Altered functional connectivity of the nucleus tractus solitarii in patients with chronic cough after lung surgery: an rs-fMRI study.

BACKGROUND: To explore the altered functional connectivity (FC) of the nucleus tractus solitarii (NTS) in patients with chronic cough after lung surgery using resting-state functional magnetic resonance imaging (rs-fMRI), and the association between abnormal FC and clinical scale scores. METHODS: A total of 22 patients with chronic cough after lung surgery and 22 healthy controls were included. Visual analog scale (VAS), Mandarin Chinese version of the Leicester Cough Questionnaire (LCQ-MC), and Hamilton anxiety rating scale (HAMA) scores were assessed, and rs-fMRI data were collected. The FC analysis was performed using the NTS as the seed point, and FC values with all voxels in the whole brain were calculated. A two-sample t-test was used to compare FC differences between the two groups. The FC values of brain regions with differences were extracted and correlated with clinical scale scores. RESULTS: In comparison to healthy controls, FC values in the NTS and anterior cingulate cortex(ACC) were reduced in patients with chronic cough after lung surgery (GRF correction, p-voxel < 0.005, p-cluster < 0.05) which were positively correlated with LCQ-MC scores (r = 0.534, p = 0.011), but with VAS (r = -0.500, p = 0.018), HAMA (r = -0.713, p < 0.001) scores were negatively correlated. CONCLUSIONS: Reduced FC of the NTS with ACC may be associated with cough hypersensitivity and may contribute to anxiety in patients with chronic cough after lung surgery.

CT airway remodelling and chronic cough.

RATIONALE: Structural airway changes related to chronic cough (CC) are described in the literature, but so far reported data are rare and non-conclusive. Furthermore, they derive mainly from cohorts with small sample sizes. Advanced CT imaging not only allows airway abnormalities to be quantified, but also to count the number of visible airways. The current study evaluates these airway abnormalities in CC and assesses the contribution of CC in addition to CT findings on the progression of airflow limitation, defined as a decline in forced expiratory volume in 1 s (FEV1) over time. METHODS: A total of 1183 males and females aged ≥40 years with thoracic CT scans and valid spirometry from Canadian Obstructive Lung Disease, a Canadian multicentre, population-based study has been included in this analysis. Participants were stratified into 286 never-smokers, 297 ever-smokers with normal lung function and 600 with chronic obstructive pulmonary disease (COPD) of different severity grades. Imaging parameters analyses included total airway count (TAC), airway wall thickness, emphysema as well as parameters for functional small airway disease quantification. RESULTS: Irrespective of COPD presence, CC was not related to specific airway and lung structure features. Independent of TAC and emphysema score, CC was highly associated with FEV1 decline over time in the entire study population, particularly in ever-smokers (p<0.0001). CONCLUSION: The absence of specific structural CT features independently from COPD presence indicate that other underlying mechanisms are contributing to the symptomatology of CC. On top of derived CT parameters, CC seems to be independently associated with FEV1 decline. TRIAL REGISTRATION NUMBER: NCT00920348.

Diagnóstico tardío de cuerpos extraños en vía aérea en pediatría en el ospital de Especialidades Carlos Andrade Marín / Late diagnosis of foreign bodies in pediatric airway in the Carlos Andrade Marín Specialties Hospital

La aspiración de cuerpos extraños es una de las principales causas de ingreso a urgencias y de morbi-mortalidad en Ecuador en pacientes pediátricos. El diagnóstico suele ser tardío, por falta de interés de los cuidadores, o por errores en la valoración. Es importante detectar el cuadro a tiempo, para evitar complicaciones. OBJETIVO. Demostrar la necesidad de un diagnóstico acertado ante la alta sospecha en un cuadro dudoso de aspiración de cuerpo extraño. SERIE DE CASOS. Evaluación de cuatro pacientes de ambos sexos, de entre 11 meses a 15 años de edad con antecedente de ingesta de cuerpo extraño, atendidos en la Unidad Técnica de Cirugía Pediátrica, del Hospital de Especialidades Carlos Andrade Marín, durante el periodo 2019-2020. Se realizó la extracción exitosa mediante broncoscopia rígida en tres de ellos. DISCUSIÓN. La mayoría de pacientes con aspiración de cuerpo extraño suelen ser menores de 5 años de edad, en contraste con éste estudio, donde sólo un paciente estuvo dentro de este rango, y el resto fueron escolares y adolescentes. El cuerpo extraño más común es de origen orgánico; el 50% de los casos observados fue de origen inorgánico. CONCLUSIÓN. El diagnóstico de aspiración de cuerpo extraño se condiciona a la obtención completa de datos sobre la Historia Clínica; requiere una valoración rápida y manejo adecuado por emergencias.

