Aortic Mycetoma From Disseminated Cunninghamella Species Infection.

Cunninghamella species are aggressive, opportunistic fungi that are becoming more commonly reported in immunocompromised patients. We present a case of disseminated Cunninghamella sp. infection after stem cell transplant for refractory multiple myeloma with formation of bilateral pleural effusions and an aortic mycetoma. PCR analysis of the patient's aortic mycetoma demonstrated a 90% match to Cunninghamella spp. This case illustrates the potential for severe opportunistic fungal infections in immunocompromised patients that can mimic other disease processes and result in an accelerated demise.

Comparison of Forced and Slow Vital Capacity Maneuvers in Defining Airway Obstruction.

BACKGROUND: Obstructive lung disease is diagnosed by a decreased ratio of FEV1 to the vital capacity (VC). Although the most commonly used VC is FVC, American Thoracic Society guidelines suggest alternative VCs, for example, slow VC (SVC), may offer a more-accurate evaluation of breathing capacity. There is recent evidence that using only FEV1/FVC underrecognizes obstruction in subjects at high risk and who are symptomatic. Previous studies have indicated that healthy individuals show a minimum difference between FVC and SVC; however, testing of individuals with asthma and who are symptomatic indicates that SVC can be markedly larger than FVC. OBJECTIVE: To evaluate the differences among SVC, FVC, and SVC-based measurements in the diagnosis of symptomatic obstructive lung disease. METHODS: A retrospective analysis was performed of spirometry and plethysmography measurements from studies conducted between 2011 to 2015. We established a pulmonary function database that incorporated predictive equations from the National Health and Nutrition Examination Survey III (NHANES III). The SVC to FVC difference was calculated. FEV1/SVC was compared with FEV1/FVC by using NHANES III lower limit of normal values. RESULTS: A total of 2,710 studies with 2,244 subjects were reviewed. Spirometric obstruction, as defined by NHANES III, was identified in 26.1% of the studies (707/2,710). The mean (± SD) difference between SVC and FVC was 375.0 ± 623.0 mL and 258.8 ± 532.5 mL in those with and those without obstruction, respectively. Subgroup and multivariate analysis demonstrated age, body mass index, and FEV1 associated contributions to the difference between SVC and FVC. By using FEV1/SVC, the prevalence of obstruction increased from 26.1 to 45.0% (1,219/2,710) and identified 566 additional studies of subjects with obstruction. Fifty-four percent of the subjects with newly-identified obstructive lung disease (305/566) had smoking histories, and 67.4% (345/512) received medications for obstructive lung disease. CONCLUSIONS: The isolated use of FVC-based diagnostic algorithms did not recognize individuals with symptomatic obstructive lung disease. Recognizing the difference between SVC and FVC measurements in subjects will improve testing and diagnosis of obstructive lung disease.

Study of Active Duty Military Personnel for Environmental Deployment Exposures: Pre- and Post-Deployment Spirometry (STAMPEDE II).

BACKGROUND: There is significant concern about the respiratory health of deployed military service members given the reported airborne hazards in southwest Asia, which range from geologic dusts, burn pit emissions, chemical exposures, and increased rates of smoking. There has been no previous comparison of pre- and post-deployment lung function in these individuals. METHODS: Military personnel who deployed to southwest Asia in support of ongoing military operations were recruited from the Soldier Readiness Processing Center at Fort Hood, Texas, from 2011 to 2014. The participants were asked to complete a brief survey on their respiratory health and perform both spirometry and impulse oscillometry studies at baseline with repeated survey and testing after deployment. RESULTS: Of the 1,693 deployed personnel who completed baseline examinations, 843 (50%) completed post-deployment testing. Post-deployment values demonstrated no statistical or clinical change in spirometry, with an increase in mean ± SD FEV1 (% predicted) from 95.2 ± 12.6 to 96.1 ± 12.4 (P = .14), increase in mean ± SD FVC (% predicted) from 95.9 ± 11.8 to 96.4 ± 11.9 (P = .32), and increase in mean ± SD FEV1/FVC from 81.5 ± 5.9 to 81.8 ± 6.1 (P = .29). Impulse oscillometry values showed statistical improvement with reduction in resistance (at 5 Hz and 20 Hz) and reactance (at 5 Hz). The presence of pre-deployment obstruction, self-reported asthma, smoking history, or increased body mass index also did not change spirometry values after deployment. DISCUSSION: To our knowledge, this was the first prospective evaluation of deploying military by using spirometry as an indicator for the possible development of pulmonary disease related to environmental exposures. Pre-deployment testing with spirometry and impulse oscillometry was unable to detect any significant change. In those with abnormal spirometry pre-deployment or asthma history, there was also not identifiable change that indicated worsening lung function. CONCLUSIONS: Utilization of spirometry for the deploying military population had little benefit and did not identify individuals with lung disease after deployment. Routine use was not warranted before or after deployment in the absence of pulmonary symptoms.

