A case of negative-pressure pulmonary oedema after first-time electroconvulsive therapy.

Electroconvulsive therapy (ECT) has been used for many years as an important treatment modality in patients with schizophrenia. Recently, many new oral medications have become available to treat schizophrenia. However, ECT remains a valuable therapy for patients who are resistant to oral medications. A 16-year-old girl with schizophrenia was admitted to our hospital with hypoxaemia due to negative-pressure pulmonary oedema (NPPE) after her first ECT. NPPE is an exceedingly rare complication after ECT. However, it can result in serious morbidity if not immediately recognized and treated. This case illustrates the importance of recognizing this rare complication.

Silicosis-related pleural effusion diagnosed using elemental analysis of the pleural fluid cell block: A case report.

Pleural disease in silicosis remains an underrecognized entity. Herein, we describe the case of an 85-year-old man with a 20-year history of silica exposure between the ages of 9-28 years. He presented with bilateral exudative pleural effusions, and chest computed tomography revealed typical silicosis findings. Thoracentesis was performed thrice, but did not reveal the cause of effusion. However, pleural fluid cell-block elemental analysis revealed a silicon compound, suggesting that silicosis-related pleural effusion had developed after a long latency period. Therefore, elemental analysis of the pleural fluid cell block may help diagnose occupational lung diseases with pleural effusion.

Borderline pulmonary hypertension associated with chronic hypercapnia in chronic pulmonary disease.

Pulmonary hypertension (PH) due to lung diseases is classified as group 3 by the Dana Point classification. Given the basic pathophysiological conditions of group 3 lung diseases and the previously well-known concept of hypercapnic pulmonary vasoconstriction, chronic hypercapnia besides alveolar hypoxia might be another causative factor to increase mean pulmonary arterial pressure (PAm). Two hundred twenty-five subjects with chronic pulmonary diseases were assessed by a right heart catheterization and blood gas parameters. The subjects were classified into the following 4 groups: Hypercapnic Hypoxia (HCHX), Hypercapnic Normoxia (HCnx), Normocapnic Hypoxia (ncHX), and Normocapnic Normoxia (ncnx). Compared with ncnx, the HCHX, HCnx and ncHX groups all showed significantly higher PAm and met the criteria of borderline PH. Multiple regression analysis showed that PaCO2, as well as SaO2, was an independent variable for PAm. Given the poor prognosis with borderline PH, the elimination of excess pulmonary carbon dioxide in hypercapnia could be a considerable treatment strategy in chronic pulmonary disease.

Potential Role of CT Metrics in Chronic Obstructive Pulmonary Disease with Pulmonary Hypertension.

PURPOSE: Recent imaging studies demonstrated the usefulness of quantitative computed tomographic (CT) analysis assessing pulmonary hypertension (PH) in patients with chronic obstructive lung disease (COPD-PH). The aim of this study was to investigate whether it would be also valuable for predicting and evaluating the effect of pulmonary vasodilators in patients with COPD-PH. METHODS: We analyzed a correlation between the extent of cystic destruction (LAA%) and total cross-sectional areas of small pulmonary vessels less than 5 mm(2) (%CSA <5) in many CT slices from each of four COPD-PH patients before and after the initiation of pulmonary vasodilator. To evaluate those generalized data from patients with COPD, we evaluated multiple slices from 42 patients whose PH was not clinically suspicious. We also selected five PH patients with idiopathic interstitial pneumonia (IIP-PH) and analyzed serial changes of pulmonary artery enlargement (PA:A ratio). RESULTS: In 42 COPD patients without PH, LAA% had a statistically significant negative correlation with %CSA <5. However, three of four COPD-PH patients manifested no such correlation. In two patients, clinical findings were dramatically improved after the initiation of pulmonary vasodilator. Notably, LAA% and %CSA <5 in those patients correlated significantly after its treatment. In COPD-PH, the PA:A ratio was significantly decreased after the initiation of pulmonary vasodilator therapy (1.25 ± 0.13 vs. 1.13 ± 0.11, p = 0.019), but not in IIP-PH. CONCLUSIONS: Our study demonstrates that the use of quantitative CT analysis is a plausible and beneficial tool for predicting and evaluating the effect of pulmonary vasodilators in patients with COPD-PH.

Pneumocystis pneumonia induced by treatment with low-dose tacrolimus and methylprednisolone in a patient with rheumatoid arthritis: a case report.

BACKGROUND: Tacrolimus is an immunosuppressive drug used to prevent acute rejection following organ transplantation and to treat autoimmune disease. Tacrolimus is usually prescribed in such situation at a dose of 3.0 mg/day. Pneumocystis pneumonia induced by this dose of tacrolimus has been reported in many cases; however, we encountered a rare case of Pneumocystis pneumonia induced by low-dose tacrolimus and methylprednisolone. CASE PRESENTATION: We herein report the case of an 82-year-old Asian Japanese female with rheumatoid arthritis and Pneumocystis pneumonia who was being treated with low-dose tacrolimus and low-dose methylprednisolone therapy. She was diagnosed with rheumatoid arthritis at 52 years of age and was administered oral low-dose methylprednisolone and salazosulfapyridine. Her condition had been stable under this treatment for 30 years. However, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy. However, on the 14th day of admission, she developed acute respiratory failure due to Pneumocystis pneumonia and died on the 17th day of admission in spite of adequate treatment. CONCLUSION: Our report highlights the importance of providing prompt prevention, diagnosis and treatment of Pneumocystis pneumonia in rheumatoid arthritis patients under tacrolimus and low-dose methylprednisolone therapy.