Is endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) reliable and safe procedure in geriatric patients?

BACKGROUND: Even though studies have indicated the usefulness and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), elderly patient data are limited due to the small sample sizes. AIM: We aimed to evaluate usage and safety of EBUS-TBNA in elderly population. METHODS: This single-center retrospective study was conducted with patients who underwent an EBUS-TBNA procedure between September 2011 and December 2019. The patients were categorized into two groups: those aged 65 years or older (elderly group) and those younger than 65 years (younger group). RESULTS: 2444 patient data, 1069 of which were in the elderly group, were analyzed. The cytological examination of EBUS-TBNA identified specimen adequacy in 96.8% of patients. One hundred and thirty patients (5.3%) experienced complications, with similar complication rates recorded in both the elderly and younger groups (5.4% vs 5.2%, p: 0.836). Logistic regression analyses revealed that age, and presence of hypertension, diabetes mellitus, coronary artery disease and malignancy are associated significantly with complication-related EBUS-TBNA. For the lymph nodes with a final diagnosis of malignancy, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EBUS-TBNA revealed a diagnostic performance in excess of 90% except for metastasis and lymphoma. CONCLUSION: EBUS-TBNA can be considered a safe and effective technique in patients aged 65 years and over.

Evaluation of lung cancer biomarkers profile for the decision of targeted therapy in EBUS-TBNA cytological samples.

BACKGROUND: Guidelines recommend performing biomarker tests for epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), BRAF and ROS proto-oncogene-1(ROS1) genes and protein expression of programmed death ligand-1(PD-L1) in patients with non-small lung cell carcinoma (NSCLC). Studies reported that endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) can provide sufficient material for cancer biomarker analyses, but there are still concerns about the subject. AIM: The purpose of the study was to assess the adequacy of EBUS-TBNA for testing lung cancer biomarkers. METHODS: We retrospectively reviewed patients with NSCLC whose EBUS-TBNA was analysed for EGFR, ALK, ROS-1, BRAF and PD-L1 expression between December 2011 and December 2020. RESULTS: A total of 394 patients were enrolled in the study. EGFR mutation and ALK fusion were the most common studied biomarkers. EBUS-TBNA adequacy rate for biomarker tests was found 99.0% for EGFR, 99.1 for ALK, 97.2% for ROS1, 100% for BRAF and 99.3% for PD-L1 testing. Multivariate analysis revealed the histological type, history of treatment for NSCL, size, or 18-fluorodeoxyglucose uptake of sampled lesion did not show any association with TBNA adequacy for biomarker testing. CONCLUSION: EBUS-TBNA can provide adequate material for biomarker testing for EGFR, ALK, ROS-1, BRAF and PD-L1 expression.

Allergic bronchopulmonary aspergillosis with endobronchial signs: Two cases.

Pulmonary aspergillosis may be classified under three categories depending on whether the patient is atopic or immunocompromised: invasive, chronic necrotizing, and allergic bronchopulmonary aspergillosis (ABPA), which is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus spp., manifesting with poorly controlled asthma. ABPA is diagnosed using major and minor criteria. Herein, we present two ABPA cases with endobronchial signs on bronchoscopy. Asthmatic 31-year-old male and 59-year-old female patients were admitted with dyspnea and bilateral rhonchi. Total IgE levels were elevated. Peripheral eosinophilia was also present. Chest computed tomography revealed consolidated areas, peribronchial micronodules, ground-glass appearance, and increased nodular densities. Bronchoscopy showed brownish-yellow membranes on the bronchial mucosa of these patients. Aspergillus spp. growth was observed in bronchial lavage culture. ABPA is a curable disease only if diagnosed correctly. Notwithstanding the large number of cases reported to date, we aimed to emphasize the importance of bronchoscopic examination in endobronchial fungal infections.

A new device for bronchoscopy for better protection.

