[Recurrent hemoptysis secondary to an aortobronchial fistula]. / Hemoptisis recurrente secundaria a una fístula aortobronquial.

Aortobronchial fistula is a rare but serious cause of hemoptysis. It can develop from an aneurysm of the descending thoracic aorta in the context of infections or it may appear as a sequel of surgical repair of congenital heart defects. Presenting symptoms include mild bronchial hemorrhages and recurrent chest pain, culminating in a normally fatal massive hemorrhage. Diagnosis by imaging is not always conclusive and clinical suspicion based on medical history is essential. Surgical placement of an endovascular stent graft is the treatment of choice. Post-surgical prognosis is good although there is a risk of recurrence in the case of superinfection.

Hemoptisis recurrente secundaria a una fístula aortobronquial / Recurrent hemoptysis secondary to an aortobronchial fistula

La fístula aortobronquial es una causa rara pero grave de hemoptisis. Se produce como evolución de un aneurisma de la aorta torácica descendente en procesos infecciosos o tras la reparación quirúrgica de cardiopatías congénitas. Se suele manifestar con episodios de hemorragia bronquial leve y dolor torácico recurrentes, hasta la aparición de una hemoptisis masiva, mortal en la mayoría de los casos. El diagnóstico definitivo por técnicas de imagen no siempre es posible, por lo que es fundamental la sospecha clínica tras una anamnesis adecuada. El tratamiento de elección es quirúrgico, mediante la colocación de una prótesis endovascular. El pronóstico tras la intervención es bueno, aunque con riesgo de recurrencia si se produce una sobreinfección

Aortobronchial fistula is a rare but serious cause of hemoptysis. It can develop from an aneurysm of the descending thoracic aorta in the context of infections or it may appear as a sequel of surgical repair of congenital heart defects. Presenting symptoms include mild bronchial hemorrhages and recurrent chest pain, culminating in a normally fatal massive hemorrhage. Diagnosis by imaging is not always conclusive and clinical suspicion based on medical history is essential. Surgical placement of an endovascular stent graft is the treatment of choice. Post-surgical prognosis is good although there is a risk of recurrence in the case of superinfection

[Pulmonary metastasis of Basal cell carcinoma of the skin]. / Metástasis pulmonares de un carcinoma basocelular cutáneo.

Basal cell carcinoma of the skin is a common neoplasm usually considered benign. Rarely, distant metastases can involve organs such as the brain, lung, and bone. We report the case of a 41-year old man diagnosed with lung metastasis secondary to base cell carcinoma. Given that the development of metastasis is associated with short survival and the therapeutic arsenal is scarce, we emphasize the importance of long-term follow up of such patients.

Metástasis pulmonares de un carcinoma basocelular cutáneo / Pulmonary metastasis of basal cell carcinoma of the skin

El carcinoma basocelular cutáneo es una neoplasia común, que usualmente se considera benigna. Las metastásis a distancia son muy raras y pueden afectar a órganos como el cerebro, pulmón y hueso. Publicamos el caso de un varón de 41 años diagnosticado de metástasis pulmonares secundarias a un carcinoma basocelular recidivante. Dado que el desarrollo de metástasis se asocia a una corta supervivencia y que el arsenal terapéutico del que disponemos es escaso, queremos destacar la importancia que tiene el seguimiento a largo plazo de estos pacientes

Basal cell carcinoma of the skin is a common neoplasm usually considered benign. Rarely, distant metastases can involve organs such as the brain, lung, and bone. We report the case of a 41-year old man diagnosed with lung metastasis secondary to base cell carcinoma. Given that the development of metastasis is associated with short survival and the therapeutic arsenal is scarce, we emphasize the importance of long-term follow up of such patients

[Acute non-cardiogenic pulmonary edema secondary to hydrochlorothiazide therapy]. / Edema agudo de pulmón no cardiogénico secundario a hidroclorotiazida.

