Toxicidad pulmonar por amiodarona. No olvidemos lo aprendido / Pulmonary toxicity by amiodarone. Let's not forget what we learned

La toxicidad pulmonar es un efecto adverso poco frecuente de la amiodarona cuyo diagnóstico es una tarea complicada ya que debe tenerse una alta sospecha clínica y descartar otras patologías que pueden confundirse con este proceso. Es importante que el diagnóstico sea precoz para poder instaurar un tratamiento temprano y evitar la progresión a fibrosis pulmonar. Presentamos un caso que manifiesta la importancia de un diagnóstico preciso y la buena evolución del mismo tras la retirada del fármaco y la instauración de tratamiento. (AU)

Pulmonary toxicity is a rare adverse effect of amiodarone, the diagnosis of which is a complicated task since a high clinical suspicion must be maintained and other pathologies that may be confused with this process must be ruled out. It is important that the diagnosis is early to be able to establish early treatmentand avoid progression to pulmonary fibrosis. We present a case that shows the importance of an accurate diagnosis and its good evolution after drug withdrawal and treatment initiation. (AU)

Factores asociados a la demora de consulta en pacientes con cáncer de pulmón / Factors associated with delayed consultation in patients with lung cancer

INTRODUCCIÓN: la presentación tardía de síntomas relacionados con el cáncer de pulmón (CP) y la demora en consultar es frecuente. OBJETIVO: conocer los síntomas referidos por los pacientes con CP, la demora hasta la primera consulta y valorar los factores relacionados con la misma. MÉTODOS: estudio prospectivo observacional de pacientes ingresados con CP. Se recogieron los síntomas sospechosos de CP referidos espontáneamente y tras mostrarles un listado estructurado de síntomas mediante entrevista personal; definiendo la fecha del primer síntoma reconocido espontáneamente y el tiempo hasta la primera consulta. RESULTADOS: se incluyeron 317 pacientes diagnosticados de CP (85,2% varones; edad media: 66 ± 10,6 años) El 89,9% presentaban comorbilidades: EPOC: 42%, patología cardiovascular: 37,5% y neoplasia previa: 19,6%. El 53% valoraban no tener o ser muy bajo su riesgo para desarrollar un CP, y un 49,2% no reconocían los síntomas del CP. Los síntomas más frecuentes referidos espontáneamente fueron: tos (52,1%), aumento de disnea (29%), cambios en la expectoración (24,9%) y dolor torácico (29,3%); aumentando su frecuencia al mostrarles un listado de síntomas. La demora hasta la primera consulta fue de 22,27 ± 53,4 días. La pérdida de peso, la ausencia de hemoptisis y la ausencia de comorbilidades, destacando la presencia de patología psiquiátrica se relacionaron con mayores demoras hasta la primera consulta. CONCLUSIONES:- Los síntomas sospechosos de CP fueron infravalorados, demorando su primera consulta más de 20 días.- La percepción de riesgo y los conocimientos acerca del CP fueron escasos.- La pérdida de peso, la ausencia de hemoptisis y de comorbilidades se asociaron con una mayor demora hasta la primera consulta

INTRODUCTION: The late presentation of symptoms related to lung cancer (LC) and delayed consultation is frequent. OBJECTIVE: To learn the symptoms referred to by patients with LC, the delay until the first consultation and to evaluate the factors related to this delay. METHODS: A prospective observational study in patients hospitalized with LC. Suspected LC symptoms referred to spontaneously and after showing patients a structured list of symptoms were recorded during a personal interview, determining the date of the first spontaneously recognized symptom and the time until the first consultation.RESULTS: 317 patients diagnosed with LC were included (85.2% male; average age: 66 ± 10.6 years). Of these, 89.9% had comorbidities: COPD, 42%; cardiovascular disease, 37.5%; and previous neoplasm, 19.6%. 53% considered themselves to have no or a very low risk of developing LC and 49.2% did not recognize the symptoms of LC. The most frequent symptoms referred to spontaneously were cough (52.1%), increased dyspnea (29%), changes in expectoration (24.9%) and chest pain (29.3%), increasing their frequency after showing patients a list of symptoms. The delay until the first consultation was 22.27 ± 53.4 days. Weight loss, the absence of hemoptysis and the absence of comorbidities, emphasizing the presence of psychiatric disorders, were associated with greater delays until the first consultation. CONCLUSIONS:- Suspected symptoms of LC were underestimated, delaying the first consultation more than 20 days.- The perception of risk and knowledge about LC were lacking.- Weight loss, the absence of hemoptysis and comorbidities were associated with a greater delay until the first consultation

