Diagnostic approach to localised organising pneumonia--A case report.

INTRODUCTION: Localised organising pneumonia, radiologically presented with oval or round shadows mimicing lung cancer or metastases, is a major issue in differential diagnosis. CASE REPORT: A female patient was hospitalized to clarified the etiology of multiple nodular lung lesions. The chest X-ray and the chest computed tomography (CT) revealed bilateral patchy and nodular shadows, and round lung lesions, respectively. Neither sputum analyses, nor histology of bronchoscopy samples clarified the etiology of these lung lesions. As secondary deposits in the lungs were suspected, video-assisted thoracoscopy and anterolateral right minithoracotomy with atypical upper and lower lobe resection were performed. The frozen-section analysis suggested the benign nature of the lesion, and the definite histopathological finding of localised organising pneumonia was established. Due to bilateral lung lesions, corticosteroids were applied. Seven weeks later, the chest CT finding revealed a total regression of the lesions. CONCLUSION: A surgical resection was necessary to diagnose the localised organising pneumonia which mimiced secondary malignant lesions, thus establishing the definite etiology of lung lesions. Bronchoscopic cryobiopsy, recently introduced in order to obtain peripheral lung biopsy samples, has provided new possibilities in the diagnosis and treatment of neoplastic and non-neoplastic lung diseases.

[Parapneumonic effusions: features, diagnostics and treatment options].

INTRODUCTION: Parapneumonic effusions, as a complication of inflammatory processes in the lungs, usually have a good course, but they sometimes progress into pulmonary empyema, thus becoming a significant clinical problem. OBJECTIVE: To review clinical and radiological features, as well as diagnostic and therapeutic options in parapneumonic effusions. METHODS: The analysis included 130 patients with parapneumonic effusions hospitalized at the General Pulmonology Clinic of the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica during 2013. RESULTS: Of 385 patients with pneumonia, 130 (33.8%) had parapneumonic effusion, 78 (60.0%) of whom were males. Most patients (361; 27.7%) were 60-69 years of age. The most common symptoms included fever (92; 70.8%) and cough (91; 70.0%). Hypertension was the most common comorbidity registered in 81 (62.3%) patients, and chronic obstructive pulmonary disease present in 33 (25.4%) patients. Pleural puncture was performed in 62 (47.7%) patients. Macroscopically, effusion was clear in most cases (31; 50.0%), and cytologically the mixed type was most frequently established (26; 41.9%). Bronchoscopy was performed in 52 (40.0%) patients, and video-assisted thoracoscopy in 9 (6.9%) patients. Empyema signs were registered in 13 (10.0%) patients; in all a thoracic drainage with administration of intrapleural streptokinase was performed. CONCLUSION: Patients with a parapneumonic effusion have the symptoms of acute respiratory infection and frequent concomitant diseases. Further diagnostic and therapeutic treatment depends on pleural fluid features and chest CT finding.

Multisystem Langerhans cell histiocytosis coexisting with metastasizing adenocarcinoma of the lung: a case report.

INTRODUCTION: Langerhans cell histiocytosis (LCH) is an uncommon disease of unknown etiology characterized by uncontrolled proliferation and infiltration of various organs by Langerhans cells. CASE REPORT: We presented a 54-year-old man, heavy smoker, with dyspnea, cough, hemoptysis, headache and ataxia, who died shortly after admission to our hospital. On the autopsy, tumor was found in the posterior segment of the right upper pulmonary lobe as well as a right-sided occipitoparietal lesion which penetrated into the right ventricle resulting in internal and external hematocephalus. Histologically and immunohistohemically, the diagnosis of primary lung adenocarcinoma with brain metastasis was made (tumor cells showed positivity for CK7 and TTF-1 which confirmed the diagnosis). In the lung parenchyma around the tumor, as well as in brain tissue around the metastatic adenocarcinoma histiocytic lesions were found. Light microscopic examination of the other organs also showed histiocytic lesions involving the pituitary gland, hypothalamus, spleen and mediastinal lymph nodes. Immunohistochemical studies revealed CD68, S-100 and CD1a immunoreactivity within the histiocytes upon which the diagnosis of Langerhans' cells histiocytosis was made. CONCLUSION: The multisystem form of LCH with extensive organ involvement was an incidental finding, while metastatic lung adenocarcinoma to the brain that led to hematocephalus was the cause of death.

The most common isolates from pleural infections.

