Transtracheal aspiration and fine needle aspiration biopsy for the diagnosis of pulmonary infection in heart transplant patients.

A total of 129 transtracheal aspirations or fine needle aspirations, or both, were performed in 65 heart and heart-lung transplant patients to identify the causative pathogen in suspected pulmonary infection. Transtracheal aspiration was performed in 82 instances, fine needle aspiration in 47, and both procedures in 23. Both transtracheal and fine needle aspiration were highly specific, 96% and 100%, respectively. Sensitivity for transtracheal aspiration was lower than for fine needle aspiration, 70% and 89%, respectively. The lower sensitivity of transtracheal aspiration is attributed to its performance in all patients with suspected infection regardless of chest radiographic findings. Fine needle aspiration was performed when identifiable lesions could be used as a "target." Overall accuracy of transtracheal aspiration was 78% compared to 91% for fine needle aspiration both alone and combined with transtracheal aspiration. More invasive procedures such as bronchoalveolar lavage and open lung biopsy were required in only three patients (2%). Transtracheal aspiration resulted in one minor complication (1%). The commonest complication of fine needle aspiration was pneumothorax (21%). There were no deaths associated with either procedure. We conclude that in heart and heart-lung transplant patients with suspected pulmonary infection, transtracheal aspiration and fine needle aspiration are safe and accurate methods to identify the causative organism. More invasive techniques may be required in a small minority of patients.

Cutaneous ulceration due to contrast extravasation. Experimental assessment of injury and potential antidotes.

Severe cutaneous ulceration may occur as a result of contrast media extravasation. We established a definitive animal model for assessing the cutaneous toxicity of commonly employed agents and used this model to evaluate possible antidotes to the effects of contrast media extravasation. The contrast agents studied were: meglumine/sodium diatrizoate 76%, meglumine iothalamate 60% and 43%, meglumine/sodium ioxaglate 60%, iohexol 350, and iopamidol 370, in varying volumes and osmolalities. Hypertonic saline (950 and 1900 mOsm/kg) also was injected. Agents were injected intradermally into BALB/c mice. The higher osmolality agents produced dose-dependent skin ulcerations. The lower osmolality agents failed to produce any skin lesions after the same volume doses. Hypertonic saline produced skin toxicity in a dose-dependent fashion similar to hyperosmolar contrast agents. Three antidotes were tested: hyaluronidase, topical heat, and topical cold. Hyaluronidase significantly reduced skin toxicity when injected immediately following contrast injection. Cold also significantly reduced skin toxicity, while heat caused no improvement.

Asymptomatic hepatic mass in a 34-year-old woman.

Hepatomegaly was discovered on a routine physical examination of a 34-year-old, asymptomatic Mexican-American female. She was referred for a sonogram and a liver-spleen scan. Oral cholecystography was also requested.

Computed radiographic evaluation of simulated pulmonary nodules. Preliminary results.

We evaluated the capabilities of a computed radiography system (CRS) and a standard radiography system (SRS) in the detection of simulated solitary pulmonary lung nodules of various sizes and contrast. A phantom simulated the pulmonary anatomy, and specially shaped plexiglass disks were externally mounted to simulate solitary pulmonary nodules of different diameters and thicknesses. ROC curves were generated based on the performance of each of the radiologists observing each film set. In this preliminary study, the overall performance for both the CRS and the SRS were comparable in detecting simulated pulmonary nodules.

Evaluation of aneurysms by computed tomography.

It is possible to image a variety of anomalies and pathologic conditions of the vascular system by means of computed tomography (CT). Noninvasive preoperative evaluation of aneurysms frequently can best be accomplished by CT, often providing more usable information than angiograms or even ultrasound. The use of a "bolus" of contrast, with scans performed immediately following the injection, after an initial nonenhanced study, provides excellent definition of such lesions. In this report we relate our experience with CT in patients with aneurysms.

Posttreatment laparotomy for Hodgkin's disease.

