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Frequency of Hoover's sign in stable patients with chronic obstructive pulmonary disease.

Hoover's sign (the inward motion of the lower lateral rib cage with inspiration) is conventionally considered to be a sign of severe disease in chronic obstructive pulmonary disease (COPD). However, no studies have been done regarding the frequency of Hoover's sign in patients with stable COPD. We aim to establish the frequency of Hoover's sign in a large series of stable patients with COPD and to analyse the characteristics associated with its presence. One hundred and fifty-seven consecutive patients with COPD, 150 of whom were men (95%), with a mean (standard deviation) age of 68 (8) years were included. Seventy-one patients had Hoover's sign (45%) on clinical examination. Hoover's sign was not detected in mild COPD patients, and it was present in 36% of moderate, 43% of severe and 76% of very severe COPD patients. In the multivariate analysis, dyspnea, body mass index (BMI), number of exacerbations and number of prescribed drugs were independently associated with the presence of Hoover's sign in COPD. Hoover's sign is a frequent finding in COPD, and the frequency increases with severity. Its presence is independently related to higher values of dyspnea, BMI, number of exacerbations and number of prescribed drugs.

[Chronic idiopathic lithoptysis]. / Litoptisis crónica idiopática.

Broncholiths, which usually arise from calcified peribronchial lymph nodes, can be found by radiography or bronchoscopy. We describe the case of a 19-year-old man who had experienced lithoptysis of bronchial hydroxyapatite calculi for over 6 months and who reported having sandy expectoration since childhood. Exhaustive clinical, radiographic, and endoscopic diagnostic studies detected no calcified lesions in the thorax that could explain the origin of the broncholiths. Therefore, we propose that broncholiths may form by mechanisms similar to those involved in calculi formation in other locations.

Litoptisis crónica idiopática / Chronic idiopathic lithoptysis

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[Paradoxical costal shift throughout inspiration (Hoover's sign) in patients admitted because of dyspnea]. / Movimiento costal paradójico durante la inspiración (signo de Hoover) en pacientes hospitalizados por disnea.

OBJECTIVE: To study the frequency and diagnostic usefulness of Hoover's sign (paradoxical costal shift throughout inspiration) in patients admitted because of dyspnea. PATIENTS AND METHODS: 268 patients admitted because of dyspnea in an Internal Medicine Department were included in the study. Physical examination was carried out on the first day of admission to establish the presence of Hoover's sign. RESULTS: Hoover's sign was present in 62 patients of 82 with a diagnosis of chronic obstructive pulmonary disease (COPD) (sensitivity: 76%), in 3 patients of 101 (3%) with a diagnosis of congestive heart failure, in 3 patients of 23 (13%) with a diagnosis asthma, and in 6 patients of 62 (10%) with other diagnoses. Specificity of Hoover's sign for EPOC diagnosis was 94%. CONCLUSIONS: Hoover's sign is a frequent finding in patients admitted because of EPOC and is found only rarely in patients without obstructive pulmonary disease. This sign contributes useful information for the evaluation of patients admitted because of dyspnea.

Movimiento costal paradójico durante la inspiración (signo de Hoover) en pacientes hospitalizados por disnea / Paradoxical costal shift throughout inspiration (Hoover’s sign) in patients admitted because of dyspnea

Objetivo. Estudiar la frecuencia y utilidad diagnóstica del signo de Hoover (movimiento costal paradójico durante la inspiración) en pacientes hospitalizados por disnea. Material y métodos. Se incluyeron en el estudio 268 pacientes que ingresaron por disnea en un servicio de Medicina Interna. Los pacientes fueron explorados el primer día del ingreso para determinar la presencia del signo de Hoover. Resultados. El signo de Hoover estaba presente en 62 de los 82 pacientes diagnosticados de enfermedad pulmonar obstructiva crónica (EPOC) (sensibilidad: 76%), en 3 de 101 (3%) con insuficiencia cardíaca congestiva, en 3 de 23 (13%) con asma y en 6 de 62 (10%) con otros diagnósticos. La especificidad del signo de Hoover para diagnosticar EPOC fue del 94%. Conclusiones. El signo de Hoover es un hallazgo frecuente en pacientes hospitalizados con EPOC y está presente muy pocas veces en pacientes sin enfermedad pulmonar obstructiva. Este signo aporta información útil en la evaluación de pacientes hospitalizados por disnea

Objective. To study the frequency and diagnostic usefulness of Hoover’s sign (paradoxical costal shift throughout inspiration) in patients admitted because of dyspnea. Patients and methods. 268 patients admitted because of dyspnea in an Internal Medicine Department were included in the study. Physical examination was carried out on the first day of admission to establish the presence of Hoover’s sign. Results. Hoover’s sign was present in 62 patients of 82 with a diagnosis of chronic obstructive pulmonary disease (COPD) (sensitivity: 76%), in 3 patients of 101 (3%) with a diagnosis of congestive heart failure, in 3 patients of 23 (13%) with a diagnosis asthma, and in 6 patients of 62 (10%) with other diagnoses. Specificity of Hoover’s sign for EPOC diagnosis was 94%. Conclusions. Hoover’s sign is a frequent finding in patients admitted because of EPOC and is found only rarely in patients without obstructive pulmonary disease. This sign contributes useful information for the evaluation of patients admitted because of dyspnea

Mesotelioma, adenosindesaminasa y proteína C reactiva / Mesothelioma, adenosine deaminase, and C-rective protein

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Pseudochylothorax in pleural effusion due to coronary artery bypass surgery.