Factores relacionados con la estancia hospitalaria en pacientes contromboembolismo pulmonar / Factors related to hospital stay in patients with pulmonary thromboembolism

OBJETIVO: Detectar factores que pueden condicionar la duración de la estancia hospitalaria de los pacientes ingresados por TEP. METODOLOGÍA: Estudio retrospectivo de cohortes de pacientes diagnosticados de TEP ingresados en el Servicio de Neumología del Hospital Universitario de Badajoz entre enero de 2007 y mayo de 2016. RESULTADOS: Se incluyeron 430 pacientes (edad media: 63,7 ± 16,5 años, 55,3% hombres) La mediana de la estancia hospitalaria fue 12 días. RIQ: 3 - 80 días) La estancia fue más prolongada en: pacientes de más edad(61,9 ± 17,3 vs 65,8 ± 12,5; p = 0,012), mayor puntuación en la escala Pulmonary Embolism Severity Index (PESI) (88,7 ± 31,6 vs 95 ± 30,8; p = 0,038), obesos (55,4% vs 42,7%: p = 0,03), con antecedente quirúrgico (56,6% vs 43,5; p = 0,07), ausencia de TEP previo (46,2% vs 28%; p = 0,09), presencia de sincope (57,1% vs 42,8%; p = 0,035), menor PaO2 (p = 0,003), glucemias más elevadas (p = 0,005), aparición de complicaciones hemorrágicas (66,7% vs 42,4%; p = 0,002) y no hemorrágicas durante el ingreso (68% vs 37,9%; p = 0,0005), e ingreso en UCI (57,5% vs 40,7%; p = 0,002). Se asociaron de forma independiente a una mayor estancia: la edad (OR: 1,01; IC 95%: 1 - 1,02), obesidad (OR: 1,88: IC 95%: 1,12 - 3,14), ausencia de TEP previo (OR: 3,09; IC 95%: 1,17 - 8,16), ingreso en UCI (OR: 1,68; IC 95%: 1,03 - 2,73) y la presencia de complicaciones, tanto hemorrágicas (OR: 2,20; IC95%: 1,09 - 4,43), como no hemorrágicas (OR: 2,80; IC95%: 1,70 - 4,62). CONCLUSIONES: En pacientes con TEP, diversas características epidemiológicas (edad, obesidad, primer episodio de TEP), variables de severidad en la presentación y, sobre todo, variables de evolución (ingreso en UCI, aparición de complicaciones hemorrágicas y no hemorrágicas) se asociaron con estancias más prolongadas

OBJECTIVE: To detect factors that determine the length of hospital stay in patients admitted for PTE. MATERIAL AND METHODS: A retrospective cohort study of patients diagnosed with PTE who were hospitalized in the Pulmonology Department at the University Hospital of Badajoz between January 2007 and May 2016. RESULTS: 430 patients (average age: 63.7 ± 16.5 years, 55.3% men) were included. The average hospital stay was 12 days (IQR: 3-80 days). Hospital stay was longer for: older patients (61.9 ± 17.3 vs 65.8 ± 12.5; p = 0.012), a higher Pulmonary Embolism Severity Index (PESI) score (88.7 ± 31.6 vs 95 ± 30.8; p = 0.038), obese patients (55.4% vs 42.7%: p = 0.03), those with a history of surgery (56.6% vs 43.5; p = 0.07), absence of previous PTE (46.2% vs 28%; p = 0.09), presence of syncope (57.1% vs 42.8%; p = 0.035), lower PaO2 (p = 0.003), higher blood-glucose levels (p = 0.005), appearance of bleeding (66.7% vs 42.4%; p = 0.002) and non-bleeding complications during hospitalization (68% vs 37.9%; p = 0.0005), and ICU admission (57.5% vs 40.7%; p = 0.002). The following were independently associated with a longer hospital stay: age (OR: 1.01; CI 95%: 1-1.02), obesity (OR: 1.88: CI 95%: 1.12-3.14), absence of previous PTE (OR: 3.09; CI 95%: 1.17-8.16), ICU admission (OR: 1.68; CI 95%: 1.03-2.73) and the presence of complications, both bleeding (OR: 2.20; CI 95%: 1.09-4.43) and non-bleeding (OR: 2.80; CI 95%: 1.70-4.62). CONCLUSION: In patients with PTE, several epidemiological characteristics (age, obesity, first episode of PTE), variables related to severity of presentation and, above all, variables related to progress (ICU admission, appearance of bleeding and non-bleeding complications) were associated with longer hospital stays

