Using cryoprobes of different sizes combined with cone-beam computed tomography-derived augmented fluoroscopy and endobronchial ultrasound to diagnose peripheral pulmonary lesions: a propensity-matched study.

BACKGROUND: Endobronchial ultrasound (EBUS) and cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) are utilized for the diagnosis of peripheral pulmonary lesions (PPLs). Combining them with transbronchial cryobiopsy (TBC) can provide sufficient tissue for genetic analysis. However, cryoprobes of different sizes have varying degrees of flexibility, which can affect their ability to access the target bronchus and potentially impact the accuracy. The aim of this study was to compare the diagnostic efficacy of cryoprobes of varying sizes in CBCT-AF and EBUS for the diagnosis of PPLs. METHODS: Patients who underwent endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) and TBC combined with CBCT-AF for PPLs diagnosis between January 2021 and May 2022 were included. Propensity score matching and competing-risks regression were utilized for data analysis. Primary outcome was the diagnostic accuracy of TBC. RESULTS: A total of 284 patients underwent TBC, with 172 using a 1.7-mm cryoprobe (1.7 group) and 112 using a 1.1-mm cryoprobe (1.1 group). Finally, we included 99 paired patients following propensity score matching. The diagnostic accuracy of TBC was higher in the 1.1 group (80.8% vs. 69.7%, P = 0.050), with a similar rate of complications. Subgroup analysis also revealed that the 1.1 group had better accuracy when PPLs were located in the upper lobe (85.2% vs. 66.1%, P = 0.020), when PPLs were smaller than 20 mm (78.8% vs. 48.8%, P = 0.008), and when intra-procedural CBCT was needed to be used (79.5% vs. 42.3%, P = 0.001). TBC obtained larger specimens than TBB in both groups. There is still a trend of larger sample size obtained in the 1.7 group, but there is no statistically different between our two study groups (40.8 mm2 vs. 22.0 mm2, P = 0.283). CONCLUSIONS: The combination of TBC with CBCT-AF and EBUS is effective in diagnosing PPLs, and a thin cryoprobe is preferred when the PPLs located in difficult areas.

Endobronchial ultrasound-guided transbronchial biopsy with or without a guide sheath for peripheral pulmonary malignancy.

Endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) is a common procedure used to diagnose peripheral pulmonary lesions (PPLs). However, existing literature did not conclusively show a difference in the ability of EBUS-TBB with and without a guide sheath (GS) to diagnose PPLs. This multicenter cohort study enrolled patients presenting for EBUS-TBB of PPLs that finally proved to be malignant. The diagnostic yield and complication rate were compared between patients undergoing EBUS-TBB with and without a GS (EBUS-TBB+GS versus EBUS-TBB-GS). A propensity score matching method was used to balance differences of pertinent clinical features between the two groups. The original cohort consisted of 975 patients (556 in EBUS-TBB-GS; 419 in EBUS-TBB+GS). GS guidance was more likely to be used with smaller (40 mm versus 44 mm) and middle or lower lobe (60% versus 35%) lesions. After propensity score matching, 720 (360 in each group) patients were included; the diagnostic yields for PPLs were 79% and 78% for EBUS-TBB-GS and EBUS-TBB+GS groups, respectively (p=0.649). The complication rates (5.8% versus 7.2% for bleeding; 0.6% versus 1.9% for pneumothorax) appeared to be lower in the EBUS-TBB+GS group, but the differences did not reach statistical significance. The procedure time was significantly longer in the EBUS-TBB+GS group than in the EBUS-TBB-GS group (29 min versus 24 min; p<0.001). In conclusion, adding a GS to EBUS-TBB did not improve the diagnostic yield for malignant PPLs. GS guidance was seemingly associated with a lower number of complications after TBB but contributed significantly to a longer procedure time.

Monitoring levels of vimentin-positive circulating cancer stem cells and tumor cells in patients with advanced EGFR-mutated non-small cell lung cancer.

