Maximum phonation time: an independent predictor of late-onset pneumonia after esophageal cancer surgery.

Dysphagia after esophagectomy is a major risk factor for aspiration pneumonia, thus preoperative assessment of swallowing function is important. The maximum phonation time (MPT) is a simple indicator of phonatory function and also correlates with muscle strength associated with swallowing. This study aimed to determine whether preoperative MPT can predict postoperative aspiration pneumonia. The study included 409 consecutive patients who underwent esophagectomy for esophageal cancer between 2017 and 2021. Pneumonia detected by routine computed tomography on postoperative days 5-6 was defined as early-onset pneumonia, and pneumonia that developed later (most often aspiration pneumonia) was defined as late-onset pneumonia. The correlation between late-onset pneumonia and preoperative MPT was investigated. Patients were classified into short MPT (<15 seconds for males and <10 seconds for females, n = 156) and normal MPT groups (≥15 seconds for males and ≥10 seconds for females, n = 253). The short MPT group was significantly older, had a lower serum albumin level and vital capacity, and had a significantly higher incidence of late-onset pneumonia (18.6 vs. 6.7%, P < 0.001). Multivariate analysis showed that short MPT was an independent risk factor for late-onset pneumonia (odds ratio: 2.26, P = 0.026). The incidence of late-onset pneumonia was significantly higher in the short MPT group (15.6 vs. 4.7%, P = 0.004), even after propensity score matching adjusted for clinical characteristics. MPT is a useful predictor for late-onset pneumonia after esophagectomy.

Sarcoidosis with small syringotropic granulomas presenting clinically as a pigmented purpuric dermatosis: Inconspicuous clinical and histopathological clues to systemic illness.

Sarcoidosis is a multisystem granulomatous disease with a myriad of clinical manifestations and a predilection to involve the lungs, eyes, lymph nodes, and skin. A 38-year-old man presented to dermatology with a history of progressive dyspnea, pulmonary consolidations on chest X-ray, and hilar adenopathy on computed tomography scan. Skin exam revealed asymptomatic, yellow to brown macules on the right lower extremity. Biopsy of a lesion showed diminutive syringotropic granulomas and perivascular hemosiderin; stains for bacteria, mycobacteria, and fungi were negative. Subsequent fine needle aspiration of a hilar mass revealed non-necrotizing epithelioid granulomas further supporting a diagnosis of sarcoidosis. The patient was placed on systemic steroids and had improvement of his pulmonary symptoms and stabilization of his hilar lymphadenopathy without resolution of his pigmented purpuric dermatosis (PPD) like lesions. Only three prior cases of syringotropic sarcoidosis have been reported; however, the biopsies had revealed conspicuously large granulomas in contrast with the small granulomas in our case, and none of the prior patients had clinical examination findings that mimicked PPD. Recognition of rare dermatologic and histopathological appearances of sarcoidosis is paramount as cutaneous sarcoidosis may be the harbinger of a systemic illness, which requires a timely diagnosis.

Impact of delay in early swallow screening on pneumonia, length of stay in hospital, disability and mortality in acute stroke patients.