This study describes a 64-yr-old male with a chronic left pleural effusion following a coronary artery bypass 3 yrs earlier. On thoracocentesis, turbid fluid was obtained with crystals of cholesterol on microscopic examination, establishing the diagnosis of pseudochylothorax. The pleural fluid cholesterol level was 207 mg x dL(-1) (5.36 mmol x L(-1)). This is the first report of pseudochylothorax in a chronic pleural effusion due to coronary artery bypass surgery.

[Pleural fluid to serum cholinesterase ratio to discriminate between transudates and exudates: reevaluation in 177 patients]. / Relación entre colinesterasa pleural y sérica para diferenciar trasudados y exudados: reevaluación en 177 pacientes.

BACKGROUND AND OBJECTIVES: In a previous study we concluded that the pleural fluid/serum (PF/S) ratio of cholinesterase was the most useful parameter to discriminate between exudates and transudates. The objective of the present study was to confirm these findings in a prospective series of patients with pleural effusion. MATERIAL AND METHODS: A total of 177 patients, consecutively studied at two institutions, with the diagnosis of pleural effusion were included in this study. Thirty-six (20.3%) effusion were transudates and 141 (79.7%) exudates; of these, 73 and 68 were of malignant and benign origin, respectively. Both PF/S cholinesterase and Light's criteria were compared. RESULTS: The PF/S cholinesterase ratio incorrectly classified 12 pleural effusions (6.8%). These included 7 out the 36 transudates (19.4%) and 5 out of the 141 exudates (3.5%), the latter of malignant etiology. Following Light's criteria, four (2.2%) exudates were misclassified, all of them transudates. The higher accuracy of Light's criteria was statistically significant (p = 0.04). CONCLUSIONS: In this series of patients, Light's criteria were more accurate than PF/S cholinesterase ratio to discriminate between transudates and exudates. From these results, the use of the PE/S cholinesterase ratio parameters is no longer recommended.

[The diagnostic usefulness of cholinesterase in pleural exudates]. / Utilidad diagnóstica de la colinesterasa en los exudados pleurales.

BACKGROUND AND OBJECTIVES: The pleural fluid/serum cholinesterase ratio (PF/S) is the most efficient parameter to differentiate transudates from exudates. The objective of this study was to evaluate whether its determination might yield additional diagnostic information in pleural exudates. MATERIALS AND METHODS: A total of 167 patients with the diagnosis of pleural exudate were studied: 74 carcinomatous, 32 tuberculous, 31 parapneumonic, 30 other causes. Pleural fluids were divided on the basis of lymphocyte or polymorphonuclear predominance and were grouped according to diagnosis. The PF/S cholinesterase ratio was determined in all patient. RESULTS: In lymphocytic exudates, when PF/S ratio was < 0.42 pleural effusion was classified as malignant, with a sensitivity (S) of 56% (95% CI: 43%-66%) and a specificity (SP) of 90% (95% CI: 78%-95%). For the diagnosis of tuberculosis, in the total of pleural effusions, a ratio > or = 0.45 showed a S of 97% (95% CI: 82%-99%) and a SP of 51% (95% CI: 42%-59%). CONCLUSIONS: The PF/S cholinesterase ratio yielded an useful information on the diagnosis of pleural exudates. Thus, in our series of patients, a ratio < 0.42 in a lymphocytic effusion suggested a malignant origin, and a ratio < 0.45 practically ruled out tuberculosis, irrespective of the cellular predominance in the pleural fluid.

Elevated level of carcinoembryonic antigen in nonmalignant pleural effusions.

STUDY OBJECTIVE: Carcinoembryonic antigen (CEA) is the most frequently used tumor marker in pleural fluid. Nevertheless, little is known about the causes of false-positive results. The aim of the study was to analyze the frequency, etiologies, and characteristics of the nonmalignant pleural effusions associated with elevated levels of CEA in pleural fluid. PATIENTS: Two hundred seventy-three consecutive patients with pleural effusions were evaluated, 91 (33%) associated with malignancy, and 182 (67%) due to benign diseases (51 transudates, 38 tuberculosis, 37 parapneumonic, 56 other). RESULTS: A level of CEA in pleural fluid above 10 ng/mL was found in 47% of pleural effusions associated with malignancy. Elevated levels of CEA were also found in 17 of the 182 (9%) nonmalignant pleural effusions: all five empyemas, one of the 23 typical parapneumonic (4%), two of the six borderline complicated (33%), and four of the eight complicated parapneumonic effusions (50%), one of the 38 tuberculous pleurisy (3%), one of the 11 hepatic transudates (9%), in the only patient with urinothorax, in the only patient with acute pancreatitis, and in one patient with postsurgery pleural effusion but with esophageal carcinoma and elevated CEA level in serum. CONCLUSIONS: Although an elevated level of CEA in pleural fluid is suggestive of malignancy, CEA can be elevated in 9% of pleurisy owing to benign diseases, especially in empyemas and in complicated parapneumonic effusions. Identifying the most frequent causes of false-positive results of CEA helps to correctly interpret the findings of this tumor marker.