Several commonly prescribed drugs can cause acute non-cardiogenic pulmonary edema. A cause-effect relationship is usually difficult to establish because symptoms are not specific. We report a case of pulmonary edema induced by a common diuretic, hydrochlorothiazide. This complication can occur after a first dose of the drug or in patients who have been taking it with no side effects. Edema is due to an idiosyncratic reaction rather than an immune response. The clinical course is usually favorable over the first 24 hours with treatment of blood pressure and respiratory support. Given that severity increases with recurrence, we underline the importance of diagnosis in the first episode.

Edema agudo de pulmón no cardiogénico secundario a hidroclorotiazida / Acute non-cardiogenic pulmonary edema secondary to hydrochlorothiazide therapy

Diversos fármacos utilizados con asiduidad pueden producir edema agudo de pulmón no cardiogénico. En la mayoría de los casos es difícil establecer la relación causal por la inespecificidad de los síntomas. Presentamos el caso clínico de un edema pulmonar inducido por un diurético de uso frecuente, la hidroclorotiazida. Esta complicación puede presentarse tras la primera toma del fármaco, o aparecer en pacientes que lo habían tomado previamente sin problemas. Se debe a una reacción idiosincrásica, no inmunitaria. La evolución suele ser favorable en las primeras 14 h con tratamiento de soporte respiratorio y hemodinámico. En caso de recurrencia, aumenta la gravedad, por lo que señalamos la importancia del diagnóstico en el primer episodio (AU)

[Round atelectasis]. / Atelectasias redondas.

The objective of this study was to analyse the epidemiologic, clinical, radiological and functional characteristics as well as the evolutive pattern of a group of patients diagnosed of round atelectasis (RA). Patients with a radiological diagnosis of RA were retrospectively identified from January 1993 to January 1998. Cases with diagnosis not confirmed by high resolution computerized axial tomography (HRCAT) were excluded. A total of 29 patients were identified, with a mean age of 65 +/- 13 years (27 men and 2 women). At diagnosis 14 patients (34%) were smokers and 14 (49%) ex-smokers. Regarding occupation, 11 individuals (38%) had history of occupational exposure to asbestos. Regarding symptomatology, round atelectasis was a radiological finding in 15 patients (52%) and the most common symptom was chest pain (34%). The most common findings detected in the chest X-ray included pleural thickening (45%), pleural effusion (38%), nodular lesion (34%) and loss of volume (24%). The most common changes detected by HRCAT were pleural thickening (45%) and bronchovascular arch (55%). In two cases magnetic resonance (MR) was performed and in no case did this examination provided additional information for the diagnosis of RA. Functional respiratory examination did not identify and predominant pattern. During the follow-up period (2.2 years) 24 patients (83%) remained radiologically stabilized, one improved and the other four worsened (two due to enlargement and two due to increase in number). Chest X-ray is a good method for the presumptive diagnosis of RA. HRCAT is an excellent technique to confirm the diagnosis and rule out the presence of malignancy. MR provides no additional information in the study of RA. There is a frequent association between RA and asbestos exposure.

Atelectasias redondas / Round atelectasis

El objetivo del estudio fue analizar las características epidemiológicas, clínicas, radiológicas y funcionales y el patrón evolutivo de un grupo de pacientes diagnosticados de atelectasia redonda (AR).Se identificaron retrospectivamente los pacientes que presentaron un diagnóstico radiológico de AR entre enero de 1993 y enero de 1998. Se excluyeron los casos en los que el diagnóstico no se había confirmado mediante tomografía axial computarizada de alta resolución (TACAR).Se hallaron un total de 29 pacientes con una edad media de 65 ñ 13 años (27 varones y 2 mujeres).En el momento del diagnóstico fumaban 10 (34 por ciento) y 14 (49 por ciento) eran ex fumadores. En relación a su profesión, 11 sujetos (38 por ciento) tenían historia de exposición laboral a asbesto. En cuanto a la sintomatología, en 15 pacientes (52 por ciento) la atelectasia redonda fue un hallazgo radiológico y el síntoma más frecuente fue el dolor torácico (34 por ciento).Los hallazgos más frecuentes encontrados en la radiografía de tórax fueron: engrosamiento pleural (45 por ciento), derrame pleural (38 por ciento), lesión nodular (34 por ciento) y pérdida de volumen (24 por ciento). Las alteraciones más frecuentes detectadas en la TACAR fueron el engrosamiento pleural (45 por ciento) y el arco broncovascular (55 por ciento). En 2 casos se realizó resonancia magnética (RM) y en ninguno de ellos esta prueba aportó información adicional para el diagnóstico de AR. La exploración funcional respiratoria no logró identificar ningún patrón predominante. Durante el período de seguimiento (2,2 años) 24 pacientes (83 por ciento) permanecieron estables desde el punto de vista radiológico, 1 experimentó mejoría y los 4 restantes empeoraron (2 por aumento de tamaño y 2 por aumento de número).La radiografía de tórax es un buen método de presunción diagnóstica de AR. La TACAR es una técnica excelente para confirmar el diagnóstico y descartar la presencia de malignidad. La RM no añade información adicional en el estudio de la AR. Existe una frecuente asociación entre AR y exposición a asbesto (AU)