OBJECTIVES: Circulating tumor cells (CTCs) are associated with tumor spread, whereas cancer stem cells may be related to drug resistance. However, few studies have analyzed the levels of circulating cancer stem cells (CCSCs) and CTCs in patients with advanced non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Treatment-naïve patients with EGFR-mutated NSCLC who received epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) therapy were recruited prospectively. The cell surface vimentin antibody was used for CTC detection and CD133 antibody for CCSC detection. CCSC and CTC levels were measured as cell count per 4 mL of blood, before treatment, after 2 and 12 weeks of treatment, and at disease progression. Data on clinical characteristics and outcomes were also collected. RESULTS: At diagnosis (n = 29), the median CCSC and CTC levels were 0 (interquartile range, 0-2) and 3 (2-9), respectively. After 12 weeks, the CCSC and CTC levels were lower than those at diagnosis (CCSC: 0 (0-0), p = 0.14; CTC: 1 (0-4), p = 0.048). At disease progression, the median CCSC and CTC levels were 0 (0-1) and 1 (0-2), respectively. Patients with higher CCSC and CTC levels at diagnosis had a numerically shorter progression-free survival. CONCLUSION: In patients with EGFR-mutated NSCLC, CCSC and CTC levels became lower after 12 weeks of EGFR-TKI therapy and remained low at disease progression. High pre-treatment CCSC and CTC levels may be associated with a trend towards poor treatment outcomes.

Clinical Trajectories and Causes of Death in Septic Patients with a Low APACHE II Score.

Clinical course and mortality in septic patients with low disease severity remain poorly understood and is worth further investigation. We enrolled septic patients admitted to intensive care units (ICUs) between 2010 and 2014 with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of ≤15. We sought to determine their clinical trajectories and causes of death, and to analyze risk factors associated with in-hospital mortality. A total of 352 patients were included, of whom 89 (25%) did not survive to hospital discharge, at a rate higher than predicted (<21%) by the APACHE II score. Approximately one third (31/89) of non-survivors succumbed to index sepsis; however, more patients (34/89) died of subsequent sepsis. New-onset ICU sepsis developed in 99 (28%) patients and was an independent risk factor for mortality. In addition, septic patients with comorbid malignancy or index infection acquired in the hospital settings were more likely to have in-hospital mortality than those without. In conclusion, septic patients with low APACHE II scores were at a higher mortality risk than expected, and subsequent sepsis rather than index sepsis was the primary cause of death. This study provides insight into unexpected clinical trajectories and outcomes of septic patients with low disease severity at ICU admission and highlights the need for more research and clinical attention in this patient population.

Validity of ICD9-CM codes to diagnose chronic obstructive pulmonary disease from National Health Insurance claim data in Taiwan.

PURPOSE: Claim data from Taiwan's National Health Insurance (NHI) database have previously been utilized in the study of COPD. However, there are limited data on the positive predictive value of claim data for COPD diagnosis. Therefore, this study aimed to characterize and validate the COPD cohort identified from the NHI research database. METHODS: This cross-sectional study compared records from claim data with those from a medical center. From 2007 to 2014, a COPD cohort was constructed from claim data using ICD9-CM codes for COPD. The diagnostic positive predictive value of these data was assessed with reference to physician-verified COPD. In addition, a multivariate logistic regression model was built to identify independent factors associated with the positive predictive value of COPD diagnosis by claim data. RESULTS: During the 8-year study period, a total of 12,127 subjects met the criterion of having two or more outpatient codes in 1 year or one or more inpatient COPD codes in their claim data. Of this total, the diagnosis of COPD was verified by physicians in 7,701 (63.5%) subjects. Applying a more stringent criterion - three or more outpatient codes or two or more inpatient codes - improved the diagnostic positive predictive value to 72.2%. Age ≥65 years and a claim for spirometry were the two most important factors associated with the positive predictive value of claim-data-defined COPD. Adding spirometry testing to diagnostic ICD9-CM codes for COPD increased the positive predictive value to 84.6%. CONCLUSION: This study emphasizes the importance of validation of disease-specific diagnosis prior to applying an administrative database in clinical studies. It also indicates the limitation of ICD9-CM codes alone in recognizing COPD patients within the NHI research database.

Experience improves the performance of endobronchial ultrasound-guided transbronchial biopsy for peripheral pulmonary lesions: A learning curve at a medical centre.