A Comparison of Global Lung Initiative 2012 with Third National Health and Nutrition Examination Survey Spirometry Reference Values. Implications in Defining Obstruction.

RATIONALE: Obstructive lung disease is diagnosed by a decreased ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC); however, there is no universally accepted lower limit of normal for the FEV1/FVC ratio. Current established reference values use the Third National Health and Nutrition Examination Survey (NHANES III) database. In 2012, the Global Lung Initiative (GLI) introduced GLI12, which is a compilation reference set that uses standard deviation values to define normal spirometry. OBJECTIVES: To evaluate the changes in classification of obstructive spirometry with use of GLI12 compared with NHANES III in a heterogeneous, multiracial population. METHODS: We evaluated the spirometry studies conducted in our pulmonary function laboratory between January 2005 and December 2015. NHANES III reference equations were calculated to predict lower limits of normal for FEV1, FVC, and FEV1/FVC. GLI12 values were established using European Respiratory Society published computer software. FEV1 severity was graded using 2005 American Thoracic Society guidelines for NHANES III and using z-score-based criteria for GLI12. Asymmetric partition analysis evaluated agreement between the reference sets. RESULTS: A total of 11,888 studies were evaluated. Obstruction was diagnosed in 2,857 studies using NHANES III versus 2,489 studies using GLI12. Agreement regarding the presence or absence of obstruction occurred in 2,483 of studies with obstruction and 9,025 studies without obstruction (agreement, 96.8%; κ = 0.91). Of the studies with obstruction, 1,595 had agreement in severity grading. Overall, agreement regarding obstruction and severity grading occurred in 10,620 studies, representing 89.3% of all studies. A total of 380 studies (3.2%) had discordance regarding the presence or absence of obstruction, 34.0% (844 of the 2,483 obstruction studies) had a one-degree of change in FEV1 disease severity scoring, with 44 cases (1.8%) that had changes of two categories in FEV1 severity scores. No studies had greater than two degrees of change. Asymmetric partition analysis suggested that the highest clinically significant changes were seen in older individuals, particularly African American men older than 65. CONCLUSIONS: Our evaluation suggests that there is moderate overall agreement between NHANES III and GLI12. We found a 3.2% change in classification of obstruction when transitioning from NHANES III to GLI12. When incorporating a z-score-based FEV1 and GLI12 reference set, 10.7% of the spirometry studies had a change in their categorization. The disagreement between the two datasets was most pronounced in elderly subjects. Although we cannot endorse one reference set over the other, we highlight the potential implications of adopting the GLI12 reference sets and suggest caution when interpreting spirometry in the elderly.

Transudative chylothorax from cirrhosis complicated by lung entrapment.

A patient with long-standing cirrhosis due to hepatitis C and hepatic hydrothorax was evaluated for increasing symptoms and presence of a large right pleural effusion. Thoracentesis revealed evidence of a chylothorax with rapid reaccumulation of pleural fluid. Repeat thoracentesis with manometry identified presence of entrapped lung which complicated treatment options. This is the first case report of a hepatic chylothorax with features of entrapped lung.

Effect of a pulmonary nodule fact sheet on patient anxiety and knowledge: a quality improvement initiative.

INTRODUCTION: The utilisation of chest CT for the evaluation of pulmonary disorders, including low-dose CT for lung cancer screening, is increasing in the USA. As a result, the discovery of both screening-detected and incidental pulmonary nodules has become more frequent. Despite an overall low risk of malignancy, pulmonary nodules are a common cause of emotional distress among adult patients. METHODS: We conducted a multi-institutional quality improvement (QI) initiative involving 101 participants to determine the effect of a pulmonary nodule fact sheet on patient knowledge and anxiety. Males and females aged 35 years or older, who had a history of either screening-detected or incidental solid pulmonary nodule(s) sized 3-8 mm, were included. Prior to an internal medicine or pulmonary medicine clinic visit, participants were given a packet containing a pre-fact sheet survey, a pulmonary nodule fact sheet and a post-fact sheet survey. RESULTS: Of 101 patients, 61 (60.4%) worried about their pulmonary nodule at least once per month with 18 (17.8%) worrying daily. The majority 67/101 (66.3%) selected chemotherapy, chemotherapy and radiation, or radiation as the best method to cure early-stage lung cancer. Despite ongoing radiographic surveillance, 16/101 (15.8%) stated they would not be interested in an intervention if lung cancer was diagnosed. Following review of the pulmonary nodule fact sheet, 84/101 (83.2%) reported improved anxiety and 96/101 (95.0%) reported an improved understanding of their health situation. Patient understanding significantly improved from 4.2/10.0 to 8.1/10.0 (p<0.01). CONCLUSION: The incorporation of a standardised fact sheet for subcentimeter solid pulmonary nodules improves patient understanding and alleviates anxiety. We plan to implement pulmonary nodule fact sheets into the care of our patients with low-risk subcentimeter pulmonary nodules.