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[Treatment with Bi-PAP in patients with bilateral diaphragm paralysis]. / Tratamiento con Bi-PAP en pacientes con parálisis diafragmática bilateral.

Two patients with bilateral diaphragmatic paralysis are described. The first case occurred secondary to open chest surgery; the second occurred in a polytraumatized patient. Both were successfully treated with intermittent bi-level positive airway pressure (Bi-PAP). Bilateral diaphragmatic paralysis can be related to a variety of processes, although idiopathic forms also occur. Diagnosis can be difficult and should involve a high level of clinical suspicion. Treatment and prognosis are determined by the underlying disease. Some cases may require the establishment of nighttime support ventilation. Techniques for non-invasive ventilatory assistance such as Bi-PAP can improve symptoms markedly and allow patients to live independently.

Utility of complete dead space washout by real-time gas analysis in the measurement of transfer factor in patients with chronic airflow limitation.

Chronic obstructive pulmonary disease (COPD) is associated with impaired gas mixing and increased dead space, but little is known about the effect of improving alveolar gas sample by complete correction of dead space in an attempt to significantly improve the final result of transfer factor compared with standard guidelines of the European Respiratory Society (ERS) and American Thoracic Society (ATS). By using a rapid infrared analyzer, TLCO was measured by the single breath method in 152 COPD patients at different stages of severity (FEV1:57% predicted; CI 95%:24-91). Standard washout volume of 0.75 liter was insufficient to clear phases I and II in 36 patients (23.7%). In 19 subjects (12.5%), a washout volume larger than 1 liter was necessary for complete dead space clearance, although in these patients, correction visually adequate to complete clear phases I and II resulted in higher TLCO values. Only in 5 patients (3.3%) did the final result change by more than 5% from the previous value. A vital capacity higher than 3 liters, rather than the degree of airflow limitation was a better predictor for larger washout volume requirements. We conclude that in the measurement of TLCO by the breathholding method, ERS and ATS recommendations for washout volume can be safely used for clinical purposes in a wide range of patients with mild to severe obstruction.

Severe upper airway obstruction in essential tremor presenting as asthma.

A 57 year old man with essential tremor (ET) presented with a 2 year history of paroxysmal attacks of dyspnoea and wheezing. He had been diagnosed as having bronchial asthma, and propanolol was excluded from his treatment. Flow-volume loops showed abrupt changes in maximum flows, with poor reproducibility. A diagnosis of functional upper airway obstruction was confirmed by fibreoptic bronchoscopy. The importance of establishing the precise diagnosis, in order to provide appropriate treatment, is emphasized.

[2 cases of bilateral diaphragmatic paralysis]. / Dos casos de parálisis diafragmática bilateral.

Bilateral diaphragmatic paralysis is characterized by severe dyspnea in decubitus, with or without known respiratory or cardiac disorders. In both patients clinical diagnosis was confirmed by measuring the transdiaphragmatic pressure which was approximately zero. The first patient, previous to the clinical onset, had an episode of gastroenteritis and later developed a pneumonia; in the second patient, clinical manifestations started after neck surgery and both the clinical and functional disorders recovered within the following eight months.