BACKGROUND/OBJECTIVES: Early swallow screening, within 4 h of admission, is required for all acute stroke patients to commence nutritional support, as recommended. We evaluated the impact of delay in early swallow screening on outcomes in patients admitted with acute stroke. SUBJECTS/METHODS: Prospective cohort study of 1656 men (mean ± SD age = 73.1y ± 13.2) and 1653 women (79.3y ± 13.0) admitted with stroke to hyperacute stroke units (HASUs) in Surrey. Logistic regression was used to assess the risk (adjusted for age, stroke severity and co-morbidities) of delay in swallow screening on pneumonia, length of stay (LOS) > 3 weeks in HASU or hospital, moderately severe to severe disability on discharge (modified Rankin scale score = 4-5) and mortality during admission. RESULTS: Compared with those who received swallow screening within 4 h of admission, a delay between 4 and 72 h was associated with greater risks of pneumonia: OR = 1.4 (95%CI:1.1-1.9, P = 0.022), moderately severe to severe disability on discharge: OR = 1.4 (1.1-1.7, P = 0.007) and a delay beyond 72 h was associated with even greater risks of pneumonia: OR = 2.3 (1.4-3.6, P < 0.001), prolonged LOS in HASU: OR = 1.7 (1.0-3.0, P = 0.047, median LOS = 6.2 vs. 14.7 days) and hospital: OR = 2.1-fold (1.3-3.4, P = 0.007, median LOS = 6.8 vs. 14.9 days), moderately severe to severe disability on discharge: OR = 2.5 (1.7-3.7, P < 0.001) and mortality: OR = 3.8 (2.5-5.6, P < 0.001). These risks persisted after excluding 103 patients who died within 72 h. CONCLUSIONS: Delay in early screening for swallow capacity in acute stroke patients is detrimental to outcomes, possibly due to delaying nutritional provision or through inappropriate feeding leading to aspiration. Routine early screening needs greater attention in HASUs.

Early Dysphagia Screening by Trained Nurses Reduces Pneumonia Rate in Stroke Patients: A Clinical Intervention Study.

BACKGROUND AND PURPOSE: Dysphagia is a common stroke symptom and leads to serious complications such as aspiration and pneumonia. Early dysphagia screening can reduce these complications. In many hospitals, dysphagia screening is performed by speech-language therapists who are often not available on weekends/holidays, which results in delayed dysphagia assessment. METHODS: We trained the nurses of our neurological department to perform formal dysphagia screening in every acute stroke patient by using the Gugging Swallowing Screen. The impact of a 24/7 dysphagia screening (intervention) over swallowing assessment by speech-language therapists during regular working hours only was compared in two 5-month periods with time to dysphagia screening, pneumonia rate, and length of hospitalization as outcome variables. RESULTS: Overall, 384 patients (mean age, 72.3±13.7 years; median National Institutes of Health Stroke Scale score of 3) were included in the study. Both groups (pre-intervention, n=198 versus post-intervention, n=186) were comparable regarding age, sex, and stroke severity. Time to dysphagia screening was significantly reduced in the intervention group (median, 7 hours; range, 1-69 hours) compared with the control group (median, 20 hours; range, 1-183; P=0.001). Patients in the intervention group had a lower rate of pneumonia (3.8% versus 11.6%; P=0.004) and also a reduced length of hospital stay (median, 8 days; range, 2-40 versus median, 9 days; range, 1-61 days; P=0.033). CONCLUSIONS: 24/7 dysphagia screening can be effectively performed by nurses and leads to reduced pneumonia rates. Therefore, empowering nurses to do a formal bedside screening for swallowing dysfunction in stroke patients timely after admission is warranted whenever speech-language therapists are not available.

Retrospective evaluation of patients with organizing pneumonia: is cryptogenic organizing pneumonia different from secondary organizing pneumonia?

INTRODUCTION: Organizing pneumonia (OP) is an uncommon clinic opathological situation among lung diseases. If no underlying cause can be detected, it is named as cryptogenic OP (COP). In this study, the etiologic and clinical characteristics of patients diagnosed as OP in our hospital in the last ten years were evaluated retrospectively. It was also aimed to make a comparison between COP and secondary OP patients. MATERIALS AND METHODS: One hundred sixty-five patients diagnosed as OP pathologically in the 10 year period from August 2003 to August 2013 were included into that study. Patients' data were evaluated retrospectively from the medical records. RESULT: One hundred sixty five patients pathologically diagnosed as OP were included. Diagnostic methods were trans-thoracic fine-needle biopsy (TTFNB) in 89 (53.9%) patients, open lung biopsy (lobectomy, wedge resection, segmentectomy) in 52 (31.5%) patients and transbronchial biyopsy (TBB) in 24 (14.5%) patients. One hundred (60.6%) of the patients were defined as COP and 65 (39.4%) as secondary OP. Cough, fatigue and dyspnea were the most common symptoms on admission. We detected OP cases secondary to anthracosis and cyst hydatic besides other well known etiologies. In 61 patients, the main radiologic manifestation was multiple bilateral patchy consolidation typical for OP. In 76 patients focal lesions (solid mass, cavitating mass lesion) and in 6 patients infiltrative opacities were detected radiologically. CONCLUSIONS: There is no difference between properties of OP from clinical, laboratory and radiologic finding sin the criptogenic and seconder form of OP. Although it is not asserted, cyst hidatic and anthracosis could be kept in mind for the list of underlying ethiologies for secondary OP.

