups of patients, 16 with endobronchial KS, 15 with endobronchial KS and an opportunistic lung infection, and 40 with Pneumocystis carinii pneumonia (PCP) without concomitant pulmonary KS. The majority of pulmonary KS patients had extensive cutaneous disease at the time of pulmonary diagnosis, and the diagnosis of pulmonary KS was easily established by the characteristic appearance of the endobronchial lesions. Dyspnea, fever, and cough were common presenting symptoms, but occurred more commonly in association with accompanying opportunistic infection. Diffuse interstitial infiltrates were observed in most patients in both groups, but the findings of nodular parenchymal densities or pleural effusion were more commonly observed in patients with pulmonary KS than in those with PCP alone. Pulmonary uptake of gallium-67 citrate or a diffusing capacity less than 80% were unusual in patients with pulmonary KS alone, but common in those with accompanying opportunistic infection or with PCP alone. Median survival in patients with pulmonary KS was only 2 months, and most patients had complicating opportunistic infections at the time of death. Pulmonary KS is generally a late and often preterminal manifestation of AIDS. Chest radiographs, gallium lung scans, and pulmonary function testing may provide diagnostic information that is helpful in distinguishing pulmonary KS from opportunistic lung infections.

Role of angiography in cervicothoracic trauma.

The role of angiography in cervicothoracic trauma is controversial. Since 1967 the policy at San Francisco General Hospital has been to use liberal indications for angiography in hemodynamically stable patients with either penetrating or blunt cervicothoracic trauma. The 304 patients in Group 1 had emergency angiographic evaluation: 102 had penetrating cervical wounds: 202 had thoracic injuries-71 penetrating and 131 blunt trauma. During the same time period, 72 patients (Group II) had cervical or thoracic vascular injuries and underwent operative treatment without preoperative angiography. Sixty-six patients in Group 1 had significant vascular injury. Thirty patients with penetrating cervical injury had 38 vascular lesions. Thirty-six patients with gunshot or blunt chest trauma had 43 vascular lesions. Group II patients had two main indications for operation: exanguinating hemorrhage (45 patients) or suspected vascular injury, usually associated with hemorrhage (27 patients). Angiographic results were useful whether abnormal or normal. In cases with adnormal findings operative treatment was specific and improper incisions were avoided. In cases with normal angiographic results, clarification of the vascular status avoided unnecessary operations and permitted concentration of therapeutic effort upon the main clinical problems of the patients.

Thoracic nodal staging with PET imaging with 18FDG in patients with bronchogenic carcinoma.

PURPOSE: To assess the role of positron emission tomographic (PET) imaging with 18-fluoro-2-deoxyglucose (18FDG) in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma. MATERIALS AND METHODS: Over a 2-year period, any patient presenting to our institution with newly diagnosed bronchogenic carcinoma who was to have thoracic nodes sampled was considered eligible. All PET studies were performed prior to nodal sampling and areas of increased uptake were mapped according to the American Thoracic Society classification. Studies were correlated with CT and pathology. Sensitivity and specificity for predicting nodal metastases was calculated. RESULTS: Forty-two patients had 62 nodal stations (40 hilar/lobar, 22 mediastinal) sampled. The sensitivity and specificity for hilar/lobar lymph node station metastases using PET imaging was 73% and 76%, respectively. With CT, the sensitivity and specificity were 27% and 86%. The sensitivity and specificity using PET imaging for mediastinal node station metastases was 92% and 100%, respectively, while with CT the figures were 58% and 80%. The sensitivity and specificity for combined thoracic nodal station metastases using PET imaging was 83% and 82%, respectively, while with CT it was 43% and 85%. There was a strong statistical relationship between positive PET imaging and lymph node abnormalities. CONCLUSIONS: 18FDG-PET imaging is accurate in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma. Normal results of PET studies virtually preclude the need for mediastinal nodal sampling prior to surgery, whereas abnormal results of studies most likely represent mediastinal metastases. Treatment can be based on the extent of disease suggested by PET imaging.

Correlation of tumor size and survival in patients with stage IA non-small cell lung cancer.

