Pulmonary manifestations of early schistosome infection among nonimmune travelers.

PURPOSE: The clinical aspects of acute pulmonary schistosomiasis among nonimmune patients have not been well characterized. METHODS: We evaluated 8 patients who presented with pulmonary symptoms and abnormal chest radiographs after recent travel to Africa. Diagnosis was based on the detection of schistosomal eggs or positive serology. RESULTS: Of 60 patients evaluated in our center for schistosomiasis during a 3-year period, 8 (6 with Schistosoma hematobium, 2 with S. mansoni) had pulmonary symptoms. These symptoms appeared 3 to 6 weeks after exposure and consisted of dry cough and shortness of breath without concurrent fever. The mean (+/- SD) eosinophil count was 4020 +/- 1400 per micromL. Chest radiography revealed multiple small nodules in 7 patients; in 1 patient, a diffuse interstitial infiltrate was also seen. Computerized tomographic scans of the chest were obtained in 4 patients; the scans confirmed the nodular pattern and detected a greater number of nodules. A transbronchial biopsy in 1 patient revealed eosinophilic pneumonia without detection of larva or eggs. CONCLUSION: Pulmonary manifestations during the early stage of schistosomal infection may occur with either S. hematobium or S. mansoni infection. These manifestations may represent an immunologic process, as is thought to be responsible for the febrile systemic response (Katayama fever) to acute infection.

Pulmonary-renal syndrome in systemic sclerosis.

BACKGROUND AND OBJECTIVE: Renal failure, pulmonary hypertension, and interstitial lung disease are major causes of morbidity and mortality in systemic sclerosis (SSc). However, the concomitant occurrence of pulmonary hemorrhage associated with acute renal failure in SSc has been rarely described. The present study is the first analysis of pulmonary-renal syndrome in SSc. PATIENT AND METHODS: We present a 44-year-old woman with SSc who died of a fulminant course of acute renal failure associated with diffuse alveolar hemorrhage. We termed this uncommon and fatal complication of SSc scleroderma-pulmonary-renal syndrome (SPRS). A search of the English-written literature yielded reports of 10 additional similar cases. These patients, together with our present case, form the basis of the present analysis. RESULTS: The average age of the patients with SPRS was 46 years. The majority of the patients (80%) were women, and most had diffuse SSc. SPRS occurred an average of 6.4 years after disease onset and was associated with prior fibrosing alveolitis and/or D-penicillamine treatment. Interestingly, normotensive renal failure seems to characterize the scleroderma patients, because 9 of 11 (82%) had normal blood pressure. SPRS bears a poor prognosis: all of the 11 patients (100%) died within 12 months of admission. However, only 60% of the 5 patients for whom we have treatment data received corticosteroids. CONCLUSIONS: Pulmonary-renal syndrome is a rare but fatal complication of SSc. Because the treatment data are scarce and the prognosis is poor, aggressive treatment with pulse corticosteroids, cyclophosphamide, and possibly plasmapheresis is suggested.

Pleuro-pulmonary manifestations of systemic lupus erythematosus: clinical features of its subgroups. Prognostic and therapeutic implications.

Correct identification of the subsets of pulmonary lupus has an unquestioned importance in planning the proper therapeutic regimen in this extremely variegated disease. Asymptomatic pulmonary lupus needs no treatment; however, pulmonary involvement in lupus may be life threatening, in which case prompt and aggressive treatment is mandatory. The different aspects of pulmonary lupus are demonstrated through the clinical histories of patients who suffered from pleuro-pulmonary lupus. The following entities are presented: lupus pneumonitis, lymphocytic interstitial pneumonia, pulmonary hypertension, pulmonary hemorrhage, pulmonary embolism associated with circulating lupus anticoagulant, lupus pleuritis and weakness of the diaphragm.

Castleman's disease. An uncommon computed tomographic feature.

A case of localized intrathoracic Castleman tumor demonstrated, on CT scan, calcifications in a circumferential distribution. The prevalence of calcifications in Castleman's disease and the differential diagnosis of the above unusual CT findings are discussed.

Synergism between infarct-borne left ventricular dysfunction and cardiomegaly in increasing the risk of coronary bypass surgery.