The Safety and Utility of Fiberoptic Bronchoscopy in the Very Elderly.

BACKGROUND: Flexible bronchoscopy (FB) is a common modality for diagnostic sampling within the thorax. It is utilized often in the elderly population, but there is limited data on the safety and utility of the procedure in the very elderly. METHODS: FBs performed outside the intensive care unit in the San Antonio Military Health System on patients 85 years and older were reviewed. Outcomes including indications, complications, diagnostic yield, and final diagnosis were compared with a control group consisting of patients' ages of 65 to 79 years old. RESULTS: Seventy-three bronchoscopies were performed in each group. The mean age of the older group was 87.1±2.6 years, and had a higher American Society of Anesthesiology (ASA) class than the younger group (P=0.03). There were no significant differences in the indications for bronchoscopy (P>0.05), sampling performed (P>0.05), complication rates (P>0.05), diagnostic yield (P>0.05), or final diagnoses (P>0.05). Similar proportions of each group with a malignancy diagnosis received some form of therapy (P>0.05), although fewer of the older group underwent surgery (P=0.03). Analysis of the cohort demonstrated that ASA class 3 to 4 was associated with increased rate of complications and use of anesthesia compared with lower ASA class (P<0.02). CONCLUSION: FB in the elderly demonstrated no differences in procedural complications, diagnostic yield, and utility of the procedure for an underlying diagnosis. This study suggests bronchoscopy is as safe and useful in the very elderly as a population of the age of 65 to 79.

Pulmonary Function and Respiratory Health of Military Personnel Before Southwest Asia Deployment.

BACKGROUND: Significant concern exists regarding the respiratory health of military personnel deployed to Southwest Asia, given their exposures to numerous environmental hazards. Although the deployed military force is generally assumed to be fit, the pre-deployment respiratory health of these individuals is largely unknown. METHODS: Soldiers deploying to Southwest Asia were recruited from the pre-deployment processing center at Fort Hood, Texas. Participants completed a general and respiratory health questionnaire and performed baseline spirometry. RESULTS: One thousand six hundred ninety-three pre-deployment evaluations were completed. The average age of the participants was 32.2 y, and 83.1% were male. More than one third of surveyed solders had a smoking history, 73% were overweight or obese, and 6.2% reported a history of asthma. Abnormal spirometry was found in 22.3% of participants. Soldiers with abnormal spirometry reported more asthma (10.1% vs 5.1%, P < .001), failed physical fitness tests (9.0% vs 4.6%, P = .02), and respiratory symptoms (32.8% vs 24.3%, P = .001). DISCUSSION: This is the first prospective pre-deployment evaluation of military personnel that delineates factors potentially associated with the development of pulmonary symptoms and/or disease. This study suggests that deploying soldiers are older, heavier, frequently smoke, and may have undiagnosed pre-deployment lung disease. Abnormal spirometry is common but may not represent underlying disease. Self-reported asthma, wheezing, and slower 2-mile run times were predictive of abnormal spirometry. CONCLUSIONS: Pre-deployment evaluation of military personnel identified numerous soldiers with active pulmonary symptoms and abnormal spirometry. When combined with questions regarding asthma history, wheezing and exercise intolerance, spirometry may identify individuals at risk for deployment-related respiratory complaints.

Non-traumatic Pulmonary Emergencies in the Deployed Setting.

PURPOSE OF REVIEW: Pulmonary disorders accounted for up to 8% of the over 70,000 medical evacuations conducted from Iraq and Afghanistan in the past 15 years. This review of non-traumatic pulmonary emergencies provides an overview of deployed military medical treatment capabilities and highlights pulmonary emergencies requiring aeromedical evacuation from theater. RECENT FINDINGS: Recent studies have improved the epidemiologic evaluation of non-traumatic pulmonary disease, highlighted specific parenchymal diseases, and revealed infection pathologies unique to the deployed setting. Literature regarding possible chemical exposures in the current deployed environment remains limited. SUMMARY: Respiratory disorders requiring medical evacuation represent a wide variety of diseases. Complications such as pulmonary emboli, infectious pathogens, and hazardous chemical exposures threaten the deployed warfighter. Adequate medical care requires an understanding of these potential environmental exposures. This review serves as a general overview of this topic; however, more research regarding epidemiologic and environmental exposures is required.

Chronic Left Lower Lobe Pulmonary Infiltrates During Military Deployment.