Drug resistant pulmonary tuberculosis mimicking a flu-like syndrome in an elderly man: an atypical case report.

Despite remarkable reductions in its incidence and mortality, tuberculosis (TB) continues to be a major health burden globally. Pulmonary TB occasionally challenges physicians, either due to TB's ability to mimic many different conditions or because of the increasing number of drug-resistant Mycobacterium tuberculosis isolates. Here we present a case of pulmonary TB with both characteristics and a brief review of the relevant literature.

A cat has 9 lives: The dilemma of diagnosing non hodgkin's lymphoma in intensive care unit.

Non hodgkins lymphoma is a common haematological malignancy characterized by abnormal clonal proliferation of T-cells, B-cells or both. The incidence of non hodgkins lymphoma is rapidly rising. The diagnosis and management of NHL presents as a challenge in developing countries like India due to high prevalence of tuberculosis, cost and poor patient compliance. We describe an unusual case of a patient who presented as a diagnostic dilemma and took 8 diagnosis before finally being confirmed as a case of NHL. A suspicion for NHL should always be kept in mind in a patient presenting with pneumonia, bilateral pulmonary infiltrates and eosinophilia.

Risks and benefits in treatment of mediastinal abscess by endobronchial ultrasound-guided transbronchial needle aspiration.

INTRODUCTION: Mediastinal abscess is a fatal condition, treatment of mediastinal abscess is with antibiotics and sometimes surgery for debridement and drainage. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe assessment and candidate treatment method of mediastinal lesions. OBJECTIVES: This study aimed to HYPERLINK "javascript:void(0);" discuss risks and benefits in treatment of mediastinal abscess by EBUS-TBNA. METHODS: We noticed a 56-year-old man with developed bilateral pneumonia and sepsis after puncture of mediastinal abscess by EBUS-TBNA. The patient was successfully treated with a combination of systemic anti-infection treatment and intracavitary administration of antibiotics, antifungal and repeated drainage and lavage via EBUS-TBNA, in 1 year follow-up without recurrence. RESULTS: This study indicated infection spread risk of mediastinal abscess after EBUS-TBNA, and mediastinal abscess was successfully cured by combination of systemic anti-infection and local intervention through EBUS-TBNA. CONCLUSION: EBUS-TBNA is a potential effective minimally invasive treatment for mediastinal abscess, and it is necessary to be aware of clinical complications after puncture of mediastinal infectious lesions by EBUS-TBNA.

Síndrome de Mendelson: reporte de un caso / Mendelson syndrome: a case report

El Síndrome de Mendelson es una presentación infrecuente pero catastrófica, consiste en la aspiración de contenido gástrico acido hacia los pulmones causando una neumonitis química por el paso de sustancias toxicas a las vías respiratoria inferiores. El cuadro clínico está caracterizado por hipoxemia, disnea, broncoespasmo, taquipnea, edema pulmonar, hipotensión, cianosis y atelectasias. La dificultad respiratoria se debe al edema agudo de pulmón y la necrosis. El diagnostico del Síndrome de Mendelson es de presunción en base a la sintomatología, la evolución de la enfermedad y los hallazgos en los exámenes de gabinete. Su tratamiento correcto es fundamental debido a la alta morbimortalidad que conlleva. Se presenta el caso de síndrome de Mendelson en un paciente de 89 años de edad debido a la enfermedad de Alzheimer, un trastorno neurodegenerativo. Se presentó a emergencias con un cuadro de vómitos postprandiales en abundante cantidad con contenido bilioso con secreciones flemosas, nauseas y dolor abdominal. La broncoscopia de urgencia fue clave para el diagnostico y el posterior tratamiento.