BACKGROUND: Endobronchial ultrasound(EBUS)-guided transbronchial biopsy(TBB) is the preferred diagnostic tool for peripheral pulmonary lesions(PPLs) and mastering this procedure is an important task in the training of chest physicians. Little has been published about the learning experience of physicians with this technique, particularly at an institutional level. We aimed to establish a learning curve for EBUS-guided TBB for PPLs at a medical center. METHODS: Between 2008 and 2015, consecutive patients with PPLs referred for EBUS-guided TBB at National Taiwan University Hospital were enrolled. To build the learning curve, the diagnostic yield of TBB (plus brushings and washings) was calculated and compared. Meanwhile, lesion characteristics, and procedure-related features and complications were obtained to analyze associations with TBB yield and safety profile. RESULTS: A total of 2144 patients were included and EBUS-guided TBB was diagnostic for 1547(72%). The TBB yield was 64% in 2008 and reached a plateau of 72% after 2010. It took approximately 400 EBUS-guided procedures to achieve stable proficiency. Further analysis showed that improvement in diagnostic yield over time was mainly observed in PPLs, in cases in which the diameter was ≤2 cm or the EBUS probe could not be positioned within. Complication rates were low, with 1.8% and 0.5% for pneumothorax and hemorrhage, respectively. CONCLUSIONS: Even though EBUS-guided TBB is an easy-to-learn technique, it takes 3 years or around 400 procedures for a medical center to achieve a better and stable performance. In particular, the diagnostic yield for lesions without the probe within or those sized ≤2 cm could improve with time.

Diabetes mellitus in patients with chronic obstructive pulmonary disease-The impact on mortality.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the leading cause of morbidity and mortality worldwide. There is evidence to support a connection between COPD and diabetes mellitus (DM), another common medical disorder. However, additional research is required to improve our knowledge of these relationships and their possible implications. In this study, we investigated the impact of DM on patient outcomes through the clinical course of COPD. METHODS: We conducted a cohort study in patients from the Taiwan Longitudinal Health Insurance Database between 2000 and 2013. Patients with COPD were identified and assessed for pre-existing and incident DM. A Cox proportional hazards model was built to identify factors associated with incident DM and to explore the prognostic effects of DM on COPD patients. A propensity score method was used to match COPD patients with incident DM to controls without incident DM. RESULTS: Pre-existing DM was present in 332 (16%) of 2015 COPD patients who had a significantly higher hazard ratio (HR) [1.244, 95% confidence interval (CI) 1.010-1.532] for mortality than that of the COPD patients without pre-existing DM. During the 10-year follow-up period, 304 (19%) of 1568 COPD patients developed incident DM; comorbid hypertension (HR, 1.810; 95% CI, 1.363-2.403), cerebrovascular disease (HR, 1.517; 95% CI, 1.146-2.008) and coronary artery disease (HR, 1.408; 95% CI 1.089-1.820) were significant factors associated with incident DM. Survival was worse for the COPD patients with incident DM than for the matched controls without incident DM (Log-rank, p = 0.027). CONCLUSIONS: DM, either pre-existing or incident, was associated with worse outcomes in COPD patients. Targeted surveillance and management of DM may be important in clinical care of the COPD population.

Preadmission tracheostomy is associated with better outcomes in patients with prolonged mechanical ventilation in the postintensive care respiratory care setting.

BACKGROUND/PURPOSE: Prolonged mechanical ventilation (PMV) is the most common situation where tracheostomy is indicated for intensive care unit (ICU) patients. However, it is unknown if this procedure confers survival benefits on PMV patients in a post-ICU setting. METHODS: Patients who were admitted to the specialized weaning unit from 2005 to 2008 and received PMV were included in this study. On admission, data pertaining to patient characteristics, physiologic status, and type of artificial airway (tracheostomy vs. no tracheostomy) were obtained. Outcomes of tracheostomized and nontracheostomized patients were evaluated using multivariate Cox proportional hazards and propensity score-matching models. The primary outcome of interest was 1-year survival. RESULTS: A total of 401 patients (mean age 74.4 years, 204 male) were identified. In multivariate analyses, higher Acute Physiology and Chronic Health Evaluation II score [hazard ratio (HR) = 1.061, 95% confidence interval (CI) = 1.016-1.107] and presence of comorbidities, including congestive heart failure (HR = 1.562, 95% CI = 1.119-2.181), malignancy (HR = 1.942, 95% CI = 1.306-2.885), and liver cirrhosis (HR = 2.373, 95% CI = 1.015-5.544), were independently associated with 1-year mortality. An association between having tracheostomy and a better 1-year outcome was observed (HR = 0.625, 95% CI = 0.453-0.863). The matched cohort study also demonstrated a favorable 1-year survival for tracheostomized patients, and these patients had significantly lower in-hospital mortality (24% vs. 36%, p = 0.049) and risk of ventilator-associated pneumonia (10% vs. 20%, p = 0.030) than nontracheostomized ones. CONCLUSION: Preadmission tracheostomy may be associated with better outcomes of PMV patients in a post-ICU respiratory care setting. The findings suggest that this procedure should be recommended before PMV patients are transferred to specialized weaning units.

