[Rare viral infections of the lungs]. / Seltene virale Infektionen der Lunge.

Due to the direct contact with the environment the lungs are exposed to a multitude of viruses. This article describes four viral pathogens, which can lead to pulmonary manifestations but are little known because they are rare in Germany. Avian influenza, Middle East respiratory syndrome (MERS), and Hantavirus infections are all zoonotic infections, whereas measles is a purely human disease. All four infections may lead to severe pulmonary complications with a high mortality. Measles, MERS and avian influenza can lead to far-reaching public health consequences due to transmission via individual patients within the human population. The article focusses on relevant aspects of epidemiology, clinical course, treatment, and prevention for each of the viruses. This knowledge seems to be important as cases of these diseases may occur at any time in Germany.

[Acute Respiratory Failure after Silicone Injection]. / Akutes respiratorisches Versagen durch Silikon-Injektion.

A 35-year-old male patient presented to the emergency department with complains of fever, dyspnea and petechiae. The chest X-ray revealed signs of bipulmonary infiltration. 5 days ago, an illicit silicone injection was performed into the penis for cosmetic reasons. Due to progressive respiratory failure the patient required mechanical ventilation. Bronchoalveolar lavage revealed diffuse alveolar hemorrhage. Silicone pneumonitis with a severe acute respiratory failure based on silicone embolization syndrome was diagnosed. Prone positioning, lung-protective ventilation and corticosteroid therapy were initiated. The patient was discharged from ICU after 19 days. In an outpatient follow up, lung function was fully recovered. CONCLUSION: Silicone pneumonitis should be considered in case of fever, respiratory distress and alveolar hemorrhage linked to cosmetic procedures. High dose corticosteroid therapy and lung-protective ventilation strategies may help for complete recovery of lung function.

[Tuberculosis and travelling]. / Tuberkulose und Reisen.

Tuberculosis (TB) in Germany in the year 2007 with 5020 reported cases (incidence: 6.1 newly diagnosed cases per 100 000 inhabitants) was continuously in decline. 43.1 % of these persons were from countries with a higher TB incidence as compared to Germany. However, not only migration but also personal journeys from low- to high-incidence countries carries an increased risk of infection with M. tuberculosis (MTB). An early active TB follows only rarely, more common, however, is a latent TB infection (LTBI). Not only the active form of TB but also LTBI, with a potential for reactivation years or decades later, can be of enormous relevance for the individual and the social environment. The early detection of an MTB infection and its possible sequelae are decisive for a continued successful battle against tuberculous diseases, especially in view of increasing travel activities.

Treatment of invasive pulmonary aspergillosis in neutropenic patients by additional bronchoscopic amphotericin B instillation.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) remains a life-threatening condition despite systemic antifungal therapy. OBJECTIVES: This retrospective analysis investigated whether additional bronchoscopic instillation of amphotericin B (amB) would improve efficacy of antifungal treatment in patients with haematological malignancies suffering from IPA. METHODS: Twenty patients (40.6 +/- 14.2 years, 14 male) with preceding chemotherapy, bone marrow or stem cell transplantation complicated by severe IPA who did not respond sufficiently to systemic antifungal therapy were additionally treated by repeated bronchoscopic instillations of amB solution (91 instillations, on average 4.6 +/- 2.2 instillations per patient over a period of 24.1 +/- 21.0 days). Therapeutic response to this combined treatment regimen was monitored by chest X-ray and CT scan. RESULTS: The mean infiltration sizes during systemic antifungal therapy alone (mean duration 11.9 +/- 9.9 days) did not change significantly. However, after additional bronchoscopic instillation of amB solution infiltration sizes were reduced significantly (p < 0.05). A total resolution of infiltrates was seen in 3 and a partial reduction in 13 of 20 patients. Mean duration of total antifungal treatment was 50.1 +/- 24.0 days. The mean follow-up period was 34.1 +/- 31.2 months. The IPA-related mortality rate was 18.8% (3 of 16 patients). CONCLUSIONS: Additional bronchoscopic instillation of amB may improve the efficacy of systemic antifungal therapy in patients with haematological malignancies complicated by severe IPA. Bronchoscopic instillation of amB should be considered as an additional treatment option in cases with IPA unresponsive to systemic therapy.

Foreign body in the airway: unusual cause of acute dyspnoe after cardiac surgery.

We report on a 68-year-old male who presented with acute onset of dyspnoea and cough. After coronary artery bypass grafting and mitral valve repair with an annuloplasty ring, postoperative recovery was initially uneventful. On the 6th postoperative day, he came back to intensive care unit due to acute dyspnoea. Fig. 1 demonstrates chest x-ray. We identified the foreign body as a dental prosthesis (Fig. 2). Removal from the right bronchial tree was successful using a flexible bronchoscope under local anesthesia; intubation was not required. This procedure was safe and well tolerated by the patient. Clinical presentation of adult foreign body aspiration are often nonspecific. Chest x-ray is very helpful for identification and localization of foreign bodies in the airway. Extraction can be performed with flexible or rigid bronchoscopy. For the removal, biopsy forceps, Fogarty balloon catheter, alligator forceps or wire baskets are effective.

[Pleuritis tuberculosa - therapeutic value of repeated chest tapping]. / Pleuritis tuberculosa - therapeutische Wertigkeit wiederholter Pleurapunktionen.

Tuberculous pleuritis tends to develop fibrosis to a high degree. The use of corticosteroids enhances the absorption of pleural effusions, the residual pleural thickening, however, remains unaffected. Whether repeated chest tapping in patients with persistent effusions in addition to antituberculous therapy favourably influences the outcome is not known. Therefore, patients with tuberculous pleuritis were examined in a prospective, randomized study. After confirmation of the diagnosis patients were randomized in group A with antituberculous treatment (Isoniazid, Rifampicin, Pyrazinamid, and Streptomycin) alone or in group B with additional pleural tapping for four weeks (phase I). In phase II patients in both groups with persistent effusions received oral prednisolone (0,75 mg/kg body weight) tapered over four weeks. The extent of pleural effusions was determined by chest X-ray. Roentgenological changes were evaluated at the end of the observation period. Lung function tests by spirometry were performed after two, four, eight weeks, and at the last follow up visit. At the end of phase I no pleural effusion could be observed roentgenologically in group A in 7 of 16 patients (44 %) and in group B in 10 of 16 patients (63 %) (p = n. s.). At the end of phase II extensive residual thickening was observed in one patient (group B) necessitating pleurectomy six months later. The lung function parameters demonstrated a restrictive pattern, which did not differ significantly at the end of the observation period. After a mean follow-up period of four months none or minimal residual changes could be observed radiologically in the remaining patients. In summary, despite the low number of patients examined, this study shows that in patients with tuberculous pleuritis repeated chest tapping in addition to antituberculous medication does not seem to benefit the patient, as neither the degree of residual pleural thickening nor the restrictive lung function impairment seem to be influenced significantly.