Incidence and distribution of intrathoracic metastases from renal cell carcinoma.

Chest roentgenographic findings in 46 patients with renal cell carcinoma were analyzed and correlated to clinical and pathologic findings. Twenty-five patients (54.3%) had intrathoracic metastasis, 17 (37%) of whom had roentgenographic evidence of intrathoracic metastasis at the time of initial diagnosis. Lung metastasis was present in 14 patients (30%), alone in ten patients and along with mediastinal or pleural metastasis in four patients. Mediastinal lymph node metastasis was present in 13 patients (28.2%) and was distributed in the following locations: bilateral hila, six; right hilum, two; right paratracheal area, two; left hilum, one; left paratracheal area, one; and left hilum and right paratracheal area, one. Mediastinal lymph node enlargement was the sole roentgenographic finding in six patients (13%). Metastasis to the lungs or mediastinum may already be present in more than a third of the patients with renal cell carcinoma at the time of diagnosis. Mediastinal lymph node metastasis from renal cell carcinoma occurs more frequently than previously reported and may be the only chest roentgenographic manifestation of the disease.

Empyema thoracis during a ten-year period. Analysis of 72 cases and comparison to a previous study (1952 to 1967).

In this series of 72 cases of empyema, 28 patients (38.8) had anaerobes isolated from their pleural fluid cultures. In 22 patients, anaerobes were the only isolates, and in six there were also aerobes. This observed frequency (38.8%) of anaerobic empyema is notably greater than the frequency noted in an earlier study (1952 to 1967) from the Veterans Administration Medical Center, Wood, Wis, while the contribution of various pathogenetic mechanisms was similar. Although closed chest tube drainage was instituted initially in 51 patients, 18 patients (35%) subsequently required additional procedures. The case-fatality ratio was 51.4% in this study compared with 46.6% in the earlier study. Twenty-two patients died during the same hospitalization period while the empyema was an active problem. Six (8.3%) of these empyema-related deaths occurred in patients without underlying disease, while 16 (22.2%) were in patients with underlying diseases.

Deep mycotic infection in the hospitalized adult: a study of 123 patients.

A prospective study of patients hospitalized in a large Veterans Administration Hospital between November 1963 and November 1973 revealed 123 patients with deep mycotic infections. The incidence of these infections almost doubled during the last 5 years. Candida (55 patients) and Aspergillus (26 patients) were the major causative agents. Nine other fungal caused infection in the remaining patients. Candidemia was rare prior to the introduction of commerical percutaneously-inserted venous catheters in 1965. The incidence increased further following the introduction of parenteral hyperalimentation in 1969, and Torulopsis fungemia (5 patients) appeared for the first time. Invasive pneumonia caused by spore-forming Aspergillus decreased when patients were moved from an old, naturally-ventilated hospital to a new, mechanically-ventilated one. The air in both hospitals was sampled on one occasion for the presence of fungal spores, and spores of Aspergillus fumigatus were detected only in the old hospital. Our experience suggests that hospital-acquired Aspergillus infection of the lung might be eliminated if all incoming hospital air is filtered, properly vented, and not recirculated. Efforts to decrease hospital-acquired fungal infections include vigorous infection control procedures for intravenous therapy, judicious use of any therapy that predisposes to infection, and further evaluation of improved mechanical control of hospital ventilation.

Pulmonary aspergilloma. A rational approach to treatment.

A prospective study of 15 patients with pulmonary aspergilloma was undertaken over an 11 year period. Serious underlying diseases, particularly chronic obstructive pulmonary disease and alcoholic cirrhosis, were present in 12 of them. Eight of 15 patients whose clinical and roentgenographic course was followed for an average of 50 months, received no specific therapy. There were four deaths in this group, none attributable to aspergilloma. The aspergilloma had lysed spontaneously in two, decreased in size in one and was unchanged in one. In the four surviving patients who had no treatment, the aspergilloma lysed spontaneously in one, remained unchanged in two and increased in size in one. Of the seven patients who were treated medically or surgically, three died. Among the seven deaths (untreated and treated patients combined), six were clearly related to underlying disease. The prognosis of aspergilloma is related primarily to the nature and severity of the underlying disease(s). Contrary to the conclusions of previous reports, the experience in our series of patients suggests that routine surgical excision of aspergilloma is not indicated.

Epidural abscess, vertebral destruction, and paraplegia caused by extending infection from an aspergilloma.

An aspergilloma developed in a lung cyst in a 53-year-old man. Aspergillus infection then contiguously spread to the epidural space, causing an abscess, vertebral destruction, and paraplegia at the level of T4. Chronic alcoholism, liver cirrhosis, and corticosteroid treatment may have been predisposing factors in this patient. Although Aspergillus epidural abscess has been described infrequently, this complication has not been described in association with an aspergilloma. Symptoms, signs, or roentgenographic or laboratory findings suggestive of vertebral or meningeal pathologic lesions in patients with aspergilloma should alert the physician to the possibility of contiguous spread of infection.