INTRODUCTION. Foreign body aspiration is one of the main causes of emergency room admissions and morbidity and mortality in pediatric patients in Ecuador. Diagnosis is usually late, due to lack of interest of caregivers, or due to errors in the assessment. It is important to detect the condition in time to avoid complications. OBJECTIVE. To demonstrate the need for an accurate diagnosis in the presence of high suspicion in a doubtful picture of foreign body aspiration. CASE SERIES. Evaluation of four patients of both sexes, between 11 months and 15 years of age with a history of foreign body ingestion, attended at the Pediatric Surgery Technical Unit of the Carlos Andrade Marin Specialties Hospital, during 2019-2020 period. Successful extraction by rigid bronchoscopy was performed in three of them. DISCUSSION. Most patients with foreign body aspiration are usually under 5 years of age, in contrast to this study, where only one patient was within this range, and the rest were schoolchildren and adolescents. The most common foreign body is of organic origin; 50% of the cases observed were of inorganic origin. CONCLUSION. The diagnosis of foreign body aspiration is conditioned to the complete collection of data on the Clinical History; it requires a rapid assessment and appropriate emergency management.

ACR Appropriateness Criteria® Chronic Cough.

Chronic cough is defined by a duration lasting at least 8 weeks. The most common causes of chronic cough include smoking-related lung disease, upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis. The etiology of chronic cough in some patients may be difficult to localize to an isolated source and is often multifactorial. The complex pathophysiology, clinical presentation, and variable manifestations of chronic cough underscore the challenges faced by clinicians in the evaluation and management of these patients. Imaging plays a role in the initial evaluation, although there is a lack of high-quality evidence guiding which modalities are useful and at what point in time the clinical evaluation should be performed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A 56-Year-Old Man With Chronic Cough, Hemoptysis, and a Left Lower Lobe Infiltrate.

CASE PRESENTATION: A 56-year-old man presented to the lung nodule clinic with abnormal chest imaging prompted by a chronic cough and hemoptysis. Approximately 2.5 years earlier, while kneeling beside his car fixing a flat tire, he fell backwards while holding the tire cap in his mouth, causing him to inhale sharply and aspirate the cap. He immediately developed an intractable cough productive of flecks of blood. He presented to an emergency room but left before being seen because of a long wait time and his lack of health-care insurance. He self-medicated for severe cough and chest discomfort with codeine, eventually developing a dependency. Approximately 3 weeks after aspirating the tire cap, his cough became productive, and he developed fever and chills. His symptoms improved transiently with antibiotics and additional narcotics. Ultimately, his chronic cough with intermittent hemoptysis affected his ability to work, and 30 months later he sought medical attention and was diagnosed with pneumonia and reactive airway disease. He was prescribed doxycycline, steroids, inhaled albuterol, and dextromethorphan, with initial improvement, but his symptoms recurred multiple times despite quitting smoking, leading to repeated medication courses.

Opsoclonus-myoclonus syndrome, a post-infectious neurologic complication of COVID-19: case series and review of literature.

Opsoclonus-myoclonus-ataxia syndrome is a heterogeneous constellation of symptoms ranging from full combination of these three neurological findings to varying degrees of isolated individual sign. Since the emergence of coronavirus disease 2019 (COVID-19), neurological symptoms, syndromes, and complications associated with this multi-organ viral infection have been reported and the various aspects of neurological involvement are increasingly uncovered. As a neuro-inflammatory disorder, one would expect to observe opsoclonus-myoclonus syndrome after a prevalent viral infection in a pandemic scale, as it has been the case for many other neuro-inflammatory syndromes. We report seven cases of opsoclonus-myoclonus syndrome presumably parainfectious in nature and discuss their phenomenology, their possible pathophysiological relationship to COVID-19, and diagnostic and treatment strategy in each case. Finally, we review the relevant data in the literature regarding the opsoclonus-myoclonus syndrome and possible similar cases associated with COVID-19 and its diagnostic importance for clinicians in various fields of medicine encountering COVID-19 patients and its complications.

A 16-Year-Old Boy With Cough and Fever in the Era of COVID-19.

A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient's respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient's clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019.

COVID-19 in cancer patients can be challenging to screen in a resource limited setting.

