Toxicidad pulmonar por gemcitabina / No disponible

Describimos el caso clínico de un paciente que presentó una insuficiencia respiratoria aguda en muy probable relación a toxicidad por gemcitabina. El aumento de incidencia de enfermedades neoplásicas conlleva un mayor uso de este fármaco en el tratamiento de las mismas, y esto a su vez provoca una mayor incidencia de efectos secundarios. La toxicidad pulmonar es especialmente relevante por el posible desenlace fatal que puede conllevar. Detectado y tratado a tiempo, el pronóstico es favorable. Con la intención de aumentar la casuística en este campo de la neumología exponemos el siguiente caso (AU)

We present a case of pulmonary toxicity associated with gemcitabina that caused respiratory insufficiency. The rise in incidences of neoplasms has led to an increase in the use of this drug. This, in turn, has led to a greater probability of side effects. Lung toxicity is particularly relevant as it can be fatal, but with rapid diagnosis and treatment the prognosis can be positive. This description of pulmonary toxicity induced by gemcitabine should provide additional information to what is already known in this field

Prevalencia de factores de riesgo cardiovascular en pacientes con síndrome de apneas-hipopneas obstructivas del sueño / Prevalence of cardiovascular risk factors in patients with obstructive sleep apnea/hypoapnea syndrome

OBJETIVO: Analizar la prevalencia de factores de riesgo cardiovascular(FRV) en pacientes con síndrome de apneas-hipopneasobstructivas del sueño (SAHOS).PACIENTES Y MÉTODO: Se incluyeron todos los pacientesdiagnosticados de SAHOS mediante estudio de sueño entre Enerode 1994 y Diciembre de 2000, analizándose los siguientes FRV:edad, sexo, hipertensión arterial (HTA), tabaquismo, obesidad,diabetes mellitus (DM), hipercolesterolemia (HCL) e hipertrigliceridemia(HTG).RESULTADOS: Se incluyeron 879 pacientes con edad media55,4±10.6 años, IAH 54,9±28,7, de los cuales 711 (80,9%) eranhombres. La prevalencia de los diferentes FRV fue la siguiente:obesidad 719 (81,8%) casos, tabaquismo 589 (67%), HTA 535(60,9%), HCL 581 (66%), HTG 191 (21,7%) y DM 312 (35,4%). Lamedia de FRV por paciente (excluyendo edad y sexo) fue de3,4±1,2, y 660 (75%) casos asociaron 3 ó más FRV. Los pacientescon IAH>30 presentaron más FRV que aquellos con IAH<30 (3,5 ±1,2 vs. 3,1 ± 1,2; p=0,02).CONCLUSIONES: Los pacientes con SAHOS presentaronuna elevada prevalencia de FRV y una tendencia acusada a la asociaciónde varios FRV en un mismo paciente. Los SAHOS gravestenían más FRV que los casos no graves

OBJECTIVE: To analyze the prevalence of cardiovascularrisk factors (CRF) in patients with obstructive sleepapnea/hypoapnea syndrome (OSHAS).PATIENTS AND METHOD: all patients diagnosed withOSHAS during a sleep study between January 1994 and December2000 were included, with the following CRF being analyzed: age,sex, arterial hypertension (AHT), smoking habits, obesity, diabetesmellitus (DM), hypercholesterolemia (HCL) and hypertriglyceridemia(HTG).RESULTS: 879 patients were included in the study, with anaverage age of 55.4±10.6 years, with an AHI (apnea/hypoapneaindex) of 54.9±28.7, of which 711 (80.9%) were men. The prevalenceof the various CRF was as follows: obesity 719 (81.8%) cases,smoking 589 (67%), AHT 535 (60.9%), HCL 581 (66%), HTG 191(21.7%) and DM 312 (35.4%). The average CRF per patient(excluding age and sex) was 3.4±1.2, and in 660 (75%) cases, therewere 3 or more associated CRF. The patients with AHI>30 presentedmore CRF than those with an AHI < 30 (3.5 ± 1.2 vs. 3.1 ±1.2; p=0.02).CONCLUSIONS: Patients with OSHAS presented anincreased prevalence of CRF and there was a marked tendency toassociate several CRF in one single patient. Serious OSHAS caseshad more CRF than the less serious cases

[Massive hyperplasia of the arytenoid mucosa with sleep apnea and stridor. Endoscopic resection by CO2 laser]. / Hiperplasia gigante de la mucosa aritenoidea con apnea del sueño y estridor. Resección endoscópicacon láser CO2*

A case is presented of a 48 year-old woman with symptoms of severe rhoncopathy and obstructive sleep apnea, followed by middle inspiratory stridor and dyspnea to any phisial effort. Redundant hyperplasia of the arytenoid mucosa was discovered during exploration, with vibration during inspiration and closure of the lumen as it goes closer to the epiglottis. Also, severe septal deviation, hypertrophy of the pharyngeal tonsil, soft palate and uvula, and macroglossia, were diagnosed. Neither CPAP/BIAP or triple anti-reflux therapy were effective, and laser endoscopic excision resolved the laryngeal obstruction. Currently the stridor has disappeared, whereas rhoncopathy is improved with low pressure CPAP. Pathogenesis of the giant hyperplasia of the arytenoid mucosa of unknown origin is discussed, as literature search revealed only three cases reported worldwide.