Mendelson's Syndrome is a rare but catastrophic presentation, is the aspiration of acidic gastric contents into the lungs causing chemical pneumonitis by the passage of toxic substances the lower respiratory tract. The clinical picture is characterized by hypoxemia, dyspnea, bronchospasm, tachypnea, pulmonary edema, hypotension, cyanosis, and atelectasis. Shortness of breath is due to acute pulmonary edema and necrosis. The diagnosis of Mendelson's Syndrome presumption is based on the symptoms, the disease evolution and the findings on tests of staff. Proper treatment is essential because of the high morbidity and mortality involved. For Mendelson's syndrome occurs in a patient of 89 years of age due to Alzheimer's disease, a neurodegenerative disorder. It was presented to emergency with symptoms of postprandial vomiting plenty flemosas content with bilious secretions, nausea and abdominal pain. Emergency bronchoscopy was key to the diagnosis and subsequent treatment.

An unusual presentation of congenital adrenocortical carcinoma: a case report and review of the literature.

We describe a case of congenital non-functional adrenocortical carcinoma in a male infant who presented with recurrent pneumonia, paraparesis and sclerotic skeletal metastasis. To the best of our knowledge such presentation has never been reported.

Coma blisters with hypoxemic respiratory failure.

A 24-year-old woman with quadriplegia was admitted with respiratory failure because of pneumonia. She was on multiple medications including diazepam, oxycodone, and amitriptyline, known to be associated with coma blisters, though she did not overdose on any of them. On hospital day 2, she developed multiple blisters on both sides of her right forearm and hand. Skin biopsy showed eccrine gland degeneration consistent with coma blisters. It was felt that hypoxemia from her pneumonia contributed to the development of these blisters, which occurred on both pressure and non-pressure bearing areas of the arm. Coma blisters are self-limited skin lesions that occur at sites of maximal pressure, mostly in the setting of drug overdose. However, coma blisters may occur with metabolic and neurological conditions resulting in coma.

Neumonía secundaria a aspiración silenciosa en pacientes con trastorno de deglución mayores de 30 años, en el Hospital Universitario San Ignacio / Pneumonia due to silent aspiration in patients with swallowing disorders over thirty years old at the San Ignacio University Hospital

Identificar pacientes en riesgo de cursar con neumonía aspirativa secundaria a trastornos de deglución y omorbilidades asociadas. Difundir la utilidad del estudio funcional dinámico de deglución (FEES, por sus siglas en inglés) para la evaluación de estos pacientes. Diseño: Observacional descriptivo. Materiales y métodos: Revisión de historias clínicas de 2005 a 2008 del Hospital San. Ignacio con diagnóstico de: neumonitis debida a aspiración de alimento y disfagia. Resultados: En nuestro hospital el 90,5 por ciento de los pacientes con posibles trastornos de deglución no son estudiados. Conclusiones e importancia clínica: Se debe implementar para pacientes con factores de riesgo elestudio funcional dinámico de la deglución si se sospecha aspiración silenciosa. Como veremos más adelante, el estudio funcional dinámico de la deglución representa una alternativa válida, ofrece ventajas con respecto a la cinedeglución y debe ser considerado como un complemento al estudio radiológico de los pacientes con trastornos de la deglución. Estudiar mejor estos pacientes permitirá desarrollar estrategias para disminuir episodios de aspiración y por consecuencia eventos de neumonía.

Objective: To identify patients in risk of dealing with aspirative pneumonia secondary to swallowing disorders and associated conditions. Spread the utility of the Functional Endoscopic Evaluation of Swallowing (FEES) for the evaluation of these patients. Design: Descriptive observational study. Materials and methods: Review of medical charts from 2005 to 2008 with diagnosis of: pneumonitis due to food aspiration and dysphagia at the San Ignacio Hospital. Results: At the hospital, 90,5 percent ofthe patients with possible swallowing disorders is not studied. Conclusions and clinical importance: The FEES must be implemented for patients with risk factors if silent aspiration is suspected. For us, the functional endoscopic evaluation of swallowing offers advantages in regard to ideofluoroscopy, and should be considered as a complimentary test in patients with swallowing disorders. Better evaluation of these patients will led us to develop in the future new strategies to diminish episodes of aspiration and events of pneumonia.

