Endobronchial involvement as an extremely rare manifestation of the Waldenström's disease.

Pulmonary infiltration is an infrequent organ involvement in Waldenström's disease (WD). Diffuse infiltration, isolated parenchymatous nodules, and pleural effusion are the most common manifestations of WD, while endobronchial mass is extremely rare. We present a case report of a 66-year-old man with a long-standing history of WD, who developed febrile neutropenia after therapy with rituximab, cyclophosphamide, and dexamethasone. X-ray and CT scan showed consolidation consistent with right-sided pneumonia. Surprisingly, bronchoscopy revealed an endobronchial tumor obstructing the right lower lobe (RLL) and two smaller granulations. Biopsies were obtained and recanalization of the RLL bronchus was performed. Immunohistological staining of the samples was consistent with lymphoplasmacytic lymphoma. Despite the change in therapy the patient died 6 weeks later. A review of published literature revealed only two case reports of endobronchial involvement in WD to this day. While one of the case reports described a patient with diffuse submucosal infiltration of the airways, the other one presented a patient with bronchus-obstructing tumor similar to the case reported here.

Concomitant use of beta-1 adrenoreceptor blocker and norepinephrine in patients with septic shock.

BACKGROUND: Betablockade has been shown to have cardioprotective effects in patients under perioperative stress. Besides animal model of septic shock and a small cohort of septic patients, these benefits have not been studied in septic shock patients who require norepinephrine administration. METHODS: After correction of preload, an esmolol bolus (0.2-0.5 mg/kg) followed by continuous 24 h infusion was administered in septic patients with sinus or supraventricular tachycardia (HR > 120/min). Exclusion criteria were severe LV systolic dysfunction, atrioventricular blockade and norepinephrine infusion at rates over 0.5 mg/kg/min. Monitoring with echocardiography and pulmonary artery catheter before, at 2, 6, 12, 24 h following the start and 6 h after ceasing of the esmolol drip. Patients were maintained normovolemic throughout the study and adjustments of concomitant norepinephrine infusion rates were made as required. RESULTS: Ten septic patients (mean age 54.4 ± 18.7), APACHE II 21.5 ± 6.2, CRP 275 ± 78 mg/l, procalcitonin 14.5 ± 10.1 mg/l, were given esmolol drip of 212.5 ± 63.5 mg/h at start to 272.5 ± 89.5 mg/h at 24 h. Heart rate decreased from mean 142 ± 11/min to 112 ± 9/min (p < 0.001) with parallel insignificant reduction of cardiac index (4.94 ± 0.76 to 4.35 ± 0.72 l/min/m(2)). Stroke volume insignificantly increased from 67.1 ± 16.3 ml to 72.9 ± 15.3 ml. No parallel change of pulmonary artery wedge pressure was observed (15.9 ± 3.2 to 15.0 ± 2.4 mmHg) as well as no significant changes of norepinephrine infusion (0.13 ± 0.17 to 0.17 ± 0.19 mg/kg/min), DO(2), VO(2), OER or arterial lactate. CONCLUSIONS: Saving the heart 30 beats/min did not demonstrate adverse impact on global haemodynamics in rates above 110/min. Using well titratable betablocker seems to be safe and cardioprotective in septic shock patients with high cardiac output.

Natural history of pulmonary complications in children after bone marrow transplantation.

We sought, in children after bone marrow transplantation (BMT), (1) to determine the natural history and incidence of pulmonary complications, (2) to evaluate the diagnostic yield of fiberoptic bronchoscopy and bronchoalveolar lavage (BAL); and (3) to determine the effect of bronchoscopy with lavage on patient outcome. The study design was a retrospective review in a tertiary care university hospital of all children undergoing BMT over a 5-year period. Patients were separated into 2 study groups: children with and without pulmonary complications. Pulmonary complications were defined as new or persistent pulmonary infiltrates on chest radiograph or chest computed tomography scan, respiratory symptoms, hypoxemia, or hemoptysis. Three hundred sixty-three pediatric patients underwent BMT between January 1, 1995, and December 31, 1999. Ninety patients (25%) developed pulmonary complications and were evaluated with bronchoscopy and BAL. Patients with pulmonary complications had a higher mortality (65% versus 44%; P < .01). The median posttransplantation survival for children with pulmonary complications was 258 days, compared with 1572 days in patients without pulmonary complications. The incidence of pulmonary complications was increased in patients with allogeneic BMT (P < .01). The time-dependent onset of severe (grade III to IV) graft-versus-host disease increased the relative risk of pulmonary complications by 2.0 (95% confidence interval, 1.1-3.7; P = .02). Pulmonary complications increased the time-dependent relative risk of mortality by 3.5 (95% confidence interval, 2.5-4.8). The diagnostic yield of bronchoscopy with lavage was 46% in patients undergoing BAL. Diagnostic bronchoscopy did not enhance either 30- or 100-day survival. Pathogen identification did not decrease mortality (P = .45). Pulmonary complications occur in 25% of children undergoing BMT and increase the risk of death in the first year after BMT. Although pathogen identification does not confer a survival advantage, rigorous, prospective screening may allow for earlier identification of pathogens and thereby provide a benefit to this uniquely vulnerable population.