BACKGROUND: During the COVID-19 pandemic, the risk of transmission of SARS-CoV-2 has not been precisely known in bronchoscopy procedures. We have designed a cabinet device called Ankara University Bronchoscopy Cabinet (Aubrocab®) to protect healthcare. We aimed to evaluate preventing effect of Aubrocab® on aerosol spreading by measuring the particles in the bronchoscopy suite. METHODS: The patients were categorized into two groups as those who underwent bronchoscopy with and without Aubrocab®. We measured PM 0.5 levels before and after bronchoscopy in the bronchoscopy suite. RESULTS: A total of 82 patients, 62 of whom underwent bronchoscopy with Aubrocab®, were enrolled in the study. The PM 0.5 level measured before bronchoscopy was similar in both groups, whereas the PM 0.5 level measured after bronchoscopy was lower in the Aubrocab® group (42,603 ± 8,632 vs. 50,377 ± 10,487, p = 0.001). The percent of particle change (50.76 ± 19.91 vs 67.15 ± 24.24, p = 0.003) and the difference of the particle numbers between pre and postprocedure (13,638 ± 4,292 and 19,501 ± 5,891, p < 0.001) were lower in the Aubrocab® group. DISCUSSION: Our institution developed a barrier device named Aubrocab® which was shown to prevent excessive aerosol release in addition to routine precautions during bronchoscopy procedures.

Pulmonary arterial hypertension and systemic sclerosis relation: a single centre experience.

AIM: In systemic sclerosis (SSc), this single-centre study aimed to define the frequency and association of pulmonary arterial hypertension (PAH), occurring either alone in SSc-PAH or together with interstitial lung disease (ILD-PH). MATERIAL-METHODS: SSc cases between the years 1990-2011 were reviewed, retrospectively. Patients' clinical, laboratory findings, Modified Rodnan Skin Score and Medsger score, 6-minute walk distance (6MWD), carbon monoxide diffusion test (DLCO), echocardiography, thorax HRCT, and right heart catheterisation findings were recorded. RESULTS: One hundred and forty-one cases (F/M:124/17, diffuse cutaneous SSc (DcSSc)/limited cutaneous SSc (LcSSc): 84/57) were included in the study with the mean age of 52.70±15.17 years and disease duration of 107.07±99.44 months. PaO2, FEV1 and FVC were lower in DcSSc (p<0.05) as compared to LcSSc, but DLCO and 6MWD did not differ significantly, between the two forms. Ground glass opacity (64.7%) and interlobular septal thickening (58.8%) were the most frequent findings on HRCT of such subjects. PAH was detected in 34 subjects (24.1%). Seven of them had SSc associated PAH (SSc-PAH) and 27 ILD-PH. Both frequencies were similar between DcSSc and LcSSc. Mean sPAP was higher in SSc-PAH. CONCLUSION: PAH was observed in approximately one fourth of patients; therefore advanced cardio-pulmonary investigation should be routinely performed in the SSc patients' management.

Importance of mediastinal granulomatous/sarcoid-like lymphadenopathy in extrathoracic malignancies.

BACKGROUND: In patients with extrathoracic malignancies (ETM), granulomatous lymph adenopathy called sarcoid-like reactions (SLR) can be seen in the regional or draining lymph nodes. We hypothesized that SLR may be a sign of imminent metastasis and investigated the clinical course and rate of recurrence in patients with ETM and granulomatous mediastinal lymphadenopathy (MLN). METHODS: In this retrospective observational study, we reviewed the medical files of patients with known ETM and who underwent EBUS-TBNA for initial staging or detection of recurrence from 2011 to 2023. Patients with granulomatous MLN were included. RESULTS: Forty-one patients (29 female) enrolled in the study. Breast and colorectal carcinomas were the most common malignancies. A total of 81 lymph nodes were sampled. The final diagnosis of patients was five sarcoidosis, one tuberculosis, one second primary, one drug reaction, and 33 SLR. Among patients with SLR, in one patient lymph nodes progressed during the follow-up and were accepted as false-negative without confirmatory biopsy. The negative predictive value (NPV) of granulomatous MLN for metastasis was 97.05%. CONCLUSION: Granulomatous MLN may be due to tuberculosis, drug reaction, sarcoidosis, or SLR in patients with ETM. SLR has a high NPV in patients with ETM. Follow-up imaging rather than confirmatory biopsy is reasonable in these patients.