OBJECTIVE: The purpose of this study was to determine the relationship between tumor size and survival in patients with stage IA non-small cell lung cancer (non-small cell lung cancer; ie, lesions < 3 cm). METHOD: Five hundred ten patients with pathologic stage IA (T1N0M0) non-small cell lung cancer were identified from our tumor registry over an 18-year period (from 1981 to 1999). There were 285 men and 225 women, with a mean age of 63 years (range, 31 to 90 years). The Cox proportional model was used to examine the effect on survival. Tumor size was incorporated into the model as a linear effect and as categorical variables. The Kaplan-Meier product limit estimator was used to graphically display the relationship between the tumor size and survival. RESULTS: The Cox proportional hazards model did not show a statistically significant relationship between tumor size and survival (p = 0.701) as a linear effect. Tumor size was then categorized into quartiles, and again there was no statistically significant difference in survival between groups (p = 0.597). Tumor size was also categorized into deciles, and there was no statistical relationship between tumor size and survival (p = 0.674). CONCLUSIONS: This study confirms stratifying patients with stage IA non-small cell lung cancer in the same TNM classification, given no apparent difference in survival. Unfortunately, these data caution that improved small nodule detection with screening CT may not significantly improve lung cancer mortality. The appropriate prospective randomized trial appears warranted.

Significance of hemoptysis following thrombolytic therapy for acute myocardial infarction.

PURPOSE: To describe the occurrence, cause, and significance of hemoptysis following thrombolytic therapy for acute myocardial infarction. PATIENTS AND METHODS: We retrospectively reviewed 2,634 patients presenting with acute myocardial infarction who received thrombolytic therapy to determine the incidence of hemoptysis. Chart and radiographic review included the type, dose, and route of thrombolytic therapy. In addition, the onset, duration, and severity of hemoptysis were recorded and correlated with radiographic and bronchoscopic findings. RESULTS: Eleven patients (0.4%) developed hemoptysis following administration of thrombolytic therapy for an acute myocardial infarction. The duration and severity had a wide range, although no patient had significant hemodynamic compromise. The source of hemoptysis was identified in only one patient who had a tongue laceration following cardiopulmonary resuscitation, and blood was seen within the oropharynx and trachea. No definitive cause was identified in all other patients. There was no correlation between the different types or doses of thrombolytic therapy and the duration or severity of hemoptysis. Chest radiographs were nonspecific and demonstrated resolution within 11 days following hemoptysis. CT of the thorax in one patient and bronchoscopy in two patients confirmed chest radiographic findings and in no patient was an underlying pulmonary abnormality identified. CONCLUSIONS: Pulmonary hemorrhage and hemoptysis are unusual complications of thrombolytic therapy in patients with acute myocardial infarction. Although hemoptysis may be the first indicator of an underlying pulmonary abnormality, we found no case in which a significant abnormality was unmasked. This study suggests that follow-up chest radiographs are recommended and further evaluation may be unnecessary if complete resolution is demonstrated.

Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage.

BACKGROUND: Malignant pleural effusions are a common problem for patients with metastatic disease. Most patients are treated with tube thoracostomy and sclerotherapy, although there remains no standard approach. The purpose of this study was to compare the efficacy of bleomycin with doxycycline sclerotherapy for the treatment of malignant pleural effusions using small-bore catheters. METHODS: All patients with a symptomatic malignant pleural effusion referred for chest tube drainage and sclerotherapy over a 2-year period were considered eligible. Using image guidance, a 14F self-retaining catheter was inserted into the pleural space and connected to continuous wall suction. When drainage fell below 200 mL/d, patients were randomized to 60 U of bleomycin or 500 mg of doxycycline sclerotherapy. Response at 30 days was determined. RESULTS: One hundred six patients were enrolled in the study. Fifteen men (29%) and 37 women (71%) with a mean age of 57 years received bleomycin sclerotherapy. Twenty-one of the 29 patients (72%) alive and evaluable at 30 days had successful sclerotherapy. Twenty-three men (43%) and 31 women (57%) with a mean age of 61 years received doxycycline sclerotherapy. Twenty-three of the 29 patients (79%) alive and evaluable at 30 days had successful sclerotherapy. There was no significant difference in response rates between doxycycline and bleomycin (p=0.760). CONCLUSIONS: These data continue to support a role for small-bore chest drainage and sclerotherapy, although there was no significant difference in 30-day response rates between doxycycline and bleomycin.

Identification of small lung nodules at autopsy: implications for lung cancer screening and overdiagnosis bias.