Metastatic renal cell carcinoma simulating sarcoidosis. Analysis of 12 patients with bilateral hilar lymphadenopathy.

Case summaries of four patients with bilateral hilar lymphadenopathy (BHL) caused by metastatic renal cell carcinoma are presented, and these and eight similar cases from the literature are analyzed. In nine patients, sarcoidosis was the provisional clinical diagnosis, but four of these patients had a past history of renal cell carcinoma. In the remaining five patients, a distinction from sarcoidosis could not be made by history, physical examination, and chest roentgenogram. This underscores the need for tissue confirmation in the diagnosis of sarcoidosis and alerts the physician to consider metastatic renal cell carcinoma in the differential diagnosis of BHL.

"Contarini's condition:" bilateral pleural effusions with markedly different characteristics.

A leukemic patient presented with bilateral pleural effusions. The effusions were markedly different in their characteristics; left-sided staphylococcal empyema and right-sided lymphocytic effusion. To our knowledge, there are no cases of this type reported in the modern literature. The importance of bilateral diagnostic thoracocentesis in patients on immunosuppressant therapy is emphasized.

Diagnosis of malignant pleural mesothelioma by axillary lymph node biopsy.

Diffuse malignant mesothelioma was diagnosed by axillary lymph node biopsy in a patient with brief asbestos exposure and extensive pleural masses. The clinical, radiographic and pathologic findings of this case are reported and lymph node involvement in DMM is briefly discussed.

Spinal cord aspergillus invasion--complication of an aspergilloma.

Acute paraplegia developed in a 53-year-old man with pulmonary aspergilloma because of contiguous extension of Aspergillus infection to the epidural and subdural spaces and spinal cord. Histopathologic findings of the spinal cord showed Aspergillus hyphae penetrating the myelin sheath and myelomalacia, predominantly in the anterior and lateral columns. To the authors' knowledge, there have been no previous descriptions or illustrations of spinal cord involvement and the pathologic changes caused by Aspergillus infection.

Acute effects of ski waxing on pulmonary function.

The objective of this study was to determine whether pulmonary function is acutely affected by moderate exposure to ski waxing. Ten healthy nonsmoking young adult volunteers were exposed to 45 min of ski waxing in a small unventilated room. The exposure occurred in pairs with one individual performing the waxing while the other overlooked the waxing process. During the period of waxing, two pairs of cross-country skis were waxed with a paraffin wax and then scraped and brushed, and two pairs of cross-country skis were waxed with a fluorinated wax and then brushed. Spirometry and single-breath carbon monoxide lung diffusion capacity (DLCO) were measured immediately before and after exposure to ski waxing, and again 5-6 h after waxing. A subset of five subjects repeated the measurements on a separate day without receiving exposure to ski waxing. Data were analyzed with repeated measures ANOVA. Exposure to ski waxing induced no significant changes in spirometry and DLCO measurements. We conclude that moderate exposure to ski waxing has no significant acute effect on lung function.

Malignant-appearing cells in pleural effusion due to pancreatitis: case report and literature review.

Malignant-appearing mesothelial cells were noted in an amylase-rich pleural effusion caused by pancreatitis in the absence of any neoplastic disease. Such changes in the mesothelial cells are believed to be the result of intense irritation of the serosal surfaces by the pancreatic enzymes. Review of the literature showed a likelihood of false-positive cytologic diagnosis of 0.44% for pleural effusions and 0.91% for all serous effusions. Because of the potential for serious error in patient management based on a false-positive cytology, it is important to recognize the conditions that may be responsible for it.

Asbestos exposure. An update on pleuropulmonary hazards.

Asbestos exposure is causally related to the development of asbestosis, bronchogenic carcinoma, malignant mesothelioma, and nonmalignant pleural disorders. Clinical and roentgenographic manifestations of asbestosis mimic other diffuse fibrotic lung diseases. However, a concomitant finding of pleural plaques strongly suggests the diagnosis. The manifestations of bronchogenic carcinoma related to asbestos exposure are varied and do not differ from those unrelated to asbestos exposure. Malignant mesothelioma signals previous asbestos exposure. Nonmalignant pleural disorders may not cause any symptoms but should alert the physician to other concurrent or potential asbestos-related diseases. To diagnose asbestos-related diseases, physicians should bear in mind the long latent period and should take a careful, comprehensive occupational and environmental history. Cigarette smoking markedly increases the risk for development of bronchogenic carcinoma in asbestos workers and increases the mortality due to asbestosis.