During this COVID-19 pandemic, patients with symptoms such as fever, cough, sore throat, and coryza were advised to have RT-PCR testing for SARS-CoV-2 infection. We described here an elderly female with chronic lymphocytic leukemia, who presented with atypical symptoms that were not directly attributable to COVID-19. This patient was admitted to the non-COVID-19 ward for supportive care. Later, her chest x-ray revealed pneumonia that was confirmed to be COVID-19 by RT-PCR testing several days later. In resource-poor settings where molecular testing results suffered from delays or were altogether unavailable, the use of diagnostic imaging such as a chest x-ray could serve as a quick guide in the assessment and management of these patients especially if the imaging results suggest COVID-19 infection.

[A dyspnoeic woman with an abnormal chest image]. / Een benauwde vrouw met een afwijkende thoraxfoto.

A 19-year-old woman presented with a productive cough, fever and chest pain. Clinical and chest X-ray findings prompted us to do a CT-scan, which revealed a mediastinal mass extending in the left thoracic cavity, suggestive of a teratoma with an obstructive pneumonia. The patient was successfully treated with intravenous antibiotics and surgical removal of the tumour.

Lung ultrasonography findings in dogs with various underlying causes of cough.

OBJECTIVE: To characterize lung ultrasonography (LUS) findings in dogs with a primary clinical complaint of cough. ANIMALS: 100 client-owned coughing dogs. PROCEDURES: A standardized LUS examination was performed for all dogs to quantify the number of B lines and identify subpleural abnormalities at 4 sites on each hemithorax. The final clinical diagnosis (reference standard) was determined by medical record review, and sensitivity and specificity of LUS for the diagnosis of selected causes of cough was determined. RESULTS: Common underlying causes of cough included dynamic airway collapse (n = 37), cardiogenic pulmonary edema (CPE; 12), and bronchitis (10). Compared with dogs with other causes of cough, dogs with bacterial pneumonia (n = 7) were more likely to have subpleural shred signs, whereas dogs with pulmonary neoplasia (4) were more likely to have subpleural nodule signs. Dogs with CPE had higher total B-line scores and higher numbers of LUS sites strongly positive for B lines (> 3 B lines/site) than other dogs. The LUS criteria of total B-line score ≥ 10 and presence of ≥ 2 sites strongly positive for B lines were each 92% sensitive and 94% specific for CPE diagnosis. Notably, 18% (16/88) of dogs with noncardiac causes of cough had been treated previously with diuretics because of prior CPE misdiagnosis. CONCLUSIONS AND CLINICAL RELEVANCE: LUS profiles in dogs with cough differed by the underlying cause. In dogs with a clinical history of cough, this imaging modality could be diagnostically useful, particularly to help exclude the possibility of underlying CPE.

A 63-Year-Old Woman With Pulmonary Micronodules and Chronic Cough.

CASE PRESENTATION: A 63-year-old woman presented with a 2-year history of nonproductive cough. She denied the presence of shortness of breath, chest pain, arthralgia, muscle weakness, weight loss, night sweats, and fatigue. She was a never smoker and had a history of arterial hypertension and diabetes. There was no history of asthma, allergic rhinitis, nasal polyps, or gastroesophageal reflux disease, known malignancy, or collagen tissue disease. She reported exposure to house mold. There was no family history of respiratory diseases. The patient denied alcohol consumption, illicit drug use, occupational exposures, any recent travel, or exposure to TB.

Altered neural activity in brain cough suppression networks in cigarette smokers.

Cough is important for airway defence, and studies in healthy animals and humans have revealed multiple brain networks intimately involved in the perception of airway irritation, cough induction and cough suppression. Changes in cough sensitivity and/or the ability to suppress cough accompany pulmonary pathologies, suggesting a level of plasticity is possible in these central neural circuits. However, little is known about how persistent inputs from the lung might modify the brain processes regulating cough.In the present study, we used human functional brain imaging to investigate the central neural responses that accompany an altered cough sensitivity in cigarette smokers.In nonsmokers, inhalation of the airway irritant capsaicin induced a transient urge-to-cough associated with the activation of a distributed brain network that included sensory, prefrontal and motor cortical regions. Cigarette smokers demonstrated significantly higher thresholds for capsaicin-induced urge-to-cough, consistent with a reduced sensitivity to airway irritation. Intriguingly, this was accompanied by increased activation in brain regions known to be involved in both cough sensory processing (primary sensorimotor cortex) and cough suppression (dorsolateral prefrontal cortex and the midbrain nucleus cuneiformis). Activations in the prefrontal cortex were highest among participants with the least severe smoking behaviour, whereas those in the midbrain correlated with more severe smoking behaviour.These outcomes suggest that smoking-induced sensitisation of central cough neural circuits is offset by concurrently enhanced central suppression. Furthermore, central suppression mechanisms may evolve with the severity of smoke exposure, changing from initial prefrontal inhibition to more primitive midbrain processes as exposure increases.

