Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients?--A cross sectional study.

BACKGROUND: Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies. METHODS: We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index. RESULTS: Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients. CONCLUSIONS: Pain localization is not helpful in discriminating CHD from other common chest pain etiologies.

Pyogranulomatous pleuropneumonia caused by Nocardia asiatica in a dog coinfected with canine morbillivirus (canine distemper virus).

Nocardia asiatica causing pyogranulomatous pleuropneumonia is reported for the first time in a dog coinfected with canine morbillivirus (CM), diagnosed based on epidemiological, clinical, haematological, images, microbiological, histopathological, polymerase chain reaction and hsp65 gene sequencing findings. The immunosuppression of CM probably favoured the opportunistic behaviour of N. asiatica. Despite the therapeutic measures, the animal died, mainly due to respiratory distress. The association of methods to improve early diagnosis, therapy procedures and prognosis of canine nocardiosis is discussed, as well as the close relationship between pets and their owners, which may favour the transmission of pathogens such as Nocardia from pets-to-humans, which poses an emerging public health issue.

Strain of mycoplasma associated with human reproductive failure.

A strain of mycoplasma not previously described has been isolated from the chorion, decidua, and amnion of a patient who sustained a spontaneous abortion during the middle trimester. The fetal membranes exhibited an inflammatory reaction, but no evidence of other infectious agents, bacterial or viral, was noted. The T strain identified is not a classical mycoplasma; it differs in growth and nutritional requirements from the T strains previously characterized.

Pleuroparenchymal fibroelastosis with positive MPO-ANCA diagnosed with a CT-guided percutaneous needle biopsy.

A 67-year-old woman was referred to our hospital because of gradually increasing dyspnoea on exertion for 6 months. Chest CT scan showed subpleural parenchymal fibrotic opacities with traction bronchiectasis in the bilateral upper lung fields. Serum rheumatoid factor and myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) were positive. There was no evident reason to suspect connective tissue disease such as ANCA-associated vasculitis or rheumatoid arthritis. We performed a CT-guided percutaneous needle biopsy of the subpleural lesion that showed slight uptake on the fluorodeoxyglucose-positron emission tomography (FDG-PET) CT scan. This specimen showed subpleural fibrosis as evidenced by an abnormal increase of elastic tissue and minimal collagen deposition, which indicated pleuroparenchymal fibroelastosis (PPFE). Although PPFE can be associated with a variety of causes, its association with MPO-ANCA is unknown. A CT-guided transthoracic lung biopsy caused no adverse events and was useful in the diagnosis of PPFE in our patient.

The value of molecular techniques to diagnose Ureaplasma urealyticum and Nocardia farcinica pleuropneumonia in a patient with diffuse large B-cell lymphoma.

An unusual case of pleural empyema related to Nocardia farcinica and Ureaplasma urealyticum, occurring after autologous haematopoietic stem cell transplantation in a 30-year-old patient with lymphoma, is reported. This case illustrates the role of repeated and comprehensive microbiological investigations and the contribution of molecular techniques in reaching the aetiological diagnosis.

[Differential diagnostics in thoracoabdominal syndrome].

The article discusses diagnostic difficulties in patients with acute abdominal pain. The author adduces data on the frequency of late diagnostics of pleuropneumonia and diaphragmatic pleuritis in patients with abdominal syndrome before admission, and in the admission department of an urgent aid hospital. The analysis of the causes of delayed diagnosis of lung and pleura diseases is exemplified with 2 clinical observations. The article also covers ways of prevention of diagnostic errors in patients with abdominal pain.

Cholesterol in pleural effusions. A diagnostic aid.

In this prospective study of 70 patients with pleural effusion, the underlying disease could be identified in 62 cases. By predefined criteria, 31 of these effusions were classified as transudates and 31 as exudates. Pleural fluid protein content, LDH activity and cholesterol level were measured to investigate their utility in differentiating the exudates from the transudates. Protein and LDH levels, and their pleural fluid-to-serum ratios, resulted in erroneous classification of 11 to 15 percent of the effusions. Mean cholesterol level in malignant effusions was 94 mg/dl, 76 mg/dl in inflammatory effusions and 30 mg/dl in the transudates. Using a dividing line of 60 mg/dl to separate the exudates from the transudates, only 5 percent were incorrectly classified. Elevated cholesterol levels in exudates seem to be independent of the serum levels. Our findings indicate that the pleural fluid cholesterol level is a simple and cost-effective aid in differentiating exudative from transudative pleural effusions.

Cranial thoracic masses in the horse: a sequel to pleuropneumonia.

The formation of cranial thoracic masses (CTM) as a sequel to infectious pleuropneumonia is described. Using ultrasound, masses were diagnosed subjectively as abscesses or loculations. Eight of 99 cases with pleuropneumonia had CTM. Clinical signs associated with the presence of a CTM included increased heart rate, jugular distention, forelimb 'pointing' and caudal displacement of the heart. Techniques used for diagnostic ultrasonographic examination of the cranial thorax are described. Five of the eight horses with CTM responded to conservative medical management; the other three required percutaneous drainage of the mass to relieve worsening signs of cardiac decompensation. Improvements in cardiovascular parameters were evident within 12 h of drainage. The indications for and limitations of invasive drainage of cranial thoracic masses are discussed.