Pleural effusions caused by infection.

Diagnostic thoracentesis is imperative when pneumonia is accompanied by an effusion (parapneumonic effusion). Examination of the pleural fluid is the only way to differentiate empyema and complicated parapneumonic effusions from uncomplicated parapneumonic effusions, and this differentiation is vital in deciding whether chest tube drainage is needed. If the aspirated pleural fluid contains pus or bacteria, closed chest tube drainage and antibiotic therapy should be started promptly. The same management approach is indicated if the pleural fluid pH is less than 7.00 or the glucose level is less than 40 mg/ml, since these effusions almost invariably are complicated parapneumonic effusions that do not resolve without fluid drainage. If the pleural fluid pH is greater than 7.20 and glucose level is more than 40 mg/ml, antibiotic therapy alone will suffice. Management of parapneumonic effusions with a pH of 7.00 to 7.20 should be based on serial observations of clinical status and pleural fluid findings.

Oral antifungal therapy. Current status of ketoconazole.

Ketoconazole, an oral, broad-spectrum antifungal agent with relatively low toxicity, is the preferred drug for treatment of chronic mucocutaneous candidiasis and an alternative choice for treatment of thrush, vaginitis, histoplasmosis, and coccidioidomycosis. Clinical trials have shown it to be effective also against dermatophytoses. Further testing is necessary to determine its effectiveness for treating blastomycosis, cryptococcosis, sporotrichosis, and aspergillosis.

Chronic obstructive pulmonary disease. Reversing airflow obstruction from chronic bronchitis and emphysema.

Chronic obstructive pulmonary disease (COPD) describes a group of disorders that cause obstruction to expiratory airflow. COPD should be suspected in a patient who has cough, sputum production, wheezing, and/or inappropriate dyspnea on exertion in the setting of prolonged exposure to cigarette smoke. With smoking cessation, avoidance of occupational and other bronchial irritants, and use of bronchodilators, antibiotics, and long-term oxygen when appropriate, the patient can minimize limitations on activity and complications.

Pulmonary tuberculosis: a multifaceted disease.

One reason for the increasing misdiagnosis of tuberculosis in adults is the fact that one of every three patients may present with a roentgenographic pattern considered atypical for the disease. In this article a number of such atypical patterns--pleural manifestations, nodular forms of the disease, and infiltrates in unusual locations--are discussed and illustrated by means of case summaries. Awareness of these variations would help in the diagnosis of tuberculosis, which is progressively becoming a responsibility of physicians involved in primary care.

Long-term use of oral anticoagulants. Current recommendations.

In many patients receiving long-term oral anticoagulation therapy, hemorrhagic complications occur less often when prothrombin time is maintained within a lower range than that required by a traditional regimen. A target prothrombin time ratio of 1.3 to 1.5 has been recommended for all circumstances except (1) prevention of thromboembolism in patients with mechanical heart valves and (2) prevention of recurrent systemic embolism. Because primary care physicians often monitor the overall treatment program of patients receiving oral anticoagulants, they need to be familiar with the indications, contraindications, and practical considerations that are associated with the use of these drugs.

Asbestos-related diseases of lung and pleura: clinical picture and illustrative cases.

Exposure to asbestos may occur in any of a large number of occupations, and the latent period from exposure to appearance of clinical or roentgenologic evidence of related disease of the lung or pleura, or both, may be more than 20 years. A complete occupational history is therefore of paramount importance in the detection of asbestos-related diseases. Illustrative cases highlight the features of benign and malignant diseases of the lung and pleura for which a causal relationship to asbestos exposure is probable or established.

Sarcoidosis presenting with posterior mediastinal lymphadenopathy.

A young man with exertional dyspnea, maculopapular skin lesions, and generalized lymphadenopathy was found to have a posterior mediastinal density on a chest roentgenogram. Sarcoidosis was diagnosed on the basis of lymph node and skin biopsy findings, and corticosteroid therapy was started. After six months of treatment the patient was free of symptoms and the posterior mediastinal density had resolved. Although posterior mediastinal lymphadenopathy is an infrequent roentgenographic manifestation of sarcoidosis, this possibility should be kept in mind in the differential diagnosis of a posterior mediastinal density.

Allergic bronchopulmonary aspergillosis: an increasing clinical problem.

Allergic bronchopulmonary aspergillosis is being recognized with increasing frequency in the United States. The characteristics of the disease are recurrent pyrexia, cough, wheezing, sputum plugs containing aspergilli, fleeting pulmonary infiltrates, eosinophilia, dual skin reactions (immediate and late), and antibodies to the fungus in the blood. The pathogenetic mechanism is believed to involve type I and type III hypersensitivity reactions. Adrenal corticosteroids are effective in treating this condition.