Identifying and Managing a Malpositioned Endotracheal Tube Bite Block in an Orotracheally Intubated Patient: A Case Report.

The universal bite block is increasingly used in orotracheally intubated patients. Here, we report a case of pilot tube dysfunction caused by a malpositioned universal bite block in an orotracheally intubated patient. We summarize the key points on identifying and managing a malpositioned universal bite block from this case and literature review.A 74-year-old woman was emergently intubated during an episode of hyperkalemia-related cardiac arrest. A universal bite block was used for fixing the endotracheal tube. After her condition stabilized, ventilator weaning was attempted; however, a positive cuff-leak test result was observed.The cuff-leak test revealed a lack of elasticity of the pilot balloon, which was completely deflated after 2 mL of air was removed. Pilot tube dysfunction was highly suspected. The bite block was slightly pulled out, and 8 mL of air was aspirated from the pilot tube. The patient was successfully extubated without stridor and respiratory distress.Our case highlighted that a malpositioned bite block may obstruct the pilot tube, causing unfavorable consequences. While fixing the bite block on an endotracheal tube, it is crucial to ensure that the takeoff point of the pilot tube is located within the C-notch of the bite block.

Coexistence of EGFR T790M mutation and common activating mutations in pretreatment non-small cell lung cancer: A systematic review and meta-analysis.

OBJECTIVE: Previous studies have indicated that EGFR exon 19 deletions in non-small cell lung cancer (NSCLC) are associated with better outcomes to tyrosine kinase inhibitors (TKIs) than the L858R mutation. This study aimed to evaluate whether T790M, a resistant mutation, is more likely to coexist with L858R mutation than with exon 19 deletions in pretreatment NSCLC patients. MATERIALS AND METHOD: We searched MEDLINE and EMBASE up to Nov 30th, 2015 to identify randomized controlled trials (RCTs) and observational studies that reported pretreatment T790M and EGFR-activating mutation. A meta-analysis was performed using a random-effects model. The primary outcome was odds ratio (OR) of pretreatment T790M mutation in NSCLC co-existing with L858R mutation and exon 19 deletions. Stratified analysis was performed based on sensitivity of mutation detection methods for T790M. RESULTS: We identified 15 observational studies and 3 RCTs for analysis. Pretreatment T790M was more frequent in L858R than in exon 19 mutated patients. The association of T790M and L858R was statistically significant in observational studies (OR, 1.65, 95% CI, 1.17-2.32), with less precision in RCTs (OR, 1.84, 95% CI, 0.96-3.52). In the stratified analysis based on the sensitivity of the mutation detection methods, the association was observed in the studies using intermediately (detection limit <5% and ≥ 0.1%; OR, 2.23, 95% CI, 1.19-4.17) and highly sensitive methods (detection limit <0.1%; OR, 1.74, 95% CI, 1.10-2.73), but not in those using low sensitivity methods (detection limit >5%; OR, 1.28, 95% CI, 0.74-2.23). CONCLUSIONS: Pretreatment EGFR T790M mutation is more likely to coexist with L858R mutation than with exon 19 deletions in NSCLC. This association was observed only in studies using sensitive mutation detection methods (<5%).

Fatal pneumonia and empyema thoracis caused by imipenem-resistant Nocardia abscessus in a cancer patient.

We describe a case of pneumonia and empyema thoracis caused by trimethoprim-sulfamethoxazole-susceptible, but imipenem-resistant Nocardia abscessus in a cancer patient. The isolate was confirmed to the species level by 16S rRNA sequencing analysis. The patient did not respond to antibiotic therapy, including ceftriaxone and imipenem, and died of progressing pneumonia and multiple organ failure.

Multi-gene analyses from waste brushing specimens for patients with peripheral lung cancer receiving EBUS-assisted bronchoscopy.