Pneumothorax in horses: 40 cases (1980-1997).

OBJECTIVE: To characterize pneumothorax in horses and to describe clinical signs, diagnostic testing, and clinical outcome of horses with pneumothorax. DESIGN: Retrospective study. ANIMALS: 40 horses. PROCEDURE: Medical records of horses with pneumothorax were reviewed to obtain information on signalment, history, clinical signs, diagnostic testing, treatment, and clinical outcome. RESULTS: Horses developed pneumothorax secondary to pleuropneumonia (17 horses), open wounds of the thorax (9), closed trauma to the thorax (7), surgery on the upper portion of the respiratory tract (3), and surgery involving the thoracic cavity (1); 3 horses had pneumothorax of unknown cause. Clinical signs included tachypnea, dyspnea, cyanosis, lack of lung sounds on auscultation of the dorsal aspect of the thorax, fever, tachycardia, signs of depression or anxiousness, and cough. Radiography and ultrasonography were useful to definitively diagnose pneumothorax. Pneumothorax was bilateral in 47.5% (19/40) and unilateral in 42.5% (17/40) of horses; designation of unilateral versus bilateral was not recorded in the remaining 4 horses. Horses with pneumothorax secondary to pleuropneumonia more commonly had unilateral pneumothorax (64.7% for unilateral vs 29.4% for bilateral; not specified for 1 horse). Horses with pneumothorax secondary to pleuropneumonia were less likely to survive than horses with pneumothorax secondary to other causes (35.3 vs 69.6% survived, respectively). CONCLUSIONS AND CLINICAL RELEVANCE: Pleuropneumonia is an important cause of pneumothorax in horses. Classic clinical signs of pneumothorax may not be evident. Radiography, ultrasonography, or both may be required for diagnosis. Prognosis for survival is better for horses with pneumothorax not associated with pleuropneumonia.

Echocardiographic detection of an intact aneurysm in a horse.

Two-dimensional real-time echocardiographic examination of a 3-year-old Thoroughbred gelding with pleuropneumonia revealed an intact aneurysm of the right sinus of Valsalva, which was confirmed at postmortem examination. The horse had no clinical signs associated with the aneurysm.

Pleural effusion associated with acute and chronic pleuropneumonia and pleuritis secondary to thoracic wounds in horses: 43 cases (1982-1992).

Case records of 43 horses with pleural effusion associated with acute pleuropneumonia, chronic pleuropneumonia, or pleuritis secondary to a penetrating thoracic wound were reviewed to determine the predisposing factors, diagnosis, and treatment of this condition. Acute pleuropneumonia was diagnosed in 36 horses, the majority of which were Thoroughbreds (89%). Of 22 (61%) horses that were in race training at the onset of illness, 11 (31%) had been recently transported a long distance and 4 (11%) had evidence of exercise-induced pulmonary hemorrhage. Physical examination findings and hematologic data were nonspecific. The most consistent abnormality was hyperfibrino-genemia. Affected horses were treated with antibiotics, thoracic drainage, nonsteroidal anti-inflammatory drugs, and supportive care. Twenty-two (61%) horses were discharged from the hospital, with the mean duration of hospitalization for those discharged being 23 days. Nine (25%) horses were euthanatized and 5 (14%) died. Bacterial culturing of thoracic fluid resulted in growth in 30 of the 36 (83%) horses. The finding of anaerobic bacteria in thoracic fluid was not associated with a lower survival rate (62%) than the overall survival rate (61%). Four horses with chronic pleuropneumonia had a history of lethargy and inappetence for > 2 weeks. Actinobacillus equuli was isolated, either alone or in combination with other bacteria, from thoracic fluid of these 4 horses. Each horse was treated with broad spectrum antibiotics and made a rapid recovery. Three horses with acute pleuritis secondary to penetrating thoracic wounds also had nonspecific clinical signs, apart from the wound and a large volume of pleural effusion. Bacteriologic isolates from these horses differed slightly from those of horses with acute pleuropneumonia.

A hematogenic pleuropneumonia caused by postoperative septic thrombophlebitis in a Thoroughbred gelding.

A 7-year-old Thoroughbred gelding was admitted to Equine Hospital, Korea Racing Association for evaluation and treatment of colic. Based on the size and duration of the large colonic and cecal impaction, a routine ventral midline celiotomy and large colon enterotomy were performed to relieve the impaction. Six days following surgery the gelding exhibited signs of lethargy, fever, inappetence and diarrhea. Eleven days following surgery, the jugular veins showed a marked thrombophlebitis. On the sixteenth day of hospitalization the gelding died suddenly. Upon physical examination, the horse was febrile, tachycardic and tachypnoeic. Thoracic excursion appeared to be increased; however, no abnormal lung sounds were detected. No cough or nasal discharge was present. Hematology revealed neutrophilic leukocytosis. Serum biochemistry was normal but plasma fibrinogen increased. In necropsy, fibrinopurulent fluid was present in the thoracic cavity. There were firm adhesions between visceral pleura and thoracic wall. White, mixed and red thrombi were formed in both jugular veins from the insertion point of IV catheter. Histopathological examination showed fibrinopurulent inflammation and vascular thrombosis in the lung. The pleura showed edematous thickening and severe congestion. The clinicopathological and pathological findings suggest that septic thrombi associated with septic thrombophlebitis metastasized into the pulmonary circulation and were entrapped in the pulmonary parenchyma and provoked pleuropneumonia.