Pseudoquilotórax en artritis reumatoide de corta evolución y sin engrosamiento pleural: reconsiderando una teoría fisiopatológica / Pseudochylothorax in short-duration rheumatoid arthritis without pleural thickening: reconsidering a physiopathological theory

El pseudoquilotórax ha sido relacionado clásicamente con un defecto en la reabsorción de líquido en el contexto de un engrosamiento pleural que aparece tras largo tiempo de evolución de la etiología subyacente. Sin embargo, durante los últimos años se han reportado en diversos países, aunque muy pocos, casos de pacientes con este tipo de derrame en los que no existía una causa de larga evolución ni engrosamiento o calcificaciones pleurales. A nivel mundial, se han comunicado menos de 10 casos de estas características. En este manuscrito presentamos el caso de una mujer de 40 años con artritis reumatoide de corta evolución que desarrolló un pseudoquilotórax sin engrosamiento pleural

Pseudochylothorax has conventionally been associated with a deficit in the reabsorption of liquid in the context of pleural thickening, which appears over a long period of underlying etiology. However, in recent years, there have been reports in different countries, though very few, of patients with this type of effusion in which there is no long-standing cause nor plural thickening or calcification. Worldwide, fewer than 10 cases with these characteristics have been reported. In this study, we present the case of a 40-yearold woman with short-duration rheumatoid arthritis who developed a pseudochylothorax without pleural thickening

Ventilación no invasiva domiciliaria en pacientes de edad avanzada / Outcome of non-invasive domiciliary ventilation in the elderly

Introducción: Conocer la evolución a largo plazo de pacientes ancianos en ventilación no invasiva domiciliaria (VNID) y qué factores se asocian a la supervivencia de los mismos. Material y métodos: Estudio prospectivo de los pacientes >75 años que han iniciado VNID en nuestro centro en un periodo de 12 años (2002 - 2014). Se realizó un análisis univariado (Kaplan-Meier) y multivariante de supervivencia (Cox). Resultados: Se incluyeron 82 pacientes. Un 67% tenían >3 comorbilidades, iniciándose la ventilación en situaciones agudas en el 76,8%. La patología causal más frecuente fue el síndrome de obesidad-hipoventilación (65,9%) y la patología toracógena (17,1%). Se consiguieron mejorías gasométricas estadísticamente significativas entre el ingreso y alta (PaO2, PaCO2 y ph) y en el seguimiento (PaCO2), así como una reducción en el número de ingresos posteriores. La media de horas de uso fue de 8,7 ± 3,2 horas/día, pero la tolerancia fue mala en el 50% de los casos. Al final del seguimiento (mediana 15 meses; rango: 3 - 135) la mortalidad fue del 70,7%. La supervivencia al año, 2º año y 3º año fue, respectivaente, del 63%, 56% y 44%. Fueron predictores independientes de supervivencia: la cumplimentación global, la patología toracógena como causa de indicación de VNID, un menor nivel de EPAP y el grado de disnea (mMRC) en el seguimiento. Conclusiones: Los resultados de la VNID en pacientes ancianos son satisfactorios, consiguiendo mejorías mantenidas en el intercambio gaseoso, reingresos y supervivencias prolongadas. La supervivencia fue superior en los pacientes cumplidores del tratamiento, con patología toracógena y con menor grado de disnea en el seguimiento