[Tuberculosis prevalence in municipality bus drivers in our dispensary region]. / Dispanser bölgemizdeki belediye otobüsü soförlerinde akciger tüberkülozu prevalansi

INTRODUCTION: Our study was designed to determine pulmonary tuberculosis rate in municipality bus drivers in our dispensary region and to determine whether or not the job is a risk factor for the disease. MATERIALS AND METHODS: Micro chest X-rays were taken of municipality bus drivers working in our region. The ones who had suspicious radiology were re-invited to dispensary; their health background was questioned and advanced investigation was performed. RESULTS: Totally 498 (97%) of 512 bus drivers working in our region came to our dispensary for the study survey. All of the attendants were male and between 19 and 57. In radiologic assessment, among 12 cases were suspected to have tuberculosis. Two of them had ARB smear positive tuberculosis and, five had inactive tuberculosis. CONCLUSION: Tuberculosis prevalence in bus drivers in our dispensary region was 0.4% (2/498). This value corresponded to 400 in 100.000 populations. Examining the statistics tuberculosis prevalence in our region was only 20 in 100.000 in 2006. This meant that, pulmonary tuberculosis is seen 20 times greater among municipality bus drivers. Taking this conclusion into consideration, we think that being a public bus driver may be accepted as a risk factor for tuberculosis.

A patient with widespread skin lesions presenting with massive pleural effusion.

Mycosis fungoides is the most commonly seen type of cutaneous T-cell lymphoproliferative disease. While mycosis fungoides is linked to an increased risk of developing secondary malignancies, the occurrence of B-cell-originated disease in association with it is exceedingly rare. A 66-year-old male with persistent papillomatous skin eruption was admitted due to dyspnea. Chest X-ray, positron emission tomography, and chest computed tomography revealed axillary and mediastinal lymph node enlargement and right lower pulmonary lobe infiltration along with right-sided massive pleural effusion. Histological and immunohistochemical findings of pleural biopsy and axillary lymph nodes suggested a diagnosis of pulmonary extranodal marginal zone lymphoma. Skin biopsies from the abdomen, chest, and legs revealed CD4/CD8 double-positive patch stage of mycosis fungoides. After completing six cycles of chemotherapy, complete remission of lymphoma was achieved, with the skin eruptions remaining unchanged. Herein, the authors present a unique case of concomitant diagnoses of mycosis fungoides and marginal zone B-cell lymphoma of the respiratory system to emphasize the importance of careful evaluation of each finding.

An aggressive and lethal course of Churg-Strauss syndrome with alveolar hemorrhage, intestinal perforation, cardiac failure and peripheral neuropathy.

Churg-Strauss syndrome (CSS) is a rare type of necrotizing vasculitis affecting small to medium-sized vessels typically characterized by asthma, lung infiltrates, necrotizing granulomas and hypereosinophilia. Herein, we describe a case of CSS presenting severe and aggressive course. A 35-year-old male patient with weight loss, dyspepsia, dyspnea and hemoptysis was admitted. The laboratory analyses indicated a remarkable eosinophilia, elevated levels of serum total IgE and positive cANCA. Thorax CT findings were suggestive of alveolar hemorrhage. Bronchoalveolar lavage revealed alveolar hemorrhage with eosinophilia and transbronchial lung biopsy showed eosinophilic vasculitis. Cardiac enzymes were increased and murmurs were audible revealing cardiomyopathy proven by echocardiography. Pulse cyclophosphamide and methyl prednisolone was immediately started. On the 21st day, intestinal perforation developed and urgent surgery was performed. During a follow-up, although a radiological improvement was observed in the chest X-ray, cardiac failure, peripheral neuropathy and skin lesions developed and high-dose intravenous immunoglobulin and anti-TNF therapy (adalimumab) were applied. Despite the therapy, he died from heart failure and septicemia at 68th day of therapy.

[Bronchoscopy suite]. / Bronkoskopi ünitesi.

Flexible bronchoscopy is usually performed at a tertiary care facility in a general endoscopy unit or a specially designed bronchoscopy suite. The procedure can also be performed outside the designated facility if the qualified personnel and required equipment can be mobilized. In this review, we discuss the essentials of a modern bronchoscopy suite based on the available information from the literature.

[Hypersensitivity pneumonitis]. / Hipersensitivite pnömonisi.

Hypersensitivity pneumonitis is an immunologically induced lung disease caused by repeated inhalation of agents in sensitized individuals. It may present with an extensive variety of clinical abnormalities depending on the nature of the inhaled dust and the amount of exposure, the time of exposure to the antigen and the immunological response of the host. In this review, we discuss the characteristics of hypersensitivity pneumonitis based on the available information from the literature.

A butterfly shaped alveolar hemorrhage caused by cytomegalovirus.

