Cavitary pneumonia due to Rhodococcus equi in a heart transplant recipient.

Rhodococcus equi is an uncommon human pathogen that usually affects immunocompromised patients. We present a case of a 68-year-old male heart transplant recipient, who developed rhodococcal pneumonia with secondary bacteremia 10 months post-transplant. The patient was a retired carpenter who was involved in breeding of horses. He responded completely to the treatment with vancomycin and imipenem/cilastin, followed by oral ciprofloxacin and minocycline for total treatment duration of 5 months. This case highlights the association between an animal exposure and infection with a unique opportunistic pathogen.

Clostridium innocuum bacteremia secondary to infected hematoma with gas formation in a kidney transplant recipient.

Clostridium innocuum is a relatively antimicrobial resistant, frequently misidentified anaerobe that has only rarely been associated with bacteremia. A 38-year-old female with chronic hepatitis C underwent a second kidney transplant operation. Two weeks after surgery a computed tomography scan of the abdomen showed a heterogeneous hematoma with pockets of gas adjacent to the allograft, which extended into the pelvis and left abdominal wall, associated with low-grade fever. An anaerobic blood culture grew a Clostridium initially identified as C. subterminale and later re-identified as C. innocuum. At abdominal exploration liquefied blood was evacuated, and the patient completed a course of antibiotics and recovered. C. innocuum should be considered as a cause of gas-producing anaerobic infection in transplant patients. Because C. innocuum is frequently misidentified by the use of commercial anaerobic identification kits, its true incidence in serious infections is likely underestimated.

Legionellosis in a lung transplant recipient obscured by cytomegalovirus infection and Clostridium difficile colitis.

A 52-year-old-white male underwent double lung transplantation for severe emphysema due to alpha-1-antitrypsin deficiency and heavy tobacco use. Following a postoperative course complicated by renal insufficiency, pulmonary emboli, and Clostridium difficile colitis, he was discharged in stable condition. Two months later, he was admitted to a local hospital with a fever, abdominal pain, diarrhea, nausea, and dyspnea. Computerized tomography (CT) of the chest revealed bilateral pleural effusions. Sigmoidoscopy was grossly normal but biopsy demonstrated cytomegalovirus (CMV) colitis, and the patient was placed on intravenous ganciclovir. Over the next week, he became progressively hypoxemic and was transferred to the University of Pittsburgh Medical Center (post-transplant day 81) for further evaluation. His medications on transfer included: ganciclovir, prednisone, tacrolimus, dapsone, fluconazole, ondansetron, lansoprazole, digoxin, and coumadin.

Whole-body FDG positron emission tomographic imaging for staging esophageal cancer comparison with computed tomography.

PURPOSE: The aim of the authors in this study was to critically evaluate the role of whole-body positron emission tomographic (PET) imaging with fluorine-18 fluorodeoxyglucose (FDG) in staging esophageal cancer, and further to compare this method with conventional imaging with computed tomography (CT). MATERIALS AND METHODS: The authors performed independent, blinded retrospective evaluations of FDG PET images obtained in 47 patients referred for the initial staging of esophageal cancer before minimally invasive surgical staging. Twenty PET studies from patients with nonesophageal thoracic cancers were randomly selected for inclusion in the PET readings. In a subset of 37 of 47 cases, the PET findings were compared with independent readings of CT studies acquired within the same 6-week interval. The utility of the imaging findings was evaluated using a high-sensitivity interpretation (i.e., assigning equivocal findings as positive) and a low-sensitivity interpretation (i.e., assigning equivocal findings as negative). RESULTS: PET was less sensitive (41% in high-sensitivity mode, 35% in low-sensitivity mode) than CT (63% to 87%) for diagnosing tumor involvement in locoregional lymph nodes, which was identified by surgical assessment in 72% of patients. Notable, however, was the greater specificity of PET-determined nodal sites (to approximately 90%) compared with CT (14% to 43%). In detecting histologically proved distant metastases (n = 10), PET performed considerably better when applied in the high-sensitivity mode, with a sensitivity rate of approximately 70% and a specificity rate of more than 90% in the total group and in the subset of patients with correlative CT data. In the low-sensitivity mode, CT identified only two of seven metastatic sites, whereas the high-sensitivity mode resulted in an unacceptably high rate of false-positive readings (positive predictive value, 29%). PET correctly identified one additional site of metastasis that was not detected by CT. CONCLUSIONS: The relatively low sensitivity of PET for identifying locoregional lesions precludes its replacement of conventional CT staging. However, the primary advantage of PET imaging is its superior specificity for tumor detection and improved diagnostic value for distant metastatic sites, features that may substantially affect patient management decisions. In conclusion, PET imaging is useful in the initial staging of esophageal cancer and provides additional and complementary information to that obtained by CT imaging.