We examined and surgically restaged (using posttreatment laparotomy) 26 patients with stage III and IV Hodgkin's disease treated with combination chemotherapy and in apparent remission to determine the status of their clinical remission. Eleven patients had normal clinical restaging and surgical restaging. Fifteen patients had abnormal clinical restaging, mainly consisting of abnormal lymphangiograms or abdominal CT scans. Ten lymphangiograms were abnormal and could not exclude persistent lymphoma. Two of the 15 patients proved to have Hodgkin's disease involving the para-aortic nodes and the spleen. With a median follow-up of 24 months, two patients had relapses in supradiaphragmatic sites and no patient with a negative laparotomy had a recurrence abdominal sites. Restaging laparotomy in selected patients with Hodgkin's disease with abnormal lymphangiograms or CT scans may identify additional patients with residual lymphoma who require further therapy and, more importantly, may identify those patients who have no residual disease and, therefore, may be spared additional therapy. Mortality and morbidity were nil.

Pulmonary digital subtraction angiography.

Pulmonary angiography using intravenous rather than intra-arterial injections and digital subtraction technique provides an alternative to dependence on clinical impression, lung scans, and the more invasive transcardiac selective pulmonary angiogram for the diagnosis of pulmonary embolism. However, successful studies of the pulmonary circulation using IV-DSA require careful preselection of patients and meticulous attention to technical detail, as well as a state-of-the-art digital imaging system.

Pattern of immunoreactive glucagon in portal, arterial and peripheral plasma before and after removal of glucagonoma.

Gel fractionation of portal, arterial and peripheral plasma glucagon levels was performed before and after the successful removal of a glucagonoma. A 47 year old woman had symptoms of dermatitis, weight loss, anemia and diabetes mellitus over a 16 year period. Removal of the alpha-cell tumor corrected all of her symptoms. Gel filtration of portal, arterial and peripheral blood showed two peaks of glucagon radioimmunoassay activity, a higher molecular weight glucagon with a molecular weight of 9,000 and a 3,500 dalton glucagon. Five minutes after tumor removal, the higher molecular weight glucagon had disappeared completely from the arterial and peripheral blood but not from the portal vein.

Digital subtraction angiography of the pulmonary arteries.

With current high-resolution equipment and proper case selection, intravenous digital subtraction angiography (IVDSA) can consistently demonstrate pulmonary emboli greater than 2.0 mm in size. IVDSA is less traumatic than conventional pulmonary angiography and is preferable for high-risk cases such as patients with pulmonary arterial hypertension. For successful IVDSA studies patients should be able to hold their breath for 10 to 20 seconds. IVDSA should not be used in patients who are extremely dyspneic, who cannot suppress a cough, or who have a low cardiac output. In these instances selective intraarterial DSA is preferable.

Chest radiographic abnormalities in Lennert's lymphoma.

In reviewing the medical records of ten patients with Lennert's lymphoma, we found chest radiographic abnormalities in five cases. Two cases had hilar and mediastinal adenopathy without associated parenchymal or pleural disease, and three cases had isolated pulmonary parenchymal abnormalities. In one patient, both the chest radiograph and the histologic findings, obtained by open lung biopsy, mimicked miliary granulomatous disease. This article emphasizes the need to be alert to this aggressive T-cell neoplasm, since its clinical course differs significantly from some of the diseases it tends to imitate. By being aware of the entity and by using thorough pathologic and immunopathologic techniques, difficult cases of Lennert's lymphoma can be successfully diagnosed.

Outcome of intraarterial urokinase for acute vascular occlusion.

Intraarterial urokinase (IAUK) was administered to 33 patients on 40 occasions for the treatment of acute extremity ischemia and long-term patency was assessed. Lysis was successful in 39 of the 40 cases (95%). Occlusive thrombus was cleared in 12 of 13 patients with native artery occlusion (7 complete, 5 partial), 8 of 9 with autologous vein grafts (5 complete, 3 partial), and in all 18 patients with synthetic grafts (17 complete, 1 partial). The primary cumulative patency following successful IAUK was 100% for native arteries and 47% for synthetic grafts at 12 months, and 23% for autologous grafts at 9 months. The difference in rethrombosis rate between autologous vein (67%) and native artery (0%) was significant (p = 0.02) as was the difference between infrainguinal prosthetic grafts (63%) and native artery (p = 0.025). IAUK is most effective for the treatment of native artery occlusion, but is significantly less effective for thrombosed infrainguinal autologous vein or synthetic grafts due to the likelihood of reocclusion, despite the high immediate success rate. For autologous vein grafts, lysis is frequently incomplete and patency rapidly deteriorates regardless of adjunctive therapy to relieve the underlying obstruction.

Evaluation of double aortic arch and aortic coarctation by intravenous digital subtraction angiography (IV DSA).