The effect of cardiomegaly on operative and late mortality in patients with left ventricular dysfunction undergoing coronary bypass operation was investigated. The study group consisted of 178 patients whose left ventricular ejection fraction was below 45% and who were operated on from 1978 through 1985. Forty-five patients (group A) had severe left ventricular dysfunction (ejection fraction < 30%) and 133 (group B) had moderate dysfunction (30% > ejection fraction > 45%). Twenty-four of group A (53%) and 54 of group B (41%) patients had cardiomegaly (cardiothoracic ratio on chest x-ray films > 0.5). There were 10 (6%) hospital deaths, four in group A (9%) and six in group B (4.5%). All four deaths in group A and the six deaths in group B were patients who had cardiomegaly. Regardless of the severity of the left ventricular dysfunction, there was no operative death among patients with normal heart size (p < 0.001). Age over 65, bypass time longer than 2 hours, and incomplete revascularization emerged as risk factors. Follow-up ranged from 5 to 13 years (mean 7.8 years). Overall 5-year actuarial survival, including hospital mortality, was 80% +/- 3%. Reduced 5-year survival was observed in patients with cardiomegaly (67% +/- 5% versus 91% +/- 3%, p < 0.05). Five- and 10-year survival of patients from group A with cardiomegaly was 53% +/- 7% and 18% +/- 13%, respectively.

Coronary calcium measurements by double helical computed tomography. Using the average instead of peak density algorithm improves reproducibility.

RATIONALE AND OBJECTIVES: Coronary calcium (CC) measured by fast computed tomography (CT) was proposed recently as a noninvasive method of monitoring the coronary atherosclerotic process. Assessment of the reproducibility of CC measurements (mainly interstudy variability) is essential for consistent interpretation of serial studies. METHODS: The authors scanned 74 patients (50 men and 24 women) twice on the same day to determine the interstudy variability of a new scoring algorithm, using the average instead of conventional peak CT density values. RESULTS: Nineteen patients had no calcium on either scan. In the remaining 55 patients, interstudy variability was decreased by 31% using the average algorithm (32%-23%; P < 0.001). CONCLUSIONS: Using the average instead of conventional peak density score provides better reproducible measurements of calcium by double helical CT.

Re-expansion pulmonary oedema following spontaneous pneumothorax.

Re-expansion pulmonary oedema may occur after chest tube drainage of pneumothorax and can give rise to cardiopulmonary manifestations which range from the mild to the severe. In order to evaluate the prevalence and the clinical manifestations of this complication, all patients with spontaneous pneumothorax managed with chest tube drainage were evaluated over an 8-yr period (1986-1994). A chest radiograph was performed routinely in all patients within 4 h of tube insertion. Lung expansion and the appearance of infiltrates within the lungs were investigated specifically. Re-expansion oedema was noted in three of 320 episodes (0.9%). Two of the three patients needed rapid and extensive clinical treatment.

Corneal transplant allograft reactions in unilateral, double corneal transplants.

In support of the idea that the HLA system plays a major role in corneal graft rejection, we report these two unique cases. Both had two penetrating grafts in the same eye. One was a regular graft and the second a patch graft to repair a perforation in the initial one. In the first case, the original graft had an allograft reaction and the patch graft remained unaffected. In the second case, an allograft reaction to the patch graft developed while the regular graft remained completely clear. Both grafts in the two cases cleared following medical therapy. The fact that in these two cases rejection reactions involved one transplant only, even though the other graft was subject to the same conditions, implies that the difference in the antigenicity of the two grafts is an important factor in the chain of events leading to rejection.

CT diagnosis of malpositioned chest tubes.

Insertion of a chest tube into the pleural space is standard management for various pleural disorders. Malpositioning of chest tubes in extrathoracic, intraparenchymal and mediastinal locations and in the fissures is common. Malpositioning results not only in inadequate drainage of air and fluid but may also result in increased morbidity and mortality. Diagnosis of a malpositioned tube is sometimes difficult to establish on a chest radiograph. CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has often provided additional valuable information with significant therapeutic impact.

Prediction of atrial and ventricular fibrillation complicating myocardial infarction from admission data: a prospective study.

This study set out to examine prospectively two logistic formulae based on admission clinical data to predict ventricular or atrial fibrillation complicating acute myocardial infarction. A prospective study of 87 consecutive patients with acute transmural myocardial infarction was conducted. The formula for predicting ventricular fibrillation from the diastolic blood pressure, degree of ST-segment elevation, and QTc had a sensitivity of 93%, specificity of 83%, and a predictive value for an abnormal test of 62% (13 of 14 patients who developed ventricular fibrillation were identified). The formula for predicting atrial fibrillation from the age of the patient, a history of heart failure, systolic blood pressure, and four electrocardiographic parameters had a sensitivity of 78%, specificity of 85%, and a predictive value of 67% (14 of 18 patients identified). Our study shows that patients with myocardial infarction who are liable to develop ventricular or atrial fibrillation can be identified on admission from simple clinical data.