[Inappropriate antidiuretic hormone secretion syndrome associated with a pleuropulmonary infection]. / Síndrome de secreción de hormona antidiurética asociado a infección pleuropulmonar.

A case of pleuropulmonary infection without a demonstrable causal agent associated to inappropriate secretion of antidiuretic hormone is reported. Although antidiuretic hormone levels were not measured, unequivocal indirect proof of elevated levels was present as evidenced by characteristic serum and urinary electrolyte abnormalities, other possible causes having been carefully ruled out. The hyposmolar clinical picture was refractory to conservative measures, and it was corrected only when a loculated empyema was surgically drained by way of thoracotomy. The literature on inappropriate secretion of antidiuretic hormone related to pleuropulmonary pathology is briefly reviewed. Particular emphasis is made on the pleural encapsulation in the present case as the factor responsible for perpetuation of pulmonary infection and origin of the hormonal disturbance.

[Acute abdomen: consider also the thorax]. / Acute buik: denk ook aan de thorax.

Three patients, 2 men aged 22 and 62 years en 1 woman aged 49, presented with symptoms of an acute abdomen. While infiltrative signs were described on radiodiagnostic images two patients underwent laparotomies. In all three subsequently the diagnosis of pneumonia was established and the patients made full recovery after antibiotic therapy. When a patient presents with symptoms of an acute abdomen, the possibility of an existing pneumonia should always be borne in mind. It is therefore recommended to make a chest radiograph with frontal and lateral view. In the presence of infiltrative signs the existence of pneumonia as the cause of abdominal symptoms should be considered in order to avoid unnecessary laparotomy.

[Lemierre's syndrome: a case report]. / Le syndrome de Lemierre: a propos d'une observation.

We report a case of Lemierre's syndrome with a pleuropulmonary complication. Lemierre's syndrome is a rare etiology of lung abscess. The diagnosis is clinical and microbiological (anaerobic organisms). This syndrome associates an acute oropharyngeal infection with septic thrombophlebitis of the internal jugular vein (sometimes many days before the lung lesion) and pulmonary abscess formation. Clinicians should be aware of this syndrome that is fatal in 10% of patients, usually after delayed or missed diagnosis. The frequency of Lemierre's syndrome would be higher if antibiotics were given only to pharyngitis patients positive for streptococcus.

[A case of total complicated pleuropneumonia in someone who worked in the cleanup of the aftermath of the Chernobyl catastrophe]. / Vypadok total'noï uskladnenoï plevropnevmoniï u likvidatora naslidkiv chornobyl'skoï katastrofy.

A case is described that is not typical one, of total complicated pleuropneumonia in the liquidator K. of 1986 Chernobyl disaster aftermath. The dose of radiation he had been exposed to amounted to 25.75 rads. In 1989 he had acute right-sided pneumonia, in 1996-acute right-sided pleuropneumonia that got complicated by purulent meningoencephalitis. Examination of the patient revealed secondary T-cellular dysbalance.

[Hepatotoxic effect of etacizin in acute pneumonia]. / Gepatotoksicheskoe deistvie étatsizina pri ostroi pnevmonii.

The paper describes one acute toxic hepatitis event in a woman of 60 with pleuropneumonia and exudative pleurisy. She had been treated with ethacizinum in small dose. To solve the problem, antioxidant and drug with hepato protective action should be prescribed along with ethacizinum.

Advantages and disadvantages of Seldniger transthoracic drainage in purulent-destructive diseases of the lung and pleura in childhood.

BACKGROUND: Suppurative-destructive diseases of the lung and pleura are prevalent kind of diseases occurring in children. They represent 9.1% of thoracic surgical diseases in this age. In such diseases, the pleural drainage is the most commonly used at present time. One of the methods is the transthoracic drainage by Seldinger. MATERIAL AND METHODS: Over the period of 13 years (2000-2012), 101 children with different forms of acute purulent destructive processes of the lung and pleura were treated in the Department of Pediatric Surgery of the University Hospital "St. George "- Plovdiv. We used percutaneous (transthoracic) drainage (Seldinger method) in the case of three children with lung abscess complicated pleuropneumonia with empyema. RESULTS: We achieved positive effect in treatment with all three children, without introducing additional operating procedures. CONCLUSION: There is still no consensus regarding the surgical treatment of various forms of acute suppurative-destructive diseases of the lungs and pleura (ASDDLP). Some authors attach great importance to the puncture method of treating ASDDLP, whilst they recommend the application of another treatment in case of failure.