Granulomatous inflammation-an underestimated cause of false-positive diagnoses in lung fine-needle aspirates: observations from the college of american pathologists nongynecologic cytopathology interlaboratory comparison program.

CONTEXT: The false-positive rate for fine-needle aspirates of the lung has been cited as less than 1% for granulomatous inflammation, comprising one of the known causes of false-positive diagnoses. OBJECTIVE: To determine the rate of false-positive diagnoses of granulomatous inflammation for lung fine-needle aspirates by assessing the false-positive response rate in the context of the College of American Pathologists Nongynecologic Cytopathology Interlaboratory Comparison Program. DESIGN: We performed a retrospective review of 1092 participant responses for lung fine-needle aspirate challenges with the reference diagnosis of specific infections/granulomatous inflammation from 1998 to 2008 from the College of American Pathologists Nongynecologic Cytopathology Interlaboratory Comparison Program. False-positive rates by participant type (pathologist versus cytotechnologist), general diagnosis category, reference diagnosis, and preparation type were analyzed for the pathologists' responses. RESULTS: Of the 502 general category responses for pathologists, 428 (85.3%) were benign, 55 (11%) were malignant, and 19 (3.8%) were suspicious. There was no difference in the false-positive rate between preparations (P  =  .76) or participants (P  =  .39). Of those responses by pathologists that were benign, only 68.7% (292 of 425) were an exact match to granulomatous inflammation. Non-small cell carcinoma, adenocarcinoma, and squamous carcinoma represented 64% of false-positive/suspicious responses, while small cell carcinoma and carcinoid comprised 13%. CONCLUSION: In an interlaboratory comparison program, granulomatous inflammation represents an important cause of false-positive/suspicious responses in lung fine-needle aspirates (14.8%) and is much higher than false-positive rates reported historically in clinical studies. These results highlight the importance of granulomatous inflammation as a mimic of carcinoma.

Pulmonary carcinosarcoma initially presenting as invasive aspergillosis: a case report of previously unreported combination.

Carcinosarcoma of the lung is a malignant tumor composed of a mixture of carcinoma and sarcoma elements. The carcinomatous component is most commonly squamous followed by adenocarcinoma. The sarcomatous component commonly comprises the bulk of the tumor and shows poorly differentiated spindle cell features. Foci of differentiated sarcomatous elements such as chondrosarcoma and osteosarcoma may be seen. Aspergillus pneumonia is the most common form of invasive aspergillosis and occurs mainly in patients with malignancy, immunocompromising or debilitating diseases. Patients with Aspergillus pneumonia present with fever, cough, chest pain and occasionally hemoptysis. Tissue examination is the most reliable method for diagnosis, and mortality rate is high.We describe a case of primary carcinosarcoma of the lung concurrently occurring with invasive pulmonary aspergillosis in a 66-year old patient.

Cytologic findings in allogeneic and autologous bone marrow transplant patients with pulmonary symptoms: a 9-year follow-up study.

OBJECTIVE: To evaluate cytologic findings in patients who underwent bone marrow transplant (BMT) and correlate with the clinical, radiologic and histologic findings. STUDY DESIGN: Cytologic findings of the BMT patients with pulmonary symptoms from 1998 to 2007 were reviewed for the presence of malignancies, infectious organisms, inflammation and reactive changes, including treatment-related cellular atypia. Corresponding clinical history, radiologic findings and histologic follow-up when available were also reviewed. RESULTS: In 313 patients who underwent BMT, 89 (71 allogeneic, 18 autologous) had pulmonary symptoms. Of these, 47 specimens from 28 patients had abnormal cytologic findings. Reactive bronchial epithelial cells were found in 4 specimens and reactive squamous cells in 1 specimen. Four patients had markedly atypical cells in 4 specimens-atypical epithelial and mesothelial cells in 3 and 1 specimens, respectively. No malignancy was seen in any specimens examined. Acute inflammation was present in 6 specimens. Candida was the most common microorganism found (21 specimens). The cytologic findings were felt to correlate with clinical and radiologic findings and histologic follow-up. CONCLUSION: Clinical and radiologic correlation and awareness of the range of cellular atypia are important for preventing potential diagnostic pitfalls and establishing an accurate cytologic diagnosis in BMT patients.