Tumors of the thymus.

Thymic neoplasms are a common cause of an anterior mediastinal mass and may be benign or malignant. Thymic cysts are congenital or acquired and may be associated with a thymic malignancy. True thymic hyperplasia and thymic lymphoid hyperplasia may enlarge the thymus and simulate a neoplasm. Thymoma and thymic carcinoma are epithelial malignancies with distinct clinicopathologic features. Thymic carcinoid is a rare aggressive neuroendocrine malignancy associated with multiple endocrine neoplasia 1. Thymolipoma is a benign neoplasm. Hodgkin and non-Hodgkin lymphoma may primarily or secondarily involve the thymus. Primary mediastinal germ cell tumors may arise primarily within the thymus and include mature teratoma, seminoma, and non-seminomatous malignant germ cell tumors.

A comparison of techniques for placement of double-lumen endobronchial tubes.

STUDY OBJECTIVE: To compare two methods of double-lumen endobronchial tube placement for thoracic surgery and to identify factors that provide a rational basis for placement method selection. DESIGN: Prospective, randomized study. SETTING: Teaching hospital. PATIENTS: 58 ASA physical status II, III, and IV patients scheduled for surgical procedures requiring elective left-sided endobronchial intubation. INTERVENTIONS: Patients were assigned randomly to either a group in which the initial placement method was the traditional approach of placing the endobronchial tube through the larynx and then advanced blindly into the left mainstem bronchus, or to a second group in which the left mainstem bronchus was intubated under direct vision using the fiberoptic bronchoscope. MEASUREMENTS AND MAIN RESULTS: Of the 32 patients who underwent the traditional approach, primary success occurred in 27 patients and eventual success in 30. In 27 patients undergoing the directed approach, primary success occurred in 21 patients and eventual success in 25. Two patients in each group required the alternative method. The blind approach took 88 (+/- 91) seconds and the directed approach took 181 (+/- 193) seconds (p = 0.029). Timing data were analyzed using analysis of variance with respect to method and secretions and then t-tests as appropriate. Categorical data were analyzed using the Kruskal-Wallis and Fisher's exact tests as appropriate. All values are reported as means +/- SD. CONCLUSION: Both the blind and directed approaches resulted in successful left mainstem placement of the endobronchial tube in the majority of patients but either method may fail when used alone. More time was required using the directed approach. Operator experience with both methods will increase the likelihood of success. The choice of the initial approach may be influenced by patient factors as well as available equipment and personnel.

Primary mediastinal tumors: part II. Tumors of the middle and posterior mediastinum.

Lymphoma, mediastinal cysts, and neurogenic neoplasms are the most common primary middle and posterior mediastinal tumors. Lymphoma may involve the anterior, middle and/or posterior mediastinum, frequently as lymphadenopathy or as a discrete mass. Foregut cysts are common congenital mediastinal cysts and frequently arise in the middle mediastinum. Pericardial cysts are rare. Schwannoma and neurofibroma are benign peripheral nerve neoplasms, represent the most common mediastinal neurogenic tumors, and rarely degenerate into malignant tumors of nerve sheath origin. Sympathetic ganglia tumors include benign ganglioneuroma and malignant ganglioneuroblastoma and neuroblastoma. Lateral thoracic meningocele is a rare cause of a posterior mediastinal mass.

Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum.