Introduction: The aim of this study was to evaluate the outcome-including long term effects of Non-invasive Domiciliary Ventilation (NIDV) in our elderly patients and to assess what factors were associated with their survival. Material and methods: Prospective study that included all patients of our Service who started NIDV at 75 years of older (January 2002 - April 2015). Analysis of survival was undertaken using Kaplan-Meier method and Cox regression. Results: 82 patients were included (72% women, mean age: 79.9 ± 3,7 years). 67% had more than three comorbidities. The most frequent causal diseases were: Obesity hypoventilation syndrome (65,9 %) and restrictive diseases (17,1 %). Significant improvements were obtained in diurnal blood gases at discharge (PaO2, PaCO2, ph) and in the follow-up (PaCO2) as well as a significant decrease in the number of hospital admissions. The mean compliance was 8.7 ± 3.2 h/day although tolerance at home was considered to be deficient in 50 %. In the end of the follow-up (median 15 months; range 0 - 135) the mortality was 70.7 %. The estimated survival at 1º year, 2 º year and 3 º year was 63 %, 56 % and 44 %, respectively. Survival was independently associated with: good compliance, restrictive disease, lower EPAP level and lower dyspnea level (mMRC) in the follow-up. Conclusions: The results of the NIDV in elderly patients are satisfactory improving arterial blood gases, hospital readmissions and achieving long survival. Survival was better in “good compliance” patients, in restrictive diseases and with lower dyspnea level at follow up

Hábitos y trastornos del sueño en adolescentes / Habits and sleep disorders in adolescents

OBJETIVOS: conocer los hábitos de sueño en adolescentes de nuestro ámbito, valorando la presencia de trastornos durante el sueño (TS) y su relación con los hábitos de vida. MÉTODOS: estudio observacional transversal de 174 jóvenes (51,7% hombres, edad media de 14,10 más o menos 1,44 años) mediante encuesta: cuestionario general sobre TS, calidad de sueño (cuestionario de Oviedo), ansiedad (cuestionario STAIC), hipersomnolencia (escala de Epworth) y sospecha de síndrome de apneas hipopneas obstructivas durante el sueño (SAHOS, cuestionarios STOP-Bang y de Berlín). RESULTADOS: un elevado porcentaje de casos presentaban TS: problemas para dormir (23,6%), despertares nocturnos (19,5%) y pesadillas o movimientos extraños (35,1%). La hipersomnia (58,3% vs 44,4%) y cansancio diurno (54,8% vs 37,8%) fue más frecuente en mujeres, y se relacionaron con el consumo de alcohol, bebidas estimulantes o tabaco y con el número de horas de sueño. La presencia de ronquido (5,2%) o apneas (1,7%) fue infrecuente. El STAIC se relacionó con el consumo de bebidas estimulantes, enfermedades previas y con alteraciones sugerentes de SAHOS. El cuestionario de Oviedo mostró una satisfacción subjetiva de sueño buena (media: 4,74 más o menos 1,9). El Epworth tuvo una puntuación media de 6 más o menos 4,5 aunque el 24,7% tuvieron puntuaciones mayores o iguales a 10. Los cuestionarios de SAHOS identificaron un bajo porcentaje de pacientes con elevada sospecha. CONCLUSIONES: un porcentaje importante de adolescentes tienen TS con una elevada prevalencia de hipersomnia (51,1%) y cansancio diurno (46%). La presencia de síntomas más específicos (ronquido, apneas) fueron inusuales. La relación de los diversos TS y los hábitos de vida en adolescentes parece evidente, pero compleja y multifactorial