OBJECTIVES: Although flexible bronchoscopy with the assistance of miniature radial-probe endobronchial ultrasound (EBUS) is increasingly employed to diagnose peripheral lung cancer, transbronchial biopsies typically offer an insufficient amount of tissue to conduct additional molecular analysis. We evaluated the feasibility of multi-gene analyses from waste brushing samples obtained by EBUS-assisted bronchoscopy. MATERIALS AND METHODS: For lung cancer patients with positive brushing cytology, analysis of EGFR, K-ras and EML4-ALK fusions were carried out, utilizing reverse transcription-polymerase chain reaction and Sanger sequencing on the cell-derived RNA retrieved from waste brushing samples. RESULTS: EBUS-guided brushings were judged positive for tumor cells in 84 (68.9%) of the 122 patients with peripheral lung cancer receiving flexible bronchoscopy. Genotyping of EGFR and K-ras was successfully implemented in 80 (95.2%) of the 84 cytology-proven brushing samples, along with satisfactory yields to detect EGFR (55.0%) and K-ras (2.5%) mutations. The results of EGFR genotyping from the brushing specimens were highly concordant with those provided from other corresponding samples (concordance rate: 94%, kappa: 0.92). Of the 19 patients with adenocarcinoma or non-small cell lung cancer not otherwise specified harboring wild-type EGFR and K-ras, two cases (10.5%) were identified to harbor EML4-ALK fusions. CONCLUSION: Our results suggest that multi-gene analyses from waste brushing specimens using RNA-based Sanger sequencing is highly feasible. This approach offers an opportunity to overcome the dilemma of flexible bronchoscopy in molecular diagnostics for lung cancer, and could potentially recruit more patients for targeted therapy according to the molecular characteristics of the tumor cells.

Risk factors of pneumothorax after endobronchial ultrasound-guided transbronchial biopsy for peripheral lung lesions.

BACKGROUND: The risk of endobronchial ultrasound-guided transbronchial biopsy-related pneumothorax is a major concern and warrants further studies. The aim of our study was to estimate the risk of pneumothorax after this procedure and identify its risk factors. METHODS: From 2007 to 2011, 399 patients who underwent endobronchial ultrasound-guided transbronchial biopsy for peripheral lung lesions were included in this study. The variables analyzed included patient factors, lesion factors and procedure factors. Multivariate logistic regression analysis was used to identify independent risk factors for pneumothorax. RESULTS: The incidence of pneumothorax was 3.3% (13/399). Chest tube placement was required for 31% (4/13) of pneumothoraces. Independent risk factors for pneumothorax included pulmonary emphysema (OR, 55.09; 95% CI, 9.37-324.03; p<0.001) and probe position adjacent to the lesion (OR, 17.01; 95% CI, 2.85-101.64; p = 0.002). The number of biopsy specimens, age, sex, history of prior lung surgery and lesion size, location and character did not influence the risk of pneumothorax in our analyses. CONCLUSIONS: The risk of pneumothorax after endobronchial ultrasound-guided transbronchial biopsy is low. To further reduce the risk of pneumothorax, every effort should be made to advance the endobronchial ultrasound probe into the bronchus where it is imaged within the target lesion before embarking on transbronchial biopsy.

Revisiting tuberculous pleurisy: pleural fluid characteristics and diagnostic yield of mycobacterial culture in an endemic area.

BACKGROUND: Tuberculous pleurisy is traditionally indicated by extreme lymphocytosis in pleural fluid and low yield of effusion culture. However, there is considerable inconsistency among previous study results. In addition, these data should be updated due to early effusion studies and advances in culture methods. METHODS: From January 2004 to June 2009, patients with tuberculous pleurisy were retrospectively identified from the mycobacteriology laboratories and the pathology and tuberculosis registration databases of two hospitals in Taiwan where tuberculosis is endemic. Pleural fluid characteristics and yields of mycobacterial cultures using liquid media were evaluated. RESULTS: A total of 382 patients with tuberculous pleurisy were identified. The median lymphocyte percentage of total cells in pleural fluids was 84% (IQR 64-95%) and 17% of cases had a lymphocyte percentage of <50%. The lymphocyte percentage was negatively associated with the probability of a positive effusion culture (OR 0.97; 95% CI 0.96 to 0.99). The diagnostic yields were 63% for effusion culture, 48% for sputum culture, 79% for the combination of effusion and sputum cultures, and 74% for histological examination of pleural biopsy specimens. CONCLUSION: The degree of lymphocyte predominance in tuberculous pleurisy was lower than was previously thought. The lymphocyte percentage in pleural fluid was negatively associated with the probability of a positive effusion culture. With the implementation of a liquid culture method, the sensitivity of effusion culture was much higher than has been previously reported, and the combination of effusion and sputum cultures provided a good diagnostic yield.