[Tuberculosis outbreak at a public school]. / Brote epidémico de tuberculosis en un colegio público.

BACKGROUND: At school there are special circumstances of living together and a particular susceptibility, which favour the emergence of tuberculosis microepidemics. We report here the microepidemic occurred at a school among 9-year old children. METHODS: After ruling out a possible familiar source in a child with pulmonary tuberculosis, we detected a case with high bacillar shedding in a female teacher and conducted a tuberculin search among children and teachers, initially outlining the theoretical groups at risk. Tuberculin positive children underwent chest-X-ray and when abnormalities were found, children were derived to the pediatrician for chemotherapy. All converters received secondary chemoprophylaxis and all non-respondents primary chemoprophylaxis. RESULTS: The classroom where the teacher spent most of het time had a higher rate of converters (70%) than other classroom, where the index teacher spent only a partial time (40%; RR: 1.75; CI: 1.06-2.88) or the collective of teachers (45.4%; RR: 1.45; CI: 0.94-2.23). Three additional cases of secondary disease were detected, all of them children. The initial compliance with chemoprophylaxis was greater among (for) children (97.0%) than among teachers (41.6%). Among children there was one case of tuberculin conversion compared with three cases among teachers. No additional cases were detected; also, an abnormal rate of reactors outside the initially studied groups was also not detected. CONCLUSIONS: Our results somehow agree with those reported from other school outbreaks. To note the anergy and lack of symptoms in the index case and the suggestion to delineate the degree of spending hours together to identify groups with a higher theoretical risk of being infected. Thus, an unnecessary expense of resources and a social alarm would be avoided.

[Pleural exudate as presentation of constrictive pericarditis]. / Exudado pleural como presentación de pericarditis constrictiva.

An exudative pleural effusion is a very infrequent form of presentation of constrictive pericarditis, and it can induce diagnostic difficulties. We present a 71 year-old woman with a pleural effusion attributed to be due to congestive heart failure which does not respond to the treatment. The pleural fluid had biochemical characteristics of an exudate. The echocardiographic study showed severe constrictive pericarditis, and after the pericardectomy the pleural effusion completely resolved. The diagnostic suspicion of constrictive pericarditis in cases of exudative pleural effusion is of special interest because an specific and effective treatment is available.

Pleural fluid to serum cholinesterase ratio for the separation of transudates and exudates.

STUDY OBJECTIVE: To evaluate the usefulness of two new parameters for separating pleural transudates and exudates: pleural fluid cholinesterase level and pleural fluid to serum cholinesterase ratio, and to compare the results with the other well-established criteria. DESIGN: Prospective evaluation of the patients referred for diagnostic thoracentesis. SETTING: Pulmonary sections of a community hospital and a university hospital. PATIENTS: One hundred ninety-three consecutive patients. Forty were excluded for different reasons. MEASUREMENTS: The following criteria for separating the pleural effusions in transudates and exudates were analyzed: Light's criteria, the pleural fluid cholesterol level, the pleural fluid to serum cholesterol ratio, the pleural fluid cholinesterase level, and the pleural fluid to serum cholinesterase ratio. RESULTS: One hundred fifty-three patients had conditions diagnosed. Thirty-five were classified as having transudates and 118 as exudates. The percentage of effusions misclassified by each parameter was as follows: Light's criteria, 7.8%; pleural fluid cholesterol, 7.8%; pleural fluid to serum cholesterol ratio, 6.5%; pleural fluid cholinesterase, 8.5%; and pleural fluid to serum cholinesterase ratio, 1.3%. CONCLUSIONS: The pleural fluid to serum cholinesterase ratio is the most accurate criterion for separating pleural transudates and exudates. If further studies confirm our results, the cholinesterase ratio could be used as the first step in the diagnosis of pleural effusions.

[Pleural effusion: criteria for distinguishing between transudates and exudates]. / Derrame pleural: criterios para diferenciar trasudados y exudados.

The first step in the diagnostic study of a pleural effusion is to classify as a transudate or exudate. Light's criteria (pleural fluid/serum proteines > 0.5; lactatedehydrogenase [LDH] > 2/3 of the upper normal limit in serum; pleural fluid/serum LDH > 0.6) usually used, incorrectly classify some cases, especially transudates. For this reason, different alternative criteria has been proposed: pleural fluid cholesterol, pleural fluid/serum cholesterol ratio, pleural fluid/serum bilirubin ratio, and serum/pleura albumin ratio. Althought the first results suggested better results that those obtained with the Light's criteria, after the analysis of the different studys we conclude that a method to diferentiate perfectly transudates and exudates is not yet available.