OBJECTIVE: learn about the sleep habits of adolescents (in Spain), assessing the presence of sleep disorders (SD) and the relationship of this with daily life habits. METHOD: an observational transversal study of 174 youths (51.7% males, with an average age of 14.10 ± 1.44) using a survey: general questionnaire about SD, quality of sleep (Oviedo questionnaire), anxiety (STAI questionnaire for children), hyper sleepiness (Epworth scale) and suspected obstructive sleep apnea/hypopnea syndrome, (OSAHS, STOP-Bang and Berlin questionnaires). RESULTS: a high percentage of cases had SD: problems falling asleep (23.6%), waking up at night (19.5%) and nightmares or strange movements (35.1%). Hyper sleepiness (58.3% vs 44.4%) and tired throughout the day (54.8% vs 37.8%) were more frequent symptoms in females; it was linked to the consumption of alcohol, energy drinks or smoking and the number of sleep hours. Snoring (5.2%) and apnea (1.7%) wererare. STAI was related to the consumption of energy drinks, prior illnesses and with alterations that suggest OSAHS. The Oviedo questionnaire showed a subjective satisfaction of good sleep (mean: 4.74 ± 1.9). The Epworth obtained a mean score of 6 ± 4.5 although in 24.7%, the scores were ≥10. The questionnaires for OSAHS identified a low percentage of patients with clinical suspicion. CONCLUSIONS: an important percentage of adolescents had SD with an elevated prevalence of hyper sleepiness (51.1%) and day-time tiredness (46%). The presence of more specific symptoms (snoring, apneas) was unusual. The relationship between the various SD and daily habits among adolescents seems evident, but complex and multifactorial

Calcificaciones metastásicas pulmonares en paciente con insuficiencia renal crónica terminal / Pulmonary metastatic calcifications in patients with terminal chronic renal insufficiency

Las calcificaciones metastásicas pulmonares son un proceso poco frecuente, que se asocian a una gran variedad de entidades clínicas. Es una enfermedad inicialmente asintomática, pero puede conducir al fallo respiratorio grave y fulminante. Los depósitos de calcio en el parénquima pulmonar suelen localizarse con mayor frecuencia en lóbulos superiores, pudiendo ser la distribución de las lesiones unilateral o bilateral. La radiografía de tórax puede ser normal, aunque entre sus alteraciones radiológicas, destacan la presencia de nódulos o calcificaciones. Presentamos el caso de una mujer de 50 años con antecedentes personales de insuficiencia renal crónica terminal en tratamiento con hemodiálisis desde hacía 2 meses, que comenzó con febrícula y disnea a moderados esfuerzos, presentando en la radiografía de tórax un infiltrado alveolar bilateral (AU)

Overview: Lung metastatic calcifications are a rare process, that are associated with a wide variety of clinical entities. It is initially asymptomatic disease, but it can lead to serious and fulminant respiratory failure. The calcium deposits in the lung parenchyma are often located more often in upper lobes, and may be unilateral or bilateral. Chest x-ray may be normal, although between their radiological alterations, highlights the presence of nodules or calcifications. We present the case of a woman of 50 years with a personal history of terminal chronic renal failure treated with hemodialysis for 2 months, it started with low grade fever and shortness of breath to moderate efforts, presenting bilateral alveolar infiltration on chest x-ray (AU)

Hemorragia alveolar difusa en un paciente con esclerosis sistémica / Diffuse alveolar haemorrhage in a patient with systemic sclerosis

Los autores presentan en el caso de un varón de 74 años con síndrome de CREST ingresado para estudio de hemorragia recurrente, siendo el diagnóstico compatible con una hemorragia alveolar difusa. Hacemos una revisión bibliográfica del tema y se hace hincapié en la importancia de un dignóstico y tratamiento precoz

The case is presented of a 74 year old male with CREST syndrome admitted for the study of recurrent haemoptysis, the diagnosis being compatible with Diffuse Alveolar Haemorrhage. A bibliographical review (..) (AU)

Utilidad de las clasificaciones pronósticas en el tratamiento de la neumonía adquirida en la comunidad / No disponible

No disponible

[Acute respiratory failure as the presentation of amyotrophic lateral sclerosis. Apropos a case]. / Fallo respiratorio agudo como presentación de una esclerosis lateral amiotrófica. A propósito de un caso.