Eleven pediatric patients with congenital aortic anomalies were evaluated using intravenous digital subtraction angiography (IV DSA). Excellent correlation was found between IV DSA, other imaging studies, and operative findings. Ten of 11 patients studied (90.9%) were correctly diagnosed using this technique. Intravenous DSA may be the procedure of choice in assessing aortic arch anomalies in selected patients.

Combined thrombolytic therapy and percutaneous transluminal angioplasty for treatment of complex arterial graft thrombosis--a case report.

Combined catheter-directed thrombolytic therapy followed by percutaneous transluminal angioplasty (PTA) was successfully performed for the treatment of a thrombosed complex mesenteric artery bypass graft resulting from an anastomotic stenosis. Restenosis of the graft due to neointimal hyperplasia was subsequently treated by PTA, with resultant long-term patency. This approach is an attractive alternative to surgical thrombectomy and graft revision, especially in patients who are poor surgical risks owing to concurrent medical problems.

Catheter-directed urokinase thrombolysis: an adjunct to PTA/surgery for management of lower extremity thromboembolic disease.

Catheter-directed thrombolysis was used either alone or as an adjunct to percutaneous transluminal angioplasty (PTA) or surgery for peripheral vascular occlusion on 112 occasions in 102 patients. Symptom duration ranged from < one to > twenty-eight days. Thrombolytic therapy using urokinase plasminogen activator thrombolysis (uPAT), including intrathrombic injection when possible, was successful (> 50% lysis) in 99 procedures (88%). Technical failure (< 50% lysis) occurred in 13 procedures (12%). In 9 of the 13 failures, intrathrombic injection of urokinase was not possible, but the duration of occlusion was > twenty-eight days in all but 1. Two other failures were from embolic sources and 2 more occurred in patients with a hypercoagulable state. The uPAT was adjunctive to PTA/surgery in 56 cases (50%). PTA following uPAT was required and successfully performed in 24 of 27 cases (88.9%). Surgery followed lytic therapy in another 32 (including the 3 failed PTAs). In the remaining 56 cases (50%), no additional intervention was required. There were 20 complications (18%), minor in 16 of 20 (80%). Minor complications included small puncture site hematomas and distal embolization resolved by continued lytic therapy. Four major complications occurred. One was retroperitoneal hemorrhage directly contributing to the only death in the series. The other 3 were hematuria (2) and femoral neuropathy (1). The authors conclude that catheter-directed lytic therapy alone or as an adjunct to PTA/surgery is a valuable approach to peripheral vascular thromboembolic disease. It is less likely to succeed in chronic occlusion. The incidence of complications is moderate but acceptable.

Demonstration of cavitated hepatic masses by "skinny needle" transhepatic cholangiography. The need for ultrasonic or computed tomography evaluation in obstructive jaundice.

A patient with cholestatic jaundice, ascending cholangitis and recent development of sepsis had an unsuspected intrahepatic abscess discovered by "skinny needle" percutaneous transhepatic cholangiography (PTC). Ultrasound and computed tomography (CT) evaluation were omitted in the work-up because of the clinical impression that the disease was almost certainly due to an obstructing calculus. The unsuspected cause of cholestasis was found by PTC but would have more easily been detected by other means, as a second similar case illustrates.

Echography: a new approach to the diagnosis of adrenal hemorrhage of the newborn.

A case of adrenal hemorrhage of the newborn, diagnosed by ultrasound, is presented. All other diagnostic modalities were found to be non-specific. Ultrasonic evaluation is recommended in the evaluation of pediatric abdominal masses. This is a safe, non-invasive, rapid and easily performed study. It is felt that the use of diagnostic ultrasound in evaluating neonates for adrenal hemorrhage wil obviate the necessity of more invasive procedures, such as exploratory laparotomy.

Phlegmon of the pancreas.

One of the significant complications of pancreatitis is the development of a pancreatic phlegmon, a noninfected solid mass of inflamed pancreatic and retroperitoneal tissues. Clinically, a phlegmon may be confused with other pancreatic masses, especially a pseudocyst. Phlegmons typically present as palpable epigastric masses which are solid on sonography and computerized tomography. They usually resolve in a few weeks with nonsurgical conservative therapy. This report discusses the radiographic and clinical picture of pancreatic phlegmons as illustrated by four cases.