Abstract. We report here a 35 year-old immunocompetent male, with a fulminantly lethal diffuse alveolar hemorrhage caused by CMV pneumonia. The patient was admitted with fever, rust colored sputum and exertional dyspnea. A chest x-ray revealed bilateral alveolar infiltration in a butterfly pattern. Bronchoalveolar lavage (BAL) was performed which revealed alveolar hemorrhage. Microscopic findings of the lavage fluid revealed large numbers of erythrocytes and hemosiderin-laden macrophages. The patient did not improve with empiric antibiotic treatment. High CMV IgG and IgM titers were found in the serum. The patient died from respiratory failure after detection of inclusion bodies on BAL before initiation of antiviral therapy.

Endotracheal tuberculosis with obstruction.

Endotracheal involvement of tuberculosis (TB), a type of endobronchial TB, is defined as granulomatous infection of the tracheobronchial tree. We present the case of a 33 year-old female agriculture engineer with endotracheal tuberculosis (ETTB). It was treated successfully with prompt long-course antituberculous medication without complications or need for endotracheal intervention. This unusual case of ETTB, diagnosed promptly by fiberoptic bronchoscopy, and microbiological studies, is presented to emphasize the importance of macroscopic recognition to start anti-TB therapy in cases with significant airway obstruction. This case is important for countries where the various presentations of TB are encountered as well as in countries where TB is not endemic.

Cotinine levels in serum and bronchoalveolar lavage fluid.

Cotinine is a major metabolite of nicotine. This study was planned to investigate the relationship between bronchoalveolar lavage (BAL) fluid cotinine levels and serum cotinine levels in smokers and nonsmokers with various pulmonary diseases and to investigate whether these levels are affected by passive smoking. Serum and BAL fluid cotinine levels were measured in 27 patients. BAL cotinine levels were measured using a sensitive ELISA kit produced to measure cotinine in saliva. Plates were read by microuant (BioTek, USA) micro plate reader. All patient serum cotinine levels were detectable except for one nonsmoker patient. However, BAL fluid cotinine levels were measurable in only 6 patients (two of them were nonsmokers). A significant positive correlation was seen between serum and BAL fluid cotinine levels (r = 0.726; p = 0.000). Serum cotinine levels were significantly higher in present smokers than non-smokers (21.0 +/- 16.01; 5.35 +/- 7.65; p = 0.004). However, there were no significant differences in BAL fluid cotinine levels between smokers and nonsmokers. Passive smoking can increase nicotine metabolites in serum and other body fluids, including BAL fluid. Since BAL fluid and serum cotinine levels were well correlated, there is no need to use invasive procedures, such as bronchoscopy and expensive, time consuming BAL fluid analyses. Serum cotinine levels can give a rough idea of smoking status. BAL fluid cotinine meaurements should be done for only scientific reasons.

Additive effect of dabigatran and high-dose aspirin in the development of haemorrhagic pleural effusion in a patient with tuberculous pleuritis.

Tuberculous pleuritis can rarely cause haemorrhagic pleural effusion. Dabigatran etexilate can have an additive effect on increasing the risk of haemorrhage. Aspirin cannot cause major haemorrhage, but in the elderly it can cause gastrointestinal bleeding via ulceration of the gastrointestinal mucosa. We report here the case of a 77-year-old male who presented to the hospital with a 2-month history of progressive dyspnoea. He had been taking dabigatran etexilate (220 mg) and high-dose acetylsalicylic acid (aspirin; 300 mg) daily for chronic atrial fibrillation. A chest X-ray revealed a moderately sized right pleural effusion confirmed by a computed tomography scan, which also showed bronchiectasis of both lungs. Dabigatran was discontinued and aspirin was decreased to the minimal therapeutic dose of 100 mg before thoracentesis was performed. Lymphocyte-predominant (50%) haemorrhagic fluid of 500 ml was drained, positive for acid-fast bacilli smear and polymerase chain reaction of Mycobacterium tuberculosis. A chest tube was placed and an additional 1250 ml of haemorrhagic exudate drained out. We treated the patient with a routine regimen of antituberculous medication and the infection resolved without complications other than the bronchiectasis present before treatment. We think that the combination of dabigatran etexilate and high doses of aspirin increased the risk of pleural haemorrhage in this patient with tuberculous pleuritis.

A Very Rare Adverse Effect of Clozapine, Clozapine-induced Interstitial Lung Disease: Case Report and Literature Review.