We report the case of a 61-year-old man with amyotrophic lateral sclerosis presenting with respiratory failure requiring long-term mechanical ventilation. Diagnostic difficulties are discussed along with the circumstances that give rise to suspicion of neuromuscular disease in a context of respiratory failure of unknown cause. The patient is at present in stable condition after 6 months of domiciliary mechanical ventilation. The treatment options in such cases and their indications are discussed.

[Factors related to diagnostic yield and complications of transbronchial biopsy]. / Factores relacionados con la rentabilidad diagnóstica y aparición de complicaciones de la biopsia transbronquial.

To study the diagnostic yield of transbronchial biopsy (TBB) in lung diseases of different ethiology, as well as to examine several factors implicated in diagnostic yield and complications of TBB. Retrospective study of a series of 172 patients (98 women and 74 men) undergoing TBB. Clinical variables, x-ray and CT patterns and technical factors related to TBB were analyzed in relation to diagnostic yield and definitive diagnosis. We recorded the main complications and studied the possible mechanisms implicated in their appearance. The results of TBB were classified as follows: 1) diagnostic TBB (42.8%); 2) nonspecific TBB (21.1%); absence of parenchyma (NP) (9.7%); 4) normal parenchyma (23.4%); 5) incorrect diagnosis (2.9%). Overall yield was 43.6% but rose to 52% when NP and no infiltrative pneumopathies were excluded. The main findings were infections (23.4%), neoplasms (19.4%), sarcoidosis (14.2%), idiopathic pulmonary fibrosis (IPF) (17.7%); and other (23.4%). Significant differences in diagnosis were found for age, sex, time of evolution prior to TBB, and x-ray and CT patterns. Complications and pneumothorax appeared more frequently in IPF, neoplasms and infections, although the differences were non significant. Diagnostic value depended mainly on type of disease and ranged from 60% for sarcoidosis to 24% for IPF (p < 0.05), with no differences related to age, sex, presence of immunosuppression, number of TBB or tolerance to exploration. Yield was higher, however, for patients with no loss of radiographic pulmonary volume (56.3% versus 37.5%) and with absence of a CT reticular pattern (44.7% versus 27.3%). Type of opacites also influenced yield (53.4% for ground glass versus 26.7% for reticular patterns), as did distribution of lesions (8.4% for peripheral patterns versus 48.3% for diffuse patterns and 50% for peribronchio-vascular patterns). The site of TBB was the only factor showing clearly significant differences in yield (100% in mild lobe versus 29.5% in upper lobes). Tolerance was poorer in older patients (63.5 +/- 10 versus 52.2 +/- 17 years) and with greater function abnormalities (%FEV1: 48.2 +/- 16.8 versus 70.2 +/- 17.1). Poor tolerance of exploration was associated with the appearance of complications (16.6% vs 6.3) and pneumothorax (25% versus 6.8%). The diagnostic yield of TBB was mainly influenced by the type of disease studied. The various imaging techniques were fundamental for establishing preliminary diagnoses and degree of evolution of a specific cases. In our series, tolerance of the technique was a reliable predictor of complications and the presence of post-biops pneumothorax.

Thoracic empyema in HIV-infected patients: microbiology, management, and outcome.

OBJECTIVES: To evaluate etiology, bacteriology, stage of disease, treatment, and outcome of HIV-infected patients with thoracic empyema (TE) over a 9-year period at a hospital teaching center. DESIGN: We have retrospectively reviewed the charts of all HIV-infected patients with a hospital discharge diagnosis of empyema between January 1985 and November 1993. PATIENTS: Twenty-three patients were identified (22 male and 1 female). The average patient age was 28.7+/-5.3 years. All the patients were injection-drug users, and 10 (43%) fulfilled criteria for an AIDS diagnosis. In 15 cases (65%), the empyema was the first cause of medical consultation, which then led to an HIV infection diagnosis in 11 of them (48%). MEASUREMENTS: In each case, symptoms, chest studies, culture results, procedure timing, length of hospitalization, and outcome were reviewed. RESULTS: Twenty-one patients (91%) had developed an empyema secondary to community-acquired pneumonia. The cultures of pleural fluid were positive in 19 cases (83%). Anaerobes were isolated from 6 patients and aerobes from 13. A single bacteria was isolated from 10 (52%), and multiple organisms (average 2.66 per case) grew in the remaining 9 positive cultures. The most common organism culture growths were Staphylococcus aureus (23%) and Gram-negative bacilli (36%). Length of hospitalization averaged 25.6 days (+/-15). Intercostal tube drainage was necessary in 18 patients and none required surgery. Patients with AIDS diagnosis needed a longer period of hospitalization, and the presence of bacteremia and bronchopleural fistula was more frequent. However, this did not influence a patient's final outcome. A follow-up was available in 18 cases, with 4 deaths recorded (average survival, 35 months; range, 4 to 84 months). CONCLUSIONS: In our series, TE associated with HIV infection was often the primary cause leading to hospital admission and later HIV diagnosis. IV drug abuse was the predominant factor for HIV infection and was also related to clinical presentation and microbiological findings. The best approach to treatment is--as with other patient groups--a prompt drainage and appropriate antibiotic treatment, since a favorable outcome is expected.