Deployment to Southwest Asia is associated with increased airborne hazards such as geologic dusts, burn pit smoke, vehicle exhaust, or air pollution. There are numerous ongoing studies to evaluate the potential effects of inhaled particulate matter on reported increases in acute and chronic respiratory symptoms. Providers need to be aware of potential causes of pulmonary disease such as acute eosinophilic pneumonia, asthma, and vocal cord dysfunction that have been associated with deployment. Other pulmonary disorders such as interstitial lung disease are infrequently reported. Not all deployment-related respiratory complaints may result from deployment airborne hazards and a broad differential should be considered. We present the case of a military member with a prolonged deployment found to have lobar infiltrates secondary to pulmonary vein stenosis from treatment for atrial fibrillation.

Deployment-related Respiratory Issues.

Military deployment to Southwest Asia since 2003 in support of Operations Enduring Freedom/Iraqi Freedom/New Dawn has presented unique challenges from a pulmonary perspective. Various airborne hazards in the deployed environment include suspended geologic dusts, burn pit smoke, vehicle exhaust emissions, industrial air pollution, and isolated exposure incidents. These exposures may give rise to both acute respiratory symptoms and in some instances development of chronic lung disease. While increased respiratory symptoms during deployment are well documented, there is limited data on whether inhalation of airborne particulate matter is causally related to an increase in either common or unique pulmonary diseases. While disease processes such as acute eosinophilic pneumonia and exacerbation of preexisting asthma have been adequately documented, there is significant controversy surrounding the potential effects of deployment exposures and development of rare pulmonary disorders such as constrictive bronchiolitis. The role of smoking and related disorders has yet to be defined. This article presents the current evidence for deployment-related respiratory symptoms and ongoing Department of Defense studies. Further, it also provides general recommendations for evaluating pulmonary health in the deployed military population.

Protein and microRNA biomarkers from lavage, urine, and serum in military personnel evaluated for dyspnea.

BACKGROUND: We have identified candidate protein and microRNA (miRNA) biomarkers for dyspnea by studying serum, lavage fluid, and urine from military personnel who reported serious respiratory symptoms after they were deployed to Iraq or Afghanistan. METHODS: Forty-seven soldiers with the complaint of dyspnea who enrolled in the STudy of Active Duty Military Personnel for Environmental Dust Exposure (STAMPEDE) underwent comprehensive pulmonary evaluations at the San Antonio Military Medical Center. The evaluation included fiber-optic bronchoscopy with bronchoalveolar lavage. The clinical findings from the STAMPEDE subjects pointed to seven general underlying diagnoses or findings including airway hyperreactivity, asthma, low diffusivity of carbon monoxide, and abnormal cell counts. The largest category was undiagnosed. As an exploratory study, not a classification study, we profiled proteins or miRNAs in lavage fluid, serum, or urine in this group to look for any underlying molecular patterns that might lead to biomarkers. Proteins in lavage fluid and urine were identified by accurate mass tag (database-driven) proteomics methods while miRNAs were profiled by a hybridization assay applied to serum, urine, and lavage fluid. RESULTS: Over seventy differentially expressed proteins were reliably identified both from lavage and from urine in forty-eight dyspnea subjects compared to fifteen controls with no known lung disorder. Six of these proteins were detected both in urine and lavage. One group of subjects was distinguished from controls by expressing a characteristic group of proteins. A related group of dyspnea subjects expressed a unique group of miRNAs that included one miRNA that was differentially overexpressed in all three fluids studied. The levels of several miRNAs also showed modest but direct associations with several standard clinical measures of lung health such as forced vital capacity or gas exchange efficiency. CONCLUSIONS: Candidate proteins and miRNAs associated with the general diagnosis of dyspnea have been identified in subjects with differing medical diagnoses. Since these markers can be measured in readily obtained clinical samples, further studies are possible that test the value of these findings in more formal classification or case-control studies in much larger cohorts of subjects with specific lung diseases such as asthma, emphysema, or some other well-defined lung disease.

Pure red cell aplasia caused by ribavirin and interferon treatment.

Anemia is a common complication of hepatitis C (HCV), and antiviral treatment can further increase this risk. We present the case of a 59-year-old man with HCV treated with ribavirin and pegylated interferon alpha (INF-α) who presented with severe anemia. Two months after initiating treatment his hemoglobin dropped from 14.2 to 5.0 g/dL. There was no evidence of bleeding or hemolysis, and a bone marrow biopsy revealed pure red cell aplasia (PRCA). Evaluations for acute cytomegalovirus and parvovirus B19 were negative. There was no evidence of malignancy or thymoma. The INF-α and ribavirin treatment were determined to have caused the PRCA, and withdrawal of the medications led to PRCA remission. INF-α and ribavirin have become the standard treatment for HCV. While these medications offer a potential cure, they are often poorly tolerated due to frequent side effects including anemia. Patients who are receiving treatment with ribavirin and INF-α warrant close monitoring for development of anemia, and PRCA should be considered in all patients in whom reticulocytopenic anemia develops.