[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.

[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.

[Diffuse pulmonary hemorrhage: review of nine cases]. / Hemorragia pulmonar difusa: revisión de nueve casos.

Nine cases of diffuse pulmonary hemorrhage (DPH) diagnosed in our hospital during the past eight years are reviewed. We assess the clinical, diagnostic, etiologic and evolutive characteristics of all these cases and, thus, of such entity in our environment. The nine patients had anemia, hemoptysis and transient pulmonary infiltrations. Renal affectation was observed in seven patients. Based on clinical and laboratory data, supplementary explorations and immunological and histological studies, the following etiologic diagnosis were established: idiopathic extracapillary glomerulonephritis (three cases), idiopathic pulmonary hemosiderosis (two cases), Wegener's granulomatosis (one case), unclassifiable systemic necrosant vasculitis or overlapping syndrome (two cases). In one patient, it was not possible to establish the etiology. Global mortality was 44.4% (four patients); two of them died during the course of the initial massive hemoptysis (not controlled, as in the other patients, with steroids) and two other patients died due to late complications. In this series, none of the patients developed a disease associated to antibodies against the basal membrane. The application of a severe diagnostic systematic has been a key factor for the management of these patients.

[Muckle-Wells syndrome associated with idiopathic interstitial pneumopathy]. / Síndrome de Muckle-Wells asociado a neumopatía intersticial idiopática.

Muckle-Wells syndrome is characterized by recurrent episodes of urticaria, fever, polyarthralgia, deafness and secondary amyloid (AA type), familial type with autosome dominant features; few cases have been described. A case of a patient with idiopathic interstitial pneumopathy, diagnosed 7 years before the onset of clinical amyloid, is presented. The patient had lymph glands enlargement and nephrotic syndrome and died 18 months later due to renal insufficiency. We have not found this association previously described in any medical literature.

Yield of percutaneous needle lung aspiration in lung abscess.

STUDY OBJECTIVE: To evaluate the accuracy of PLA with a thin needle in the bacteriologic diagnosis of patients with lung abscess and in demonstrating possible coexistence of an underlying lung carcinoma, and the influence of this technique in the treatment and outcome of these patients. DESIGN: Case series. SETTING: Tertiary university referral center. PATIENTS: Consecutive sample of 50 patients with clinical picture suggestive of pulmonary infection and single or multiple cavitation of at least 1 cm in diameter on chest x-ray films, and lack of clinical suspicion of active pulmonary tuberculosis. One patient was excluded from the study after demonstration of tuberculosis by PLA. INTERVENTIONS: Lung aspirates were obtained under fluoroscopic guidance by introduction of a 22-gauge disposable spinal needle within the abscess cavity and were immediately transported to the bacteriology laboratory and pathology department for processing. All patients were initially treated with clindamycin. Tobramycin was added in all those patients with hospital-acquired infection, lack of foulness of sputum, and those who were initially severely ill. Definite treatment was based on the results of bacteriologic cultures. MEASUREMENTS AND MAIN RESULTS: Cultures of LAs were positive in 82 percent (40/49) of patients. In 20 cases the isolates were monobacterial (13 aerobic bacteria and seven anaerobic). In the remaining 20 cases, cultures grew more than one kind of bacteria (four exclusively aerobic, five exclusively anaerobic, and 11 mixed), with an average of 3.25 types of bacteria per case. Anaerobes were found as a single bacteria or associated with other aerobic bacteria in only 58 percent (23/40). The results of LA cultures led to change in the initial antibiotic trial in 23 patients (47 percent). Of ten cases in which bronchogenic carcinoma was demonstrated, cytologic study of LA was done in nine, and eight had positive cytologic yield. Pneumothorax occurred in seven cases (14 percent) as the sole complication. CONCLUSIONS: (1) Percutaneous lung aspiration had a high diagnostic yield and accuracy in our series, with a relatively low incidence of complications. (2) Anaerobic bacteria were less frequently implicated in our cases than previously reported. This finding led to significant changes in the initial empiric antibiotic treatment.