Different forms of pulmonary aspergillosis: A pictorial essay.

Pulmonary aspergillosis is a group of mycotic diseases affecting the lungs. The form of the disease mainly depends on the immune status of the patient and underlying conditions. Invasive pulmonary aspergillosis usually affects immunocompromised patients - angio-invasive and airway-invasive forms are possible. Chronic aspergillosis usually appears in mildly immunosuppressed or immunocompetent patients with underlying structural lung changes and may have diverse forms: simple aspergilloma, chronic cavitary pulmonary aspergillosis, chronic fibrosing pulmonary aspergillosis, subacute invasive pulmonary aspergillosis, aspergillus nodules and endobronchial aspergilloma. Allergic bronchopulmonary aspergillosis is a hyper-reactivity reaction to Aspergillus species, and usually develops in asthma and cystic fibrosis patients. The aim of this article is to comprehensively overview different forms of aspergillosis, their symptoms and underlying conditions and to present imaging findings.

Early association between respiratory mechanics and radiological changes in mechanically ventilated critically ill patients with COVID-19.

The chest X-ray (CXR) Brixia scoring system was developed exclusively for COVID-19 severity assessment. However, no association between the score and respiratory mechanics during mechanical ventilation has been examined. Our aim was to evaluate the association between the CXR Brixia score and respiratory mechanics on the first day of mechanical ventilation in critically ill COVID-19 patients. A total of 77 COVID-19 patients who underwent mechanical ventilation and CXR in the ICU setting were retrospectively included. The CXR Brixia scoring system was applied, and respiratory mechanics data were recorded on the first day of invasive mechanical ventilation. Median Simplified Acute Physiologic Score II (SAPSII) and Sequential Organ Failure Assessment (SOFA) scores were 40 (31-54) and 6 (4-8), respectively. The median Brixia score was 14 (11-16). The correlation between the Brixia score and static compliance or driving pressure was significant, at r = -0.38, p < 0.001 and r = 0.33, p = 0.003, respectively. Using multivariable linear regression, the model with the B zone was significantly better associated with static compliance (F = 11.5, R2 = 0.14, p = 0.001) and driving pressure (F = 11.3, R2 = 0.13, p = 0.001). In logistic regression analysis, the Brixia score (OR 1.24; 95% CI 1.07, 1.45; p = 0.005), B zone (OR 2.60; 95% CI 1.30, 5.20; p = 0.007), C zone (OR 2.50; 95% CI 1.23, 5.11; p = 0.012), A zone (OR 2.01; 95% CI 1.16, 3.44; p = 0.012), and D zone (OR 1.84; 95% CI 1.07, 3.17; p = 0.027) significantly predicted a driving pressure > 14 cmH2O. There is a relationship between changes in Brixia-scored chest X-ray images and compliance and driving pressure on the first day of invasive mechanical ventilation. We identified some CXR areas using the Brixia score, and evaluation of the Brixia score may provide additional information for predicting respiratory mechanics.

Masks of hypersensitivity pneumonitis in children.

Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is the most common interstitial lung disease in children, but remains rarely recognized in the pediatric population. Early recognition of triggering factors and a high index of suspicion of HP could lead to timely diagnosis and individualized treatment. This study aimed to present four clinical cases of HP reported between 2012 and 2022 in Lithuania to improve the suspicion of the disease in children.

Case report: Unilateral pulmonary artery agenesis and Kommerell's diverticulum in 1-year old girl.

Background: Unilateral pulmonary artery agenesis (UPAA) and Kommerell's diverticulum (KD) are two rare embryologically unrelated congenital vascular malformations rarely diagnosed in children. This is the first report of our knowledge of the unique combination for a child as patients are at a high risk of pulmonary hypertension and rupture of the diverticulum. Our aim is to present the case of a pediatric patient with UPAA and KD with the short literature review and to highlight the importance of early diagnostics of rare congenital vascular malformations. Case report: A 1-year-old girl presented to the emergency department with prolonged cough and variable wheezing. A hypoplastic left lung was suspected in the radiographic image of the chest. A transthoracic echocardiogram revealed absence of the left pulmonary artery and right arch of aorta and anomaly of subclavian arteries was suspected. The diagnosis was confirmed by computed tomography scans of the chest that demonstrated elongation of the aorta and an aberrant right subclavian artery with KD, as well as absence of the left pulmonary artery. The patient is being followed up for the development of pulmonary hypertension and compression of vascular structures to the airways as well as any indications for surgical intervention because of the KD. Conclusions: UPAA and KD are two very rare congenital vascular anomalies usually diagnosed in adults. A high risk of pulmonary hypertension and rupture of diverticulum is noted for adult patients. This case provides us with an exclusive possibility to follow up a patient with an extremely rare combination of the two vascular anomalies with insufficiently known future complications and outcomes.

