MRI and CT in the differential diagnosis of pleural disease.

STUDY OBJECTIVE: To explore the role of MRI in the differential diagnosis of pleural disease. PATIENTS: Forty-two patients with pleural disease were included. METHOD: Retrospective study. All patients were examined with both CT and MRI. The morphologic features of pleural lesions and magnetic resonance signal intensity on T1-weighted, T2-weighted, and contrast-enhanced T1-weighted images were evaluated. RESULTS: Mediastinal pleural involvement, circumferential pleural thickening, nodularity, irregularity of pleural contour, and infiltration of the chest wall and/or diaphragm were most suggestive of a malignant cause both on CT and MRI. Pleural calcification on CT was suggestive of a benign cause. Contrary to what has been previously reported in the literature, neither on CT nor on MRI, pleural thickness >1 cm revealed significant difference between malignant and benign pleural disease (p>0.05, chi(2) test). High signal intensity in relation to intercostal muscles on T2-weighted and/or contrast-enhanced T1-weighted images was significantly suggestive for a malignant disease. Using morphologic features in combination with the signal intensity features, MRI had a sensitivity of 100% and a specificity of 93% in the detection of pleural malignancy. CONCLUSION: When signal intensity and morphologic features are assessed, MRI is more useful and therefore superior to CT in differentiation of malignant from benign pleural disease.

Bronchiolitis obliterans organizing pneumonia and chronic graft-versus-host disease in a child after allogeneic bone marrow transplantation.

We report an 8-year-old boy who developed cough and respiratory failure 7 months after bone marrow transplantation (BMT) coinciding with the onset of chronic graft-versus-host disease (GVHD). Lung function data, imaging studies, lung biopsy and bronchoalveolar lavage were consistent with the diagnosis of bronchiolitis obliterans organizing pneumonia. While this has been reported in association with chronic graft-versus-host disease in one adult case previously, we report the simultaneous occurrence of BOOP and chronic GVHD in a child after bone marrow transplantation for the first time.

[High-resolution magnetic resonance tomography (HR-MRT) of the pleura and thoracic wall: normal findings and pathological changes]. / Hochauflösende Magnetresonanztomographie (HR-MRT) von Pleura und Thoraxwand: Normalbefund und pathologische Veränderungen.

AIM: To determine the value of high-resolution MRI in pleural and chest wall diseases, the normal and pathologic costal pleura and adjacent chest wall between paravertebral and the axillary region were examined with contrast enhanced high-resolution T1-weighted MRI images using a surface coil. MATERIAL AND METHODS: Normal anatomy was evaluated in 5 healthy volunteers and a normal specimen of the thoracic wall, and correlation was made with corresponding HR-CT and histologic sections. CT-proved focal and diffuse changes of the pleura and the chest wall in 36 patients underwent HR-MRI, and visual comparison of MRI and CT was done retrospectively. RESULTS: Especially sagittal T1-weighted HR-MRI images allowed accurate delineation of the peripleural fat layer (PFL) and the innermost intercostal muscle (IIM), which served as landmarks of the intact inner chest wall. PFL and IIM were well delineated in 3/4 patients with tuberculous pleuritis, and in all 7 patients with non-specific pleuritis, as opposed to impairment of the PFL and/or the IIM, which was detected in 15/18 malignancies as a pattern of malignant chest wall involvement. In one case of tuberculous pleural empyema with edema of the inner chest wall HR-MRI produced false positive diagnosis of malignant disease. CONCLUSION: HR-MRI images improved non-invasive evaluation of pleural and chest wall diseases, and allowed for differentiation of benign and malignant changes.

[Magnetic resonance tomography (MRT) in pleural diseases. A comparison with CT and histopathological findings]. / Magnetresonanztomographie (MRT) bei Pleuraerkrankungen. Vergleich mit CT und histopathologischen Befunden.

The MRI and CT appearances in 48 patients with histologically confirmed benign and malignant pleural abnormalities were compared retrospectively. Abnormal pleural changes were shown in 47 out of the 48 patients by high signal intensity of the pleura in T2-weighted sequences and in contrast enhanced T1-weighted sequences on MRI. CT showed abnormalities in 45 out of 48 patients. Delineation of pleural and pulmonary changes by CT was possible in 13 out of 23 cases, and pleural disease from effusions in 15 out of 28 cases. T2-weighted MRI was successful in 14 out of 23 and 4 out of 28 cases, respectively. T1-weighted images after contrast were successful in 20 out of 23 and 22 out of 28 cases, respectively. Indications of malignant pleural disease were the presence of mediastinal or circumferential involvement or involvement of the entire pleura, thickness of more than 10 mm and nodular changes. The most reliable sign of malignancy was infiltration of the thoracic wall and the diaphragm; this was better demonstrated by MRI (18 out of 19 and 2 out of 2 cases) than by CT (14 out of 19 and 0 out of 2 cases).

