RESUMO
CASE PRESENTATION: A 62-year-old woman with a long-term smoking history was evaluated at our lung cancer clinic for a new 2.5-cm lung nodule. She had a history of well-controlled COPD and hypertension. She was in overall good health until 3 weeks before her evaluation in an ED for new-onset exertional dyspnea. Her physical examination was unremarkable, except for diffuse hyperpigmented scaly scalp lesions that coalesced into plaques. Her subjective symptoms were nonproductive cough, exertional dyspnea, unintentional weight loss of 10 lb, and fatigue that had started 2 months earlier. She did not have fever or night sweats.
Assuntos
Cistos , Neoplasias Pulmonares , Medula Óssea , Diagnóstico Diferencial , Dispneia/diagnóstico , Dispneia/etiologia , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico , Pessoa de Meia-IdadeRESUMO
There is an urgent need to develop novel compounds that prevent the deleterious effects of opioids such as fentanyl on minute ventilation while, if possible, preserving the analgesic actions of the opioids. We report that L-glutathione ethyl ester (GSHee) may be such a novel compound. In this study, we measured tail flick latency (TFL), arterial blood gas (ABG) chemistry, Alveolar-arterial gradient, and ventilatory parameters by whole body plethysmography to determine the responses elicited by bolus injections of fentanyl (75 µg/kg, IV) in male adult Sprague-Dawley rats that had received a bolus injection of GSHee (100 µmol/kg, IV) 15 min previously. GSHee given alone had minimal effects on TFL, ABG chemistry and A-a gradient whereas it elicited changes in some ventilatory parameters such as an increase in breathing frequency. In vehicle-treated rats, fentanyl elicited (1) an increase in TFL, (2) decreases in pH, pO2 and sO2 and increases in pCO2 (all indicative of ventilatory depression), (3) an increase in Alveolar-arterial gradient (indicative of a mismatch in ventilation-perfusion in the lungs), and (4) changes in ventilatory parameters such as a reduction in tidal volume, that were indicative of pronounced ventilatory depression. In GSHee-pretreated rats, fentanyl elicited a more prolonged analgesia, relatively minor changes in ABG chemistry and Alveolar-arterial gradient, and a substantially milder depression of ventilation. GSHee may represent an effective member of a novel class of thiolester drugs that are able to prevent the ventilatory depressant effects elicited by powerful opioids such as fentanyl and their deleterious effects on gas-exchange in the lungs without compromising opioid analgesia.
Assuntos
Analgesia/métodos , Analgésicos Opioides/efeitos adversos , Fentanila/efeitos adversos , Glutationa/análogos & derivados , Insuficiência Respiratória/prevenção & controle , Analgésicos Opioides/farmacologia , Animais , Gasometria , Dióxido de Carbono/sangue , Descoberta de Drogas , Fentanila/farmacologia , Glutationa/farmacologia , Masculino , Oxigênio/sangue , Dor/tratamento farmacológico , Manejo da Dor , Ratos , Ratos Sprague-Dawley , Respiração/efeitos dos fármacos , Insuficiência Respiratória/induzido quimicamenteRESUMO
BACKGROUND Hypereosinophilic syndrome (HES) is defined as hypereosinophilia with eosinophil mediated organ damage or dysfunction, provided that other causes of organ damage have been excluded. CASE REPORT An 83-year-old female presented with worsening dyspnea for 3 weeks. She was initially diagnosed with bronchitis and prescribed oral antibiotics along with prednisone taper. However, her dyspnea continued to worsen requiring hospitalization. Physical examination was significant for signs of volume overload. Laboratory investigations were notable for leukocytosis with eosinophilia, elevated BNP (brain natriuretic peptide) and troponin. Electrocardiogram (ECG) showed normal sinus rhythm with non-specific ST-T wave changes. Computed tomography (CT) scan of the chest showed pulmonary edema, bilateral peripheral ground glass opacities, and pleural effusions. Transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 45%. She was diagnosed with NSTEMI (non-ST-elevation myocardial infarction) with new onset heart failure; appropriate management was initiated. Left heart catheterization did not show any significant obstructive lesions. Presence of peripheral ground glass opacities on the CT chest scan and eosinophilia raised suspicion for HES. Thorough HES workup was done, all tests came back negative except for elevated serum IgE level. Cardiac biopsy returned positive for eosinophilic myocarditis. Bone marrow biopsy showed 20% eosinophils. Positron emission tomography (PET) scan did not show any hypermetabolic lesions to suggest malignancy. The patient was managed for idiopathic HES with high dose steroids resulting in significant clinical improvement. CONCLUSIONS About 40% of patient with HES manifest cardiac involvement, and one quarter of patients with HES have pulmonary involvement with variable radiologic findings. Steroids remain the mainstay treatment for idiopathic HES.
Assuntos
Síndrome Hipereosinofílica/diagnóstico , Síndrome Hipereosinofílica/terapia , Idoso de 80 Anos ou mais , Feminino , Humanos , Síndrome Hipereosinofílica/complicações , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios XRESUMO
A 76--year--old male cigarette smoker presented with a 2-week history of cough and haemoptysis. Chest CT on admission revealed multiple new lung nodules concerning for malignancy. CT--guided biopsy of the nodule in left lower lobe was attempted in prone oblique position for tissue diagnosis. Local anaesthetic (lidocaine) was administered using a 25--gauge (1.5-inch) needle to anaesthetise the skin and subcutaneous tissue. This was followed by insertion of a 25-gauge (3.5-inch) Whitacre needle to anaesthetise deeper tissues and parietal pleura. Due to patient's coughing and proximity of the nodule to the diaphragm, the circumstances were judged to be too risky for a needle biopsy. Therefore, it was decided to biopsy another nodule in the left lung that was visible on the same CT section. During this portion of the procedure, the patient became hypoxic and developed pulseless electrical activity arrest. Cardiopulmonary resuscitation was unsuccessful and the efforts ceased after 45 min. Subsequent review of CT scan revealed air in the left ventricle.