Multisystem Inflammatory Syndrome in a Young Adult (MIC-A) Following SARS-CoV-2 Infection.

Multisystem Inflammatory Syndrome (MIS) is a rare but increasingly recognized complication of SARS-CoV-2 infection, usually presenting 2 to 6 weeks after the onset of COVID-19 infection symptoms and affecting mainly children. However, there have been reported several cases of a similar multisystem inflammatory syndrome in adults (MIS-A). We describe the case of a previously healthy 28-year-old male who presented with a clinical profile with multiorgan involvement within four weeks after confirmed SARS-CoV-2 infection, suggestive for multisystem inflammatory syndrome (MIS-A). The clinical presentation included persistent high grade of fever, gastrointestinal and mucocutaneous lesions, lymphadenopathy, elevated cardiac and inflammatory biomarkers, cytopenia and shock. This case report illustrates the wide range of presentations, diagnosis, and treatment modalities of multisystem inflammatory syndrome. The pathophysiology and the mechanisms by which SARS-CoV-2 triggers an abnormal immune response leading to MIS remain poorly understood. Better characterization of MIS-A and early recognition of MIS is important because it is associated with high mortality if left untreated.

Effective Initial Treatment of Diffuse Pulmonary Lymphangiomatosis with Sirolimus and Propranolol: A Case Report.

Diffuse pulmonary lymphangiomatosis (DPL), an exceptionally rare disease, mainly occurs in children and young adults of both sexes. Even though DPL is considered to be a benign disease, its prognosis is relatively poor. Because of its rarity, little guidance on diagnosis and treatment is available, which makes working with patients with DPL challenging for clinicians. We present here a case of a young man with DPL in whom treatment with sirolimus and propranolol rapidly achieved positive radiological and clinical effects.

Is analysis of inflammatory biomarkers and lymphocyte subpopulations useful in prediction of tuberculosis treatment outcomes?

Analysis of inflammatory biomarkers and lymphocytes during the treatment of tuberculosis (TB) could yield findings that influence the routine clinical practice and use of new anti-TB drugs. This study aimed to evaluate whether the selected biomarkers-soluble intercellular adhesion molecule type 1, soluble urokinase-type plasminogen activator receptor (suPAR), and C-reactive protein (CRP)-and T-cell subpopulations are useful for predicting culture conversion, treatment outcomes, and the extent of radiological lesions (calculated using X-ray score) in patients with drug-sensitive pulmonary TB. This study included 62 patients with drug-sensitive pulmonary TB. CRP and suPAR levels significantly decreased after 1 month of treatment. Before treatment initiation, CRP and suPAR levels were significantly higher in patients without culture conversion; however, none of the selected host biomarkers appeared to significantly influence the conversion status or treatment outcomes. Some lymphocyte subpopulations were correlated with X-ray scores before TB treatment initiation, but lung destruction, as determined using X-ray scores, showed the highest correlation with the baseline CRP value. We conclude that selected host biomarkers have a very limited role in predicting TB treatment outcomes and culture conversion and do not appear to be superior to CRP in monitoring TB treatment.

Post COVID-19 Organizing Pneumonia: The Right Time to Interfere.

The COVID-19 pandemic dramatically changed medical care. Healthcare professionals are faced with new issues. Patients who survived COVID-19 have plenty of different continuing symptoms, of which the most common are fatigue and breathlessness. It is not well known how to care for patients with persistent or worsening respiratory symptoms and changes on chest X-ray following COVID-19 pneumonia. In this article, we talk about a subgroup of patients with organizing pneumonia following COVID-19 pneumonia that could be effectively treated with systemic glucocorticoids. It is important that patients with COVID-19 pneumonia be followed-up at least three weeks after diagnosis, in order to recognize early lung damage. We are providing a management algorithm for early diagnosis of lung diseases after COVID-19 pneumonia.

A case report and literature review: previously excluded tuberculosis masked by amiodarone induced lung injury.