PURPOSE: Unsuspected cases of lung cancer are reported to be uncommon in autopsy series, and these data have been used to suggest that indolent tumors are rare and that overdiagnosis bias is not an important factor in lung cancer screening. The purpose of this study was to determine if a retrospective autopsy review is indeed accurate in identifying all small lung nodules on CT, and thus provide a true estimate of unsuspected lung tumors. MATERIALS AND METHODS: We identified all 1047 patients who had an autopsy at our institution from 1994 to 1998. We then reviewed the patients radiology records and found 187 patients with a thoracic CT within 2 months of the postmortem examination. All 187 CT reports were reviewed in order to identify patients with at least one pulmonary nodule. CT studies with reports that described a nodule(s) were then re-reviewed to confirm presence and location of the nodule(s). The CT findings were than compared to the autopsy report to determine if the postmortem examination indeed found the nodule(s). RESULTS: 28 autopsy patients had at least one pulmonary nodule identified on their thoracic CT no more than 2 months before death. Nineteen patients (68%) had nodule(s) recorded on the autopsy report, two ( approximately 10%) of which proved to have undiagnosed squamous cell carcinoma. Nine patients (22%) had no mention of pulmonary nodules seen on the CT recorded on their autopsy report. CONCLUSIONS: This study suggests autopsies do not identify all small pulmonary nodules found at CT. The true incidence of clinically insignificant lung cancer is thus uncertain, and overdiagnosis bias in lung cancer screening may be more important than previously recognized.

Correlation of FDG-PET imaging with Glut-1 and Glut-3 expression in early-stage non-small cell lung cancer.

PURPOSE: To correlate FDG activity on PET with the expression of glucose transporter proteins Glut-1 and Glut-3 in patients with early stage non-small cell lung cancer (NSCLC). METHODS: Over a 5 year period, all patients with a PET scan and clinical stage I NSCLC underwent an immunohistochemical analysis of their tumor for Glut-1 and Glut-3 expression. The amount of FDG uptake in the primary lesion was measured by a standardized uptake ratio (SUR) and correlated with immunohistochemical results. RESULTS: Seventy-three patients with a mean age of 66 years had clinical stage I disease. The final pathologic stage showed 64 patients with stage IA/B disease, eight with stage IIA disease, and one patient with pathologic stage IIIA (T1N2) disease. Glut-1 transporter expression was significantly higher than Glut-3 (P<0.0001), and although there was some association between the SUR and Glut-1 (P=0.085) and SUR and Glut-3 (P=0.074) expression, this did not reach statistical significance. CONCLUSIONS: Glut-1 and Glut-3 transporter expression did not demonstrate a statistically significant correlation with FDG uptake in potentially resectable lung cancer. It appears that these transporters alone do not affect the variation in FDG activity in early stage NSCLC.

Severe chest trauma. Morbidity implication.

Patients who sustain fracture of either the first or second rib have severe injuries usually involving multiple systems. In comparing 71 patients with first rib fractures and 49 patients with second rib fractures, we found morbidity and mortality to be similar. A multidisciplinary approach to management of these patients is described and vigorous diagnostic and therapeutic measures are warranted to promptly determine the extent of injury and minimize the frequency of missed diagnosis.

Tuberculosis and AIDS.

In the mid-1980s, the incidence of tuberculosis (TB) in the United States increased. Recently, TB became an index diagnosis for AIDS. Chest radiographs in patients with AIDS and TB may be atypical; various features are addressed in this article. Radiologists should be aware of the possibility of TB because this disease is not only communicable to health care workers and other patients but more recently has become difficult to treat because of multidrug-resistant Mycobacterium tuberculosis.

Positron emission tomography imaging of the thorax.

Positron emission tomography (PET) is just beginning to emerge as a clinically useful tool in the thorax. Imaging with FDG is used primarily to differentiate benign from malignant abnormalities, including solitary pulmonary nodules, staging bronchogenic carcinoma, and differentiating recurrent tumor from fibrosis following treatment. This article discusses the fundamental properties of PET images, techniques, and current clinical indications in the thorax.

Management of malignant pleural effusions and pneumothorax.

Pneumothorax may occur spontaneously or result from underlying lung disease or as a complication of interventional thoracic procedures. Percutaneous catheter placement enables safe and effective drainage of pneumothoraces with rapid relief of symptoms and restoration of vital capacity and oxygenation.