Pneumonia in stroke patients with oropharyngeal dysphagia: a six-month follow-up study.

The aim of the study was to estimate the frequency of pneumonia and to determine the risk factors for this complication in poststroke patients with oropharyngeal dysphagia (OD). We prospectively followed up 67 patients (mean age 72.9+/-12.2 years) in the first 6 months after stroke, during which time we recorded gender, stroke side, type of lesion, diabetes, history of chronic obstructive pulmonary disease (COPD), smoking, level of consciousness, functional outcome, dietary history, occurrence of chest infection, and death. Degree of OD and presence/absence of reflex cough was assessed by Fiberoptic Endoscopic Evaluation of Swallowing. Sixty patients showed complete recovery of prestroke swallowing; 9 (13.4% IC 95%=5-20%) developed pneumonia, two of whom died. The first episode of pneumonia occurred in all nine patients within the first month after stroke onset. The pneumonia was associated with absence of reflex cough after swallow, COPD, and severe impairment of consciousness and poor functional outcome.

Neumonía recurrente / Recurrent pneumonia

Se entiende como neumonía recurrente a la presencia de al menos 2 episodios de neumonía en un año o tres episodios en toda la vida, existiendo mejoría radiológica entre ellas. En la mayoría delos casos existe alguna enfermedad de base, siendo la más frecuente el asma bronquial. Según la realidad de cada centro de salud, otras causas frecuentes las constituyen el síndrome aspirativo, inmunodeficiencias, cardiopatías congénitas, y en menor grado fibrosis quística, malformaciones, compresión, alteración funcional de vía aérea entre otras. Para enfocar adecuadamente su diagnóstico etiológico es conveniente diferenciar si se trata de neumonías localizadas o de diferente localización; así, si corresponden al primer grupo su estudio será dirigido a la búsqueda de malformaciones de vía aérea o de parénquima pulmonar; si se manifiestan en diferente ubicación deberá investigarse alguna enfermedad sistémica de base. En este trabajo se revisan algunas consideraciones diagnósticas y se brinda una aproximación al manejo práctico.

Unusual finding on bronchoscopy: trauma patient identified as a body stuffer.

We present the case of a trauma patient whose persistently abnormal chest radiography led to exploratory bronchoscopy. After the discovery of a foreign body in the right lower lobe bronchus, an attempted retrieval resulted in accidental perforation of a cocaine bag and release of the drug, which may have been the cause of the patient's subsequent pneumonitis.

Neumonía lipoidea exógena aguda, a propósito de un come fuego / Acute exogenous lipoid pneumonia

Se presenta el caso de un adulto de 19 años de edad, malabarista y manipulador de fuego quien ingresa al servicio de emergencias médicas del Hospital Dr. Rafael A. Calderón Guardia, por un cuadro súbito de dolor tóracico derecho y disnea. Se documenta derrame pleural en base pulmonar derecha y masa redondeada en base pulmonar izquierda. Inicia clínica sugestiva de bronconeumonía horas despúes, abordándosele inicialmente como neumonía adquiridad en la comunidad. Considerando sus antecedentes laborales y características clínicas, se reorienta caso y se concluye que se trata de lo que en la bibliografía médica en habla inglesa se denomina "fire-eater pneumonia", infrecuente neumonía por aspiración de la que se hace una revisión. Descriptores: neumonía lipoidea, neumonía por aspiración, neumonía en come fuego.