[Cytohistological agreement of fine-needle transthoracic lung puncture-aspiration (FNTLPA) in malignant lesions]. / Concordancia citohistológica de la punción-aspiración pulmonar transtorácica con aguja fina (PAPTAF) en lesiones malignas.

To assess agreement between cyto-histological results and fine needle aspiration (FNA) biopsy of malignant pulmonary lesions, and to study the relation with type of lesion. specimen and impact on patient management. Retrospective study of FNA performed over the past 4 years if a biopsy was available (obtained by fiberoptic bronchoscopy, thoracotomy or biopsy of extrapulmonary organs) for comparison. We recorded overall agreement (OA) and agreement by type of disease or neoplasm (DA). Also studied were the features of the lesion, the puncture technique and material obtained in function of agreement. Eighty samples were available for comparison. OA was 58.7% (K = 0.17). DA was good for epidermoid carcinoma (87%, K = 0.64) and poor for adenocarcinoma (87.5%, K = 0.30). The lowest agreement was for undifferentiated large cell carcinoma (10.3%, K = 0.07). In such cases FNA specimens were not useful for classifying 61.5% of adenocarcinomas and 21.6% of epidermoid carcinomas. Cyto-histological inaccuracy was clinically significant, however, in only 3 (3.7%) patients. Lesions for which diagnosis was consistent were larger in size (4.6 +/- 2.2 versus 4 +/- 1.6 cm, p = NS), were nearer to the visceral pleura (1.5 +/- 2.3 versus 2 +/- 2.2 cm, p = NS) and tended to have been sampled with the guidance of computerized tomography (65% versus 35%), although this did not affect the features or amount of material obtained. We found poor OA for adenocarcinoma and undifferentiated large cell carcinoma. Although disagreement was clinically significant in only 3.7% of cases, the implications indicate that the specificity of the technique should be improved, above all in small cell carcinomas. We observed no differences as to type of lesion or specimen obtained that might predict interpretive difficulties.

[Angiotensin-converting enzyme in pulmonary thromboembolism as a marker of vascular lesion]. / Enzima conversora de la angiotensina en tromboembolia pulmonar como un marcador de lesión vascular.

UNLABELLED: In pulmonary thromboembolism (PTE) metabolic changes can occur, as in serum levels of angiotensin converting enzyme (ACE); therefore, the measurement of serum levels of this enzyme might be useful for PTE evaluation. The objective of this study was to determine changes in serum ACE in patients with PTE and their possible variations after therapy. MATERIALS AND THERAPY: Thirty-one patients with PTE were studied (15 males and 16 females). The mean age was 56 +/- 16 years (range 19-82 years). The patients were included if they had: a) a suspect diagnosis of PTE; b) confirmed by high probability V/Q gammagraphy, or c) data of intermediate or low probability with positive lower limb phlebography. Patients with associated diseases, under therapy with ACE inhibitors or lost during the six months of therapy were excluded from the study. STUDY DESIGN: Patients were evaluated in the acute phase of PTE and after therapy (six months later). Biochemical, gasometric, spirometric, V/Q gammagraphy and ACE parameters were investigated. All of them were compared with reference values and those obtained in both phases of PTE. STATISTICS: The Student "t" test was used for independent parameters with the Bonferroni correction for multiple contrast and a = 0.05. The Pearson regression analysis was used for correlations. The ROC curve was used to study its usefulness at diagnosis. RESULTS: ACE decreased by a 20.5% in the acute phase (31.69% +/- 10.34 mumol/min/l) and turned to normal values (39.91 +/- 9.75 mumol/min/l) at post-therapy phase. This decrease was related with acute hypoxia and a decrease in the lung vascular bed. The analysis of the ROC curve showed an area of 0.69 and a negative predictive value of 91.67% for ACE values higher than 46 mumol/min/l. CONCLUSIONS: ACE activity is a marker for pulmonary pathology which might be indicative of injury and/or decrease of the lung vascular bed; its measurement can be useful in the clinical follow-up of PTE. A return to normal values should be interpreted as improvement in the perfusion of the lung vascular bed.