Lymphoma in the immunocompromised patient.

The increased incidence of malignant lymphomas in patients with congenital or acquired immunodeficiency states is now well recognized. In recent years, acquired immunodeficiency syndrome (AIDS) related non-Hodgkin's lymphoma has accounted for a growing proportion of these aggressive neoplasms. This article reviews the radiographic features of lymphoma in AIDS and non-AIDS immunocompromised patients.

Radiographic findings in patients with acute respiratory distress syndrome.

Since its description in 1967, acute respiratory distress syndrome (ARDS) has become a widely recognized, if somewhat imperfectly understood, entity. This article reviews the imaging characteristics of ARDS as demonstrated on plain chest radiography, CT scan, radionuclide imaging, and MR imaging. The abnormalities displayed on these modalities are well understood even though there may be some dispute as to their relative importance in diagnosing and managing patients.

Pulmonary angiography.

Pulmonary angiography is generally accepted as the standard for diagnosis of pulmonary embolism. Yet this procedure has failed to gain widespread appeal or application. This article will review the extensive literature on pulmonary angiography that has appeared since the first major article was published in 1963.

Carcinoids associated with multiple endocrine neoplasia syndromes.

Carcinoids occur in association with MEN types 1 and 2. To determine the relationship between carcinoids and MEN, we reviewed nine patients with carcinoids and other endocrine tumors. Analyzing these 9 patients and 56 other patients previously described in the literature, we found several clinically important relationships. In contrast to the usual midgut and hindgut origin, most carcinoids associated with MEN (69 percent) are of foregut origin (thymus 24 percent, bronchus 27 percent, stomach 3 percent, and duodenum 14 percent). Carcinoids are more commonly associated with MEN type 1 than MEN type 2 (59 patients and 6 patients, respectively). Thymic carcinoids associated with MEN are more common in men (15 versus 2), and most (82 percent) are malignant. Bronchial carcinoids associated with MEN are more common in women (15 versus 4), and most (74 percent) are benign. There is a strong association between thymic carcinoids and parathyroid tumors and between bronchial carcinoids and pituitary tumors. Most patients with carcinoids and hyperparathyroidism (82 percent) have had parathyroid hyperplasia or multiple parathyroid adenomas. Thus, carcinoids may occur in association with both MEN type I and MEN type II. MEN should be suspected in patients with foregut carcinoids. Patients with MEN and ectopic ACTH production should be considered to have bronchial carcinoids if they are female and thymic carcinoid if they are male. The thymus should be routinely removed in patients with MEN type I because of the possible presence of an ectopic parathyroid gland in this tissue and to prevent subsequent development of a carcinoid tumor.

Pneumocystis carinii pneumonia.

Pneumocystis carinii pneumonia (PCP) is the most common index diagnosis in patients with acquired immunodeficiency syndrome (AIDS). Eighty percent of AIDS patients will eventually develop PCP. Common presenting symptoms are shortness of breath, cough, weight loss, and fever. The chest radiograph typically reveals a diffuse, bilateral, symmetric, fine-to-medium reticulonodular pattern of opacities. Upper lobe disease has been reported recently in patients who have undergone prophylactic therapy with aerosolized pentamidine. Pneumatoceles, or thin-walled air-containing cysts, have been noted in 10% of patients with PCP. Lymphadenopathy and pleural effusion are extremely rare. Therapy with various agents is generally successful, resulting in clinical and radiographic improvement within 7 to 10 days. Recurrence of PCP is common.

Mycobacterial disease in AIDS.

An increase in tuberculosis cases in the United States has been partially linked to the large number of patients with acquired immunodeficiency syndrome. Symptoms are indistinguishable from those of other opportunistic infections and include cough, low-grade fever, and weight loss. In patients with early human immunodeficiency virus (HIV) infection, radiographic findings resemble those seen in patients with reactivation tuberculosis. In patients with advanced HIV infection, chest radiographs typically reveal bilateral, symmetric, coarse, nodular densities. An upper lobe distribution is not prevalent. Lymphadenopathy is reported in many patients. Antituberculous therapy leads to clinical and radiographic improvement. Radiographic deterioration during therapy should suggest the presence of another opportunistic infection. Mycobacterium avium complex (MAC) infection of the lung cannot be distinguished from tuberculosis clinically or radiographically. Therapy, however, is less likely to be successful in patients with MAC infection.