BACKGROUND: Amiodarone is an antiarrhythmic drug which is used to treat and prevent several dysrhythmias. This includes ventricular tachycardia and fibrillation, wide complex tachycardia, as well as atrial fibrillation (AF) and paroxysmal supraventricular tachycardia. Amiodarone may prove to be the agent of choice where the patient is hemodynamically unstable and unsuitable for direct current (DC) cardioversion. Although, it is not recommended for long-term use. The physician might encounter issues when differentiating amiodarone-induced lung toxicity with suspicion of interstitial lung disease, cancer or vasculitis. Adverse drug reactions are difficult to confirm and it leads to serious problems of pharmacotherapy. CASE PRESENTATION: A 78-year-old Caucasian male pensioner complaining of fever, dyspnea, malaise, non-productive cough, fatigue, weight loss, diagnosed with acute respiratory failure with a 16-year long history of amiodarone use and histologically confirmed temporal arteritis with long-term glucocorticosteroid (GCC) therapy. Patient was treated for temporal arteritis with GCC for ~ 1 year, then fever and dyspnea occurred, and the patient was hospitalized for treatment of bilateral pneumonia. Chest X-ray and chest high resolution computed tomography (HRCT) indicated several possible diagnoses: drug-induced interstitial lung disease, autoimmune interstitial lung disease, previously excluded pulmonary TB. Amiodarone was discontinued. Antibiotic therapy for bilateral pneumonia was started. Fiberoptic bronchoscopy with bronchial washings and brushings was performed. Acid fast bacilli (AFB) were found on Ziehl-Nielsen microscopy and tuberculosis (TB) was confirmed (later confirmed to be Mycobacterium tuberculosis in culture), initial treatment for TB was started. After a few months of treating for TB, patient was diagnosed with pneumonia and sepsis, empiric antibiotic therapy was prescribed. After reevaluation and M. Tuberculosis identification, the patient was referred to the Tuberculosis hospital for further treatment. After 6 months of TB treatment, pneumonia occurred which was complicated by sepsis. Despite the treatment, multiple organ dysfunction syndrome evolved and patient died. Probable cause of death: pneumonia and sepsis. CONCLUSIONS: The current clinical case emphasizes issues that a physician may encounter in the differential diagnostics of amiodarone-induced lung toxicity with other lung diseases.

Factors associated with sputum culture conversion in patients with pulmonary tuberculosis.

OBJECTIVE: The aim of this study was to determine what factors are associated with sputum culture conversion after 1 month of tuberculosis (TB) treatment. MATERIALS AND METHODS: A total of 52 patients with new drug susceptible pulmonary TB were included in the study. Patients completed St. George respiratory questionnaire (SGRQ), they were asked about smoking, alcohol use, living conditions and education. Body mass index (BMI) measurements, laboratory tests (C reactive protein [CRP], vitamin D, albumin) were performed, and chest X-ray was done. After 1 month of treatment sputum culture was repeated. RESULTS: Culture conversion after 1 month of treatment was found in 38.5% cases. None of investigated social factors appeared to have an effect on conversion, but worse overall health status (as reported in SGRQ) and longer duration of tobacco smoking were detected in the "no conversion" group. Concentrations of albumin, CRP, X-ray score and the time it took Mycobacterium tuberculosis culture to grow also differed. Patients who scored 30 or more on SGRQ were more than 7 times as likely to have no conversion. However, the most important factor predicting sputum culture conversion was sputum smear grade at the beginning of treatment: patients with grade of 2+ or more had more than 20-fold higher relative risk for no conversion. Using receiver operating characteristic curve analysis, we also developed a risk score for no conversion. CONCLUSIONS: The most important factors in predicting sputum culture conversion after 1 month of treatment were grades of acid-fast bacilli in sputum smears at time of diagnosis and scores of SGRQ.

A mediastinal mass mimicking asthma symptoms.

Extramedullary myeloid sarcoma is a rare form of myelogenous leukemia. It can involve any anatomical body part. Mediastinal involvement is reported in only few cases. We report on a case of extramedullary myeloid sarcoma presenting as a mediastinal mass in a previously healthy nonleukemic male teenager with primary asthmatic complaints and the signs of superior vena cava syndrome.

Pseudoaneurysm of brachiocephalic artery mimicking the mediastinal tumor.

58 year-old male admitted to the Hospital of Lithuanian University of Health Sciences due to suspicion of mediastinal tumor for diagnostic endobronchial ultrasound procedure (EBUS). The main patient's complain was progressive dyspnea. Objective investigation revealed no major findings: normal breath sounds, heart rate - 96 bpm, blood pressure - 120/80 mmHg. Chest CT scan showed the mediastinal tumor of 3.8 × 3.5 cm. During bronchoscopy smooth intratracheal nodule of 5 mm was found. Superficial biopsy showed normal airway mucosa. During EBUS procedure no clear lymph node structure or blood flow was detected. It was decided to observe the patient clinically. One month later massive hemoptysis started. Urgent bronchoscopy revealed large right-sided mass and intratracheal wall dislocation due to the possible mediastinal tumor in the same location as the polyp in the previous investigation. Repeated chest CT scan showed increasing tumor of size 4.0 × 3.2 × 4.0 cm in the mediastinum and pseudoaneurysm of brachiocephalic artery was suspected. The diagnosis was later confirmed by aortography. The patient underwent successful aneurysmectomy.