[Pseudochylothorax. Review of 5 cases]. / Seudoquilotórax. Revisión de 5 casos.

We undertook a retrospective review of five patients with pseudo-chylothorax diagnosed at our hospital between 1984 and 1994. Pseudo-chylothorax was diagnosed if crystals of cholesterol were observed (CC) or if cholesterol concentrations were over 150 mg/dl, but chylomicrons were absent from pleural effusions with cloudy supernatants after centrifugation. The five patients were males and their mean age was 53 years. All had history of pulmonary or pleural tuberculosis (mean 31 years since diagnosis). All had received chemotherapy and four had undergone therapeutic pneumothorax. Two patients were diagnosed in the course of examination for other reasons, Three were diagnosed while being examined for the cause of pleural effusion. The diagnosis of four patients was based on the presence of CC. Three patients received specific treatment and Mycobacterium tuberculosis was isolated in the pleural fluid of two. One patient required a pleural drain and antibiotics because of empyema related to pseudo-chylothorax. Decortication was needed by two. 1) Pseudo-chylothorax is at present rare. 2) All the cases we saw were associated with earlier tuberculosis infection with residual pleural lesions. 3) Diagnosis usually occurs in the course of examination for the other motives, but the possibility of infected pleural effusion or reactivation of tuberculosis should be considered.

[Usefulness of transthoracic pulmonary aspiration biopsy in lung abscess secondary to neoplasm]. / Utilidad de la punción aspirativa pulmonar transtorácica en el absceso pulmonar secundario a neoplasia.

OBJECTIVE: To evaluate the usefulness of transthoracic needle biopsy (TNB) for the diagnosis of bronchial carcinoma underlying lung abscess (LA), and to determine the bacteriology of lung abscess secondary to neoplasm (LASN). PATIENTS AND METHOD: One hundred thirteen consecutive patients diagnosed of LA were enrolled. Radiologically guided TNB was performed on all patients using 20-22 G needles. Microbiological and cytological samples were processed. Fiberoptic bronchoscopy (FB) was performed if there were risk factors for lung cancer. TNB-diagnosed cases were compared with the remaining cases of LA. RESULTS: Neoplasia was found in 21 LA patients. TNB samples provided diagnostic information in 15 cases, there were 2 false negatives, and no cytology sample was processed in 4 cases. Diagnosis was based on FB in 17 cases. All neoplasias were diagnosed with one technique or the other. TNB culture was positive in 90% (19/21) of the LASN patients, H. influenzae being the most frequently isolated bacterium. The number of cultures that presented a single microbe was significantly greater (p < 0.02) among LASN patients (14/19 versus 33/79). These patients also had significantly more aerobic bacteria (19/19 versus 45/79; p < 0.001) and fewer anaerobies (4/19 versus 52/79; p < 0.001) than did the primary LA patients. CONCLUSIONS: 1) TNB is highly useful for arriving at a bacteriologic diagnosis of LASN and in associated cancer. 2) TNB complements FB for the diagnosis of neoplasia underlying LA and helps to reduce the number of unnecessary thoracotomies. 3) A great variety of germs, particularly aerobic bacteria, are implicated in LASN.