A bimodal approach to thymic carcinoma with pericardial sac invasion.

Thymic carcinoma is a rare tumour of the thymus, representing less than 1% of thymic malignancies. 1 It has an annual incidence of 0.15-0.32 per 1 00 000 person-years. 2 It is found incidentally in 30% of the patients as an opacity on chest X-ray or with non-specific complaints of persistent cough, chest pain, fatigue, shortness of breath, arm and facial swelling, and upper airway congestion related to tumour extension. We present the case of a 59-year-old man with a history of Graves' disease status post radiation treatment presenting with cough and left lingual opacity on chest X-ray, confirmed to be thymic carcinoma with pericardial invasion and lymph node metastasis. We aim to discuss the presentation, treatment modalities and outcome associated with this rare tumour.

Lund-Mackay Computed Tomography Score Is Associated With Obstructive Pulmonary Function Changes in Chronic Cough Patients.

BACKGROUND: A remarkable relationship between upper airway conditions and lung diseases has been reported. At the same time, sinonasal findings in chronic cough patients have not been fully examined. OBJECTIVE: The purpose of this study is to show paranasal sinus findings and lung function in chronic cough patients without asthma and chest X-ray abnormalities. METHODS: A total of 1412 patients with persistent cough were enrolled in this study. Of these patients, 376 patients were evaluated for further examination, as the patients with asthma and/or chest X-ray abnormality were excluded from the study. Normal control subjects without any chronic respiratory symptoms were also recruited. Pulmonary function was examined by spirometry. A bronchial obstruction reversibility test was applied. The Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples were examined. The Sino-Nasal Outcome Test was used to determine the severity of clinical symptoms. RESULTS: The patients with an abnormal soft tissue shadow in the paranasal sinus had significant obstructive lung function. The percent predicted forced expiratory volume in 1 second (FEV1.0) and the FEV1.0/forced vital capacity ratio negatively correlated with Lund-Mackay CT scores both before and after bronchodilator inhalation. There was a statistically significant correlation between pulmonary function and eosinophil count. CONCLUSION: The patients with chronic cough frequently had paranasal sinus abnormalities. The Lund-Mackay CT score may be useful for assessing the condition of the lower airway in chronic cough patients. Upper airway examinations should play a part in the management of chronic cough.

Clinical characteristics and prognosis of idiopathic pulmonary hemosiderosis in pediatric patients.

OBJECTIVE: This study aimed to analyze the clinical characteristics and prognosis of pediatric idiopathic pulmonary hemosiderosis (IPH). METHODS: Pediatric IPH cases that were diagnosed at West China Second University Hospital, Sichuan University between 1996 and 2017 were reviewed. Follow-up data from 34 patients were collected. RESULTS: A total of 107 patients were included (42 boys and 65 girls). The median age was 6 years at diagnosis. The main manifestations of the patients were as follows: anemia (n = 100, 93.45%), cough (n = 68, 63.55%), hemoptysis (n = 61, 57%), fever (n = 23, 21.5%), and dyspnea (n = 23, 21.5%). There were relatively few pulmonary signs. The positive rates of hemosiderin-laden macrophages in sputum, gastric lavage fluid, and bronchoalveolar lavage fluid were 91.66%, 98.21%, and 100%, respectively. Seventy-nine patients were misdiagnosed. A total of 105 patients were initially treated with glucocorticoids, among whom 102 survived and three died. Among the followed up patients, two died and 32 survived, among whom 10 presented with recurrent episodes. CONCLUSIONS: The classic triad of pediatric IPH is not always present. The rates of misdiagnosis and recurrence of IPH are high. Early recognition and adequate immunosuppressive therapy are imperative for improving prognosis of IPH.

Pulmonary pythiosis in a canine patient.

A Staffordshire terrier presented for evaluation of a chronic, nonproductive cough that was unresponsive to antibiotic therapy. A large mass identified in the pulmonary hilum was most consistent with tracheobronchial lymphadenopathy on radiographic and computed tomography (CT) images. Bronchoscopy confirmed a mass compressing the dorsal portion of the intrathoracic trachea. Bronchoscopic biopsies of the tracheal mass revealed necrosuppurative and eosinophilic inflammation with intralesional Pythium insidiousum hyphae. Pythiosis should be included as a differential diagnosis for tracheobronchial lymphadenopathy and bronchopneumopathy in dogs, especially when the patient is from or has visited a region endemic for Pythium insidiosum.