Primary anterior mediastinal neoplasms comprise a diverse group of tumors and account for 50% of all mediastinal masses. Thymomas are most common and can be locally invasive and associated with parathymic syndromes. Thymic carcinomas and thymic carcinoids are rare malignancies with a propensity for local invasion and distant metastases. Thymolipomas are benign thymic tumors. The mediastinal germ cell tumors are a heterogeneous group of benign and malignant neoplasms. Mediastinal lymphangiomas are rare tumors and predominantly occur in young children. In contrast, mediastinal goiters are relatively common in adults. Mediastinal parathyroid adenomas are an uncommon cause of persistent hyperparathyroidism and rarely cause a discernible mass. The clinical, radiologic, and therapeutic aspects of the most common masses are reviewed.

Pulmonary mucormycosis: radiologic findings in 32 cases.

OBJECTIVE: The purpose of this study was to characterize the radiologic manifestations of pulmonary mucormycosis with clinical and pathologic correlation. MATERIALS AND METHODS: Clinical records, pathology reports, chest radiographs, and CT scans of 32 cases of pathologically proven pulmonary mucormycosis were retrospectively reviewed. RESULTS: The study group included 20 males and 12 females with a mean age of 47 years old. Clinical data were available for 29 patients. Signs and symptoms included fever (n = 23), cough (n = 21), bloody sputum (n = 9), dyspnea (n = 7), and chest pain (n = 6). Four patients were asymptomatic. Most patients were either immunocompromised (n = 20) or had diabetes mellitus (n = 9). Sputum or bronchoalveolar lavage cultures showed no growth in 17 of 18 cases. Diagnoses were confirmed at surgery or autopsy in all cases. Abnormalities seen on chest radiographs included lobar (n = 15) or multilobar (n = 6) consolidation, solitary (n = 7) or multiple (n = 1) masses, and solitary (n = 3) or multiple (n = 2) nodules. Cavitation was seen on chest radiographs in 13 patients, and intracavitary masses were seen in four. Associated radiographic findings included hilar (n = 3) or mediastinal (n = 3) adenopathy and unilateral (n = 6) or bilateral (n = 3) pleural effusion. CT in 19 patients revealed these significant additional findings: splenic (n = 1) or renal (n = 1) involvement, bronchial occlusion (n = 1), extrapulmonary invasion (n = 1), and pulmonary artery pseudoaneurysm (n = 1). CONCLUSION: In our study, pulmonary mucormycosis typically was manifested in immunocompromised or diabetic patients by consolidation on chest radiographs; cavitation was seen in 40% of patients. CT revealed significant unsuspected abnormalities in 26% of patients. Definitive diagnosis required pathologic demonstration of the organism in affected tissue because cultures from our patients rarely showed growth.

Pulmonary eosinophils express HLA-DR in chronic eosinophilic pneumonia.

BACKGROUND: Chronic eosinophilic pneumonia is a rare idiopathic disorder. role the eosinophil plays in the pathogenesis of this disease is unknown. The recent finding that nature eosinophils can express the class II major histocompatibility complex molecule HLA-DR suggests an immunologic role, perhaps through antigen presentation. The purpose of this research was to determine whether lung-derived eosinophils exhibit in vivo expression of HLA-DR. METHODS: Eosinophils were obtained simultaneously from bronchoalveolar lavage and peripheral blood from a 59-year-old woman with asthma and chronic eosinophilic pneumonia. Eosinophil-enriched aliquots of peripheral blood were cocultured with human lung fibroblasts (with or without additional granulocyte-macrophage colony-stimulating factor). The percentage of cells expressing HLA-DR was quantitated by flow cytometric analysis. RESULTS: Eosinophils derived from bronchoalveolar lavage displayed in vivo expression of HLA-DR (86%) in contrast to those from peripheral blood (7%), suggesting compartmentalization of eosinophil activation within the lung. Peripheral blood eosinophils retained the capacity for HLA-DR expression when coincubated with lung fibroblasts (83%) with augmentation by granulocyte-macrophage colony-stimulating factor (93%). CONCLUSION: These data demonstrate that lung eosinophil HLA-DR expression occurs in vivo; it may contribute to the pathogenesis of inflammatory lung injury.