Isolation and identification of the pathogens are important for appropriate treatment of pleural infections. Distribution of the most frequent causative agents varies throughout the world and may change in time.The objective of the study is to analyze the bacteriological isolates of pleural fluids in order to identify the most frequent infectious agents and assess their variability in time.The retrospective study included 272 patients with positive pleural fluid samples analyzed in 5-year period. The samples were examined using the conventional microbiological technique.Of 315 bacterial isolates the most common were streptococcal species, 105 (33%), of which 55 (17.3%) represented the Streptococcus milleri group. Gram-positive anaerobic cocci were detected in 56 (17.6%) isolates. Enterobacteriaceae family included 27 (8.5%) isolates and Pseudomonas aeruginosa was registered in 13 (4.1%). No statistically significant difference was registered in pathogen distribution in the examined period (p = 0.288).The most common agents of community-acquired pleural infections are the Streptococcus milleri group and anaerobic Gram-positive cocci. They differ from the most common pathogens of pneumonia. Among the hospital-acquired pleural infections, Pseudomonas species, Staphylococcus aureus and enterobacteria prevail. The distribution of bacterial agents isolated in the 5-year period exhibits no significant differences.

The role of autofluorescence bronchoscopy in monitoring a tumorous lesion in the bronchial mucosa: a case report.

INTRODUCTION: Autofluorescence bronchoscopy (AFB) is a diagnostic procedure that is included in all diagnostic algorithms discovering precancerous lesions in the large airways. CASE REPORT: We presented a 71-year-old patient submitted to exploration due to prolonged cough. Both noninvasive and invasive pulmonary diagnostic management was carried out. On bronchoscopy, an endobronchial mass was detected in the apical bronchus. A positive endoscopy finding indicated AFB which disclosed a fluorescence alteration of the tumor mucosa and the former bronchoscopy site. Histopathological analysis of the catheter biopsy obtained samples from the right upper lobe confirmed fibrinous purulent pneumonia in organization. The applied treatment resulted in regression of both symptoms and the lesion in the right upper lobe. Due to a positive AFB finding, the patient was regularly observed over the following three years, having had three control AFB to monitor the initial finding. CONCLUSION: AFB may be utilized in the routine of everyday practice to assess the spread of the disease, as well as in the postsurgical and long-term follow-up of operated patients. The procedure may also be applied to enable an easier and more reliable observation of patients with suspicious endobronchial lesions, smokers with altered fluorescence of the bronchial mucosa, and chronic patients.

Chronic necrotizing pulmonary aspergillosis.

INTRODUCTION: Chronic necrotizing pulmonary aspergillosis (CNPA) is a cavitary, infectious process of lung parenchyma with slow progressive course. Vascular invasion and dissemination to other organs are unusual. CASE REPORT: We presented a 25-year old man with bilineal acute leukaemia who developed pulmonary and systemic symptoms. Chest CT showed nodular consolidations and cavitary lesions in both lungs. Bronchial biopsy revealed necrotic hyphae but it was negative for Aspergillus by culture. Serum was positive for antibodies to Aspergillus, but it was negative for antigens. A thoracoscopic lung biopsy of the upper left lobe revealed necrosis of lung tissue, with acute and chronic inflammation of the cavity wall and the presence of hyphae consistent with Aspergillus species. CONCLUSION: Although confirmation of the diagnosis is difficult, a combination of characteristic clinical, radiological and histological findings and either serological results positive for Aspergillus or the isolation of Aspergillus from respiratory samples are highly indicative of CNPA.

Adult human case of toxocariasis with pulmonary migratory infiltrate and eosinophilia.

INTRODUCTION: Toxocariasis is a zoonosis which is in Serbia characterized with a very high infection rate of dogs and excessive contamination of the soil with the eggs of Toxocara canis, the agent of the disease. Toxocara-induced infections have in recent years been established in a few hundreds of children, but toxocariasis has rather rarely been diagnosed in adults. CASE REPORT: We reported toxocariasis (visceral larva migrans) in an adult, manifested by migratory pulmonary infiltrates and positive serological test finding to Toxocara. CONCLUSION: Human toxocariasis is a rare disease in adults, therefore it should be considered in adult patients presented with eosinophilia and migratory pulmonary infiltrates.

[Differential diagnosis problem of pulmonary changes in ulcerative colitis].

INTRODUCTION: Inflammatory intestinal diseases are often accompanied with extraintestinal and even pulmonary manifesStations. The treatment of these intestinal diseases includes sulphasalazine and mesalazine, which may have undesirable allergic and other side effects, including hypersensitive pneumonitis. CASE REPORT: Having performed colonoscopy due to abdominal pains and mushy stools, the diagnosis of ulcerous colitis was established in a 20-year-old female patient and the treatment with mesalazine initiated. However, the patient developed slimy and bloody stools, slightly increased body temperature, dry cough and bilateral lung lesions. The bronchological exploration established interstitial and organizing pneumonia. Despite the treatment with antibiotics, corticosteroids and mesalazine, dry cough, fever and bloody stools persisted, accompanied with bilateral inhomogeneous lesions of the pulmonary parenchyma. Upon discontinuation of the treatment with mesalazine, clinical symptoms and pulmonary lesions disappeared. CONCLUSION: The differential diagnosis of pulmonary lesions in patients with ulcerous colitis may be a problem. In the reported case, pulmonary lesions were interpreted as interstitial pneumonitis accompanying ulcerous colitis. However, they are most probably a consequence of allergic response to mesalazine.