[Diagnostic value of multislice computed tomography coronary angiography in patients with left bundle branch block]. / Vainikiniu arteriju angiografija daugiapjuviu kompiuteriniu tomografu esant kairiosios Hiso pluosto kojytes blokadai.

OBJECTIVE: The aim of present study was to evaluate the diagnostic value of multislice computed tomography coronary angiography in patients with left bundle branch block. MATERIALS AND METHODS: Twenty-four patients who underwent both multislice computed tomography coronary angiography and invasive coronary angiography were enrolled in the study. Findings of these imaging modalities were compared in order to determine the sensitivity, specificity, positive predictive value, and negative predictive value of multislice computed tomography angiography in identifying hemodynamically significant stenoses (> or =50%). All segments > or =2 mm in diameter were visually assessed independently from their degree of calcification and image quality. RESULTS: In total, 328 segments were analyzed. The Spearman correlation coefficient between multislice computed tomography and invasive coronary angiography was 0.76 (P<0.0001). On a per-segment basis, sensitivity, specificity, positive predictive value, and negative predictive value of multislice computed tomography angiography were 75%, 97.7%, 72%, and 98%, respectively; on a per-vessel basis, these values were 77.8%, 92.3%, 70%, and 94.7%, respectively; on a per-patient basis - 81.8%, 84.6%, 81.8%, and 84.6%, respectively. CONCLUSIONS: Multislice computed tomography coronary angiography provides a high diagnostic accuracy in detecting significant coronary artery stenoses in patients with left bundle branch block.

Image quality of 16-slice computed tomography coronary angiography in patients with complete left bundle branch block.

OBJECTIVE: Noninvasive diagnosis of coronary artery disease in patients with left bundle branch block is challenging. Multislice computed tomography can be useful in this population; however, quality of images depends on the patterns of myocardial contractions. We investigated the influence of left bundle branch block on image quality of multislice computed tomography coronary angiography. MATERIALS AND METHODS: Multislice computed tomography coronary angiography was performed in 30 patients with left bundle branch block and 30 patients without conduction disturbances. Image quality of each coronary segment was visually assessed and rated on a five-point scale (1=highest quality). RESULTS: Average image quality score in the best cardiac cycle phase did not differ significantly between groups (1.71+/-0.59 in the left bundle branch block group vs. 1.60+/-0.57 in the control group, P=0.46). In the left bundle branch block group, a significantly lower image quality score was observed in end-systolic cardiac phase (2.67+/-0.6 vs. 2.22+/-0.65 in the control group, P=0.007), whereas no difference was demonstrated in mid-diastolic phase (1.73+/-0.6 vs. 1.69+/-0.66 in the control group, P=0.81). After image assessment in multiple cardiac phases, an increase in image quality score was higher in the left bundle branch block than in the control group (0.2+/-0.17 vs. 0.11+/-0.14, P=0.003). A negative correlation was observed between image quality score and both the heart rate and heart rate variability in both groups (P<0.001). CONCLUSION: A nonsignificantly lower overall image quality of multislice computed tomography coronary angiography was demonstrated in the left bundle branch block group. In the presence of left bundle branch block, image quality in the end-systolic phase was significantly lower. Image assessment in multiple phases increased overall image quality and is therefore advisable in patients with left bundle branch block. Increased heart rate and heart rate variability worsened image quality in both groups.

[Radiographic methods in the diagnosis of tuberculous spondylitis]. / Tuberkuliozinio spondilito rentgenologines diagnostikos sunkumai.

During one year period (from May 2000 to June 2001) 136 radiographic examinations were performed in Kulautuva tuberculosis hospital due to suspision of skeletal tuberculosis. Tuberculous spondilitis being most frequent presentation of skeletal tuberculosis, showed radiographic signs in 31 cases (22.8%). The role of conventional X-rays and computed tomography diagnosis of tuberculous spondilitis is reviewed. Early changes on plain films are non-specific making early diagnosis of spine tuberculosis a challenging task. In such cases spinal computed tomography may be helpful. Must frequently pathologic changes include high spectrum varying from osteoporosis to destruction of vertebrae and two or three vertebraes and intervertebrae disks are always involved.