Clozapine is the gold-standard antipsychotic agent for treatment-resistant schizophrenia. Yet with all its clinical efficacy, there are numerous adverse effects associated with clozapine. Although many, such as leucopenia and agranulocytosis, are well established, there is little published material on the drug's rare adverse effects. Among these, very little is known about clozapine-induced interstitial lung disease. Here we present such a case. We focus on its clinical aspects and discuss its relationship to the extant literature.

An unusual cause of T tube obstruction: 'tricho-tracheobezoar'.

A T tube is an upper airway device well described in the literature which is used to maintain tracheal lumen patency. Although tube occlusion is a known complication, it can be minimized by certain precautions. Otherwise, total occlusion can result in dramatic clinical deterioration or death. Herein, we describe a new clinical entity, 'tricho-tracheobezoar', using a new term defining a hairball in the trachea, which illustrates many of the potential pitfalls in the management of T tubes.

Diagnostic accuracy of cytokine levels (TNF-alpha, IL-2 and IFN-gamma) in bronchoalveolar lavage fluid of smear-negative pulmonary tuberculosis patients.

BACKGROUND: The determination of cytokine concentrations in serum and bronchoalveolar lavage fluid (BALF) may contribute to the diagnosis of tuberculosis (TB) since cytokines have been ascribed an important role in TB pathogenesis. OBJECTIVE: To assess the diagnostic accuracy of TNF-alpha, IFN-gamma and IL-2 levels in serum and BALF of smear-negative pulmonary TB patients. METHOD: BALF was obtained from the affected lobe in patients with smear-negative TB or other pulmonary diseases (OPD), and from the right middle lobe in healthy controls. ELISA and a nephelometric method were used to detect cytokine and albumin levels. RESULTS: TNF-alpha levels in BALF were significantly elevated in the TB group (n = 15) compared with the OPD patients (n = 40) and controls (n = 17; p < 0.001). Although these three cytokines correlated well with each other in BALF (p < 0.0001, and r >or= 0.7, respectively), BALF IL-2 and IFN-gamma levels were not significantly different among the groups (p > 0.05). BALF TNF-alpha or IFN-gamma levels were significantly higher in patients with cavitary disease (n = 11) versus those without (n = 61; p < 0.05). However, no significant difference was found between cavitary (n = 7) and non-cavitary TB in cytokine levels (p > 0.05). Neither gender nor smoking status showed any statistical differences in cytokines in the groups (p > 0.05). Sensitivity and specificity of BALF TNF-alpha were found to be 73 and 76%, respectively. The positive and negative predictive values for BALF TNF-alpha were 44 and 91%, respectively. CONCLUSION: In cases of smear-negative TB, BALF TNF-alpha can be a useful tool to identify healthy subjects rather than smear-negative TB patients.

Hyperhomocysteinemia due to pernicious anemia leading to pulmonary thromboembolism in a heterozygous mutation carrier.

Pulmonary thromboembolism is a life-threatening condition resulting mostly from lower extremity deep-vein or pelvic-vein thrombosis. A 46-year-old woman was admitted to hospital with pain on the right side of the chest and hemoptysis. On laboratory analysis, D-dimer level was elevated. Computed tomographic pulmonary angiography revealed intravascular filling defects due to thrombi in right lower lobe pulmonary segmental arteries. Screening for thrombophilic states was normal except for heterozygous mutations of both prothrombin and methylene tetrahydrofolate reductase (MTHFR 677) genes. Homocysteine level was high, and vitamin B12 level and serum ferritin level were reduced. Serum antiparietal antibody was positive, and therefore, pernicious anemia was diagnosed along with iron-deficiency anemia. After the diagnoses were established, enoxaparin followed by warfarin was started in addition to oral vitamin B12, pyridoxine, thiamine, folic acid, and ferroglycine sulfate supplementation. At the end of 8 weeks of the replacement therapy, vitamin B12, folate, and homocysteine levels and red cell volume were found to be normal, with complete resolution of the thrombus confirmed by repeat computed tomographic pulmonary angiography. We conclude that hyperhomocysteinemia due to vitamin B12 deficiency associated with pernicious anemia might have decreased the threshold for thrombosis. In addition, the presence of heterozygous prothrombin and methylene tetrahydrofolate reductase mutations might serve as synergistic cofactors triggering pulmonary thromboembolism.