Computed tomography in children with esophageal and airway trauma.

Computed tomography (CT) was used in five children, four with esophageal and one with airway trauma. The examination contributed valuable information that aided in planning and evaluating therapy: (1) it assessed mediastinal and pleural cavity involvement prior to surgery or drainage; (2) it evaluated the efficacy of drainage; (3) it gave excellent information about the position of chest tubes; and (4) it demonstrated unsuspected pneumothoraces, pleural effusion, pulmonary infiltrates, and lung perforation by a chest tube. In the postoperative assessment of laryngotracheal fracture, neck radiographs were useless since the airways were obliterated by hematomas and edema. In this situation, CT showed the position and state of the laryngeal cartilages. However, CT findings were not pathognomonic for esophageal tears or airway fractures. The primary diagnosis was still made by conventional radiography. Esophageal tears were accurately demonstrated by gastrografin swallow and the tracheolaryngeal fracture was diagnosed by a lateral neck radiograph--the state of the child permitting no lengthy workup. CT and conventional radiography with contrast studies play a complementary role in esophageal and airway trauma in children.

[Pulmonary disease induced by methotrexate].

A 68-year-old man with rheumatoid arthritis developed methotrexate-induced lung disease. He presented with fever, cough, respiratory distress and pulmonary infiltrates, which were initially mistaken for pneumonia. Alertness to this rare and dangerous complication of methotrexate treatment will reduce possible damage and help maintain its place as a leading medication for rheumatoid arthritis.

Radiological findings of the urinary tract in hypospadias: a report of 110 cases.

One hundred and ten patients with hypospadias underwent excretory urography and micturating cysto-urethrography before surgical correction. Urographic studies revealed abnormalities in 50 patients (45%), mainly anomalies of ascent and rotation of the kidneys. None of these patients required corrective surgery. Voiding cysto-urethrography disclosed disease of the urinary tract in 65 of 110 patients (59%). Meatal stenosis was found in 38 patients and a rudimentary vagina or a prostatic utricle was revealed in 11 others. Vesico-ureteral reflux was present in 14 patients, seven of whom had meatal stenosis as well. Cystitis was found in eight and a stricture of the membraneous urethra in one patient. The voiding cysto-urethrogram is able to demonstrate functionally significant meatal stenosis, genital abnormalities and vesico-ureteral reflux. It can also serve as a useful baseline for comparison with postoperative studies. We therefore consider that it should be included in the preoperative work-up of every patient with hypospadias. Excretory urography, however, is perhaps indicated only in those with urinary tract infection, or in patients otherwise symptomatic.

Pneumatic rupture of the esophagus caused by carbonated drinks.

Pneumatic rupture of the esophagus occurs when gas under pressure is accidentally delivered into the oral cavity. To the 4 cases previously described we add 2 pediatric patients and in both the source of the offending gas was a bottle of carbonated drink. The mild initial symptoms were followed in both by physical and radiographic findings suggesting pharyngoesophageal perforation. Early radiologic findings included free subcutaneous and mediastinal air, followed later by hydropneumothorax and mediastinal widening as well as leak of contrast material on gastrografin swallow. CT findings contributed to patient evaluation and management.

Treatment of a recurrent bulbar urethral stricture after Urolume wallstent implantation with a second inner Urethrospiral-2 urethral stent.

Although the Urolume wallstent has been proven to be effective in the treatment of bulbar urethral strictures, in some instances obstruction may recur. We present a patient in whom recurrent stricture after wallstent implantation was managed by insertion of a second inner Porges Urethrospiral-2 stent inside the first one.

Nephroureterectomy through a single lumbar incision combined with endoscopic incision of a bladder cuff.

Nephroureterectomy is the accepted approach in treating upper urinary tract carcinoma. We present a modification of transurethral resection of the intramural ureter, using endoscopic incision of a bladder cuff around the ureteral ostium as the first step in performing nephroureterectomy through a single lumbar incision.

Isolated ectopic lung uptake of technetium 99m methylene diphosphonate on bone scintigraphy in primary amyloidosis.

Pulmonary deposition of technetium 99m methylene diphosphonate was found on a bone scan of a patient with undiagnosed primary AL amyloidosis. Unusual clinical manifestations during the course of the disease led to a post-mortem diagnosis. The mechanisms for pulmonary and other ectopic soft tissue bone scan tracer depositions, as well as their significance in the diagnosis of amyloidosis, are discussed.