Invasive trichosporonosis caused by Trichosporon asahii and other unusual Trichosporon species at a medical center in Taiwan.

BACKGROUND: During the past 2 decades, invasive trichosporonosis has emerged as an opportunistic infectious disease in immunocompromised patients. However, no case series have been reported recently. METHODS: All patients with a culture that was positive for Trichosporon species from May 2000 through May 2008 at a medical center were evaluated. The identity of all Trichosporon species was confirmed by analysis of the intergenic spacer 1 region of the fungal ribosomal RNA gene. In vitro susceptibility testing was performed using the reference broth microdilution method. RESULTS: Forty-three patients were found to have a culture that was positive for Trichosporon species. T. asahii was the most frequently isolated species (32 isolates; 74%), followed by T. dermatis (5; 12%), T. montevideense (2; 5%), and T. asteroides (1; 2%), T. cutaneum (1; 2%), T. faecale (1; 2%), and T. ovoides (1; 2%). Nineteen patients had invasive infections; 16 (84%) were caused by T. asahii, and 1 (5%) each was caused by T. dermatis, T. montevideense, and T. asteroides. Of the 19 episodes of invasive trichosporonosis, 14 (74%) were fungemia, 3 (16%) were pulmonary infection, and 1 (5%) each was soft-tissue infection and meningitis. Most invasive infections were associated with prior antibiotic therapy (95%), use of a central catheter (90%), malignancy (58%), and intensive care unit admission (47%). Azoles had good in vitro activity, whereas amphotericin B and echinocandins were not active against Trichosporon isolates. The 30-day all-cause mortality rate was 42% and was higher among patients with a malignancy (55%) than among those without an underlying malignancy (25%). CONCLUSIONS: Invasive trichosporonosis tended to develop in patients with an underlying malignancy and to be associated with higher mortality. T. asahii and other unusual Trichosporon species may cause invasive trichosporonosis.

Candida glabrata fungaemia in a tertiary centre in Taiwan: antifungal susceptibility and outcomes.

The proportion of non-albicans candidaemia has increased during recent decades, especially Candida glabrata. We evaluated the antifungal susceptibility, clinical features and outcome of C. glabrata fungaemia treated in a tertiary centre in Taiwan. All episodes of C. glabrata fungaemia during 1999-2005 were identified from microbiology laboratory records and all C. glabrata isolates were subjected to antifungal susceptibility testing by the broth microdilution method. A total of 177 episodes of C. glabrata fungaemia were documented, accounting for 30% of the 598 episodes of candidaemia. A dramatic decline of C. glabrata causing candidaemia from 2003 (46.8%) to 2005 (15.8%) was noted, accompanied by decreased fluconazole consumption. The most common underlying diseases in these patients were cancer (49%), diabetes (34%) and renal failure (25%). The most common risk factors were central venous catheter use (88%), antimicrobial treatment (87%) and parenteral nutrition (51%). The 30-day all-cause mortality was 48.6%, but only 31% of patients were eventually discharged from the hospital. There was no significant survival difference between patients with C. glabrata and Candida albicans fungaemia. Rates of antifungal susceptibility were 63% for fluconazole, 93% for voriconazole, 96% for caspofungin, 98% for amphotericin B and 99% for flucytosine. The different levels of susceptibility to fluconazole (susceptible, susceptible-dose dependent and resistant) were not significantly associated with 30-day mortality.

Recurrent respiratory papillomatosis with pulmonary involvement: a case report and review of the literature.

Recurrent respiratory papillomatosis (RRP) is a viral infection that usually affects the upper airways. Although it can spread throughout the respiratory tract, involvement of the lung parenchyma is quite rare. Radiographic images of RRP with lung involvement have been mainly presented in case reports of paediatric patients. We present the case of an adult patient with RRP and lung involvement, and detail the serial radiographic manifestations. CT and reconstructed images were obtained. The literature was also reviewed and radiographic features of RRP with lung involvement are summarized.