[Bronchial artery embolization being the therapy of choice for massive hemoptyses in bronchiectases]. / Embolizacija bronhijalnih arterija kao terapija izbora masivnih hemoptizija kod bronhiektazija.

INTRODUCTION: Hemoptyses may be very often due to bronchiectases. Although these bleedings are usually spontaneously resolved recurrent and massive hemoptyses may vitally endanger a patient. Therefore, an urgent diagnosis and treatment of hemoptyses is required. CASE REPORT: A 56-year old patient was admitted to the hospital due to massive hemoptyses, presented with a non-homogenous shadowing, paracardially on the left. The chest Computerized Tomography finding delineated atelectasis of the lower left lobe and bronchiectases. Bronchoscopy sampling of the left lung airways provided the fresh blood. The multislice angiography and embolization of the bronchial arteries was carried out, entirely ceasing hemoptyses so the patient was discharged with no symptoms. On the control examination one month later, he was well, with normal radiological finding and inflammation markers. CONCLUSION: In our patient, the life-threatening bleeding due to inflamed bronchiectases was successfully resolved by bronchial arterial embolization, thus avoiding surgery.

[Severe form of Legionnaires' disease in an immunocompetent patient].

BACKGROUND: Legionnaires' disease (LD) is a pneumonia caused by Legionella pneumophila (LP). The disease occurs more often in immunocompromised persons and can be manifested by severe pneumonia, multiple organ failure and has a high mortality. CASE REPORT: Immunocompetent patient, male, 53-year old, with severe form of LB had fever, cough, weakness and diarrhea as the initial symptoms of the disease. Laboratory results showed increased number of leukocytes, increased values of acute phase proteins, liver enzymes and hyponatremia. Computed tomography of the chest showed the marked inflammatory lessions on both sides. Pathohistological analysis of the samples retrieved by bronchoscopy pointed to a pneumonia, and diagnosis of LD was confirmed by positive urine test for LP antigen. Later, the disease was complicated by acute adult respiratory distress syndrome (ARDS). Treatment with antibiotics (erythromycin, rifampicin, azithromycin) combined with ARDS treatment led to a clinical recovery of the patient together with complete resolution of inflammatory lesions seen on chest radiography. CONCLUSION: In severe pneumonias it is necessary to consider LD in differential diagnosis, perform tests with aim of detecting LP and apply adequate antibiotic treatment in order to accomplish positive outcome of the therapy and prevent complications.

[Frequency and relevance of concomitant diseases in elderly patients hospitalized for community acquired pneumonia].

INTRODUCTION: Patients' age and concomitant diseases are relevant for the development and treatment outcome of pneumonia. OBJECTIVE: To establish the frequency and relevance of concomitant diseases in patients over 65 years of age hospitalized for community acquired pneumonia. METHODS: The research included 550 patients hospitalized at the Institute for Pulmonary Diseases of Vojvodina in Sremska Kamenica due to community acquired pneumonia. Data on concomitant diseases and mortality rate was correlated with the patients' age limit of 65 years, and then statistically analyzed and presented in tables. RESULTS: There were 446 (81.45%) patients under and 102 (18.55%) over the age of 65 years. Dyspnea, impaired consciousness, cyanosis, tachycardia and arterial hypertension were significantly more common in patients over 65 years of age, who also had a higher prognostic score. Mortality was significantly higher (21.6% vs. 6.0%) in the patients aged over 65 years (p < 0.001). Concomitant diseases were significantly more common (p < 0.001) among the patients over 65 years (94.1% vs. 69.2%), and the majority of the elderly patients had two or three comorbidities. The following comorbidities were significantly more common among the patients aged over 65 years: chronic obstructive disease, bronchiectasis, compensated and decompensated cardiomyopathy, cardiac arrhythmia, arterial hypertension and diabetes mellitus. The higher number of concomitant diseases was associated with a significantly elevated hospital mortality (p < 0.001). A statistically significant mortality rate difference was found in both age groups regarding the comorbidity of chronic obstructive disease and decompensated cardiomyopathy. CONCLUSION: The patients aged over 65 years hospitalized due to community acquired pneumonia had a statistically significantly higher prognostic score, mortality rate and concomitant diseases than the patients below 65 yeas of age. Most subjects of the older group of patients had two or three comorbidities. Concomitant diseases resulted in a statistically significant hospital mortality elevation. When comborbitities involved chronic obstructive pulmonary disease and decompensated cardiomyopathy, a statistically significant mortality difference was registered in both age groups.