[Complications of pulmonary involvement in Bechterew's disease]. / Komplikationen der pulmonalen Beteiligung beim M. Bechterew.

Fibrocystic changes in the upper lung lobes are a rare visceral manifestation of ankylosing spondylitis. The impaired bronchopulmonary clearance in bronchial, pulmonary or pleural cavities predisposes to secondary microbial colonisation. Two cases are reported--one patient proved to have non-tuberculous mycobacterial disease caused by M. kansasii, the other developed an aspergilloma.

Scintigraphic images of Swyer-James syndrome.

The Swyer-James Syndrome, first described in 1953, is a rare entity which consists of severe oligemia of one or more pulmonary lobes accompanied with bronchial deformation. Recurrent bronchial infections in childhood are believed to be the cause, leading to obliteration of small airways, alveolar overdistension and, ultimately, the destructive changes characteristic of emphysema. Secondary vascular alterations occur resulting in oligemia of the afflicted lobe. The clinical presentation is variable ranging from the totally asymptomatic patient to dyspnea on exertion or recurrent lower respiratory tract infections. The physical examination may reveal hyperresonance over the affected area, restricted chest expansion on one side, or occasionally rales on auscultation. Radiological findings are characteristic and include a pronounced one sided hyperlucency of the lung (due to oligemia), a mediastinal shift toward the affected side on inspiration, a small ipsilateral hilus, and bronchial deformities as disclosed by bronchography. Another radiologic feature, described as a "sine quanon" condition for diagnosis by Fraser and Paré is the development of air trapping during expiration. Various diagnostic modalities including roentgenography, bronchoscopy, bronchography, angiography and radionuclide imaging are necessary to obtain the diagnosis.

[Antimycotic treatment of pulmonary aspergilloma in patients without neutropenia]. / Antimykotische Therapie pulmonaler Aspergillome bei nicht neutropenischen Patienten.

BACKGROUND AND OBJECTIVE: Pulmonary aspergillomas are associated with a high morbidity and mortality. There are only very few data about non-surgical treatment in immunocompetent patients. METHODS: We evaluated 30 patients (19 male/11 female; mean age: 54 years) with pulmonary aspergillosis, their symptoms, treatment and outcome during a time period of 9 years. All patients had either definitive (18/60 %) or probable (12/40 %) aspergillosis with a cultural confirmation. RESULTS: Underlying diseases were tuberculosis (16/53 %), malignancy (8/30 %), COPD (15/50 %), pneumonia (3/10 %). Only five patients were immunocompromised (steroid medication: n = 4, chronic lymphatic leukemia: n = 1) All patients had a contraindication against surgery, 26 received antifungal treatment (mostly with voriconazole or itraconazole). The overall response was 61 %, there was an improvement of radiological signs in seven (23 %). Especially hemoptysis and dyspnea resolved. 12 patients died during the 9 years (40 %), nine from their underlying disease, three from the pulmonary aspergilloses (hemoptysis: n = 2, secondary invasive aspergillosis: n = 1). CONCLUSION: Pulmonary aspergilloma in its chronic form is a disease of patients with pulmonary disease but who are immunocompetent. Antifungal treatment seems to be a therapeutic option, if surgery is not possible.

[Incompatibility of tuberculosis therapy in a patient with AIDS]. / Unverträglichkeit der Tuberkulosetherapie bei AIDS.

A man with advanced HIV infection (CD4 lymphocytes 90/microliter, CD4/CD8 ratio 0.2) was admitted to hospital with fever, cough and weight loss. The radiological and bronchoscopic findings, together with the presence of acid-fast bacilli in the sputum, pointed to open pulmonary tuberculosis caused by Mycobacterium tuberculosis, a diagnosis confirmed by histological examination and culture. Quadruple antibiotic therapy with isoniazid (INH), rifampicin (RMP), ethambutol (EMB) and amikacin was immediately begun and was at first clinically successful. Ten days later, however, a rash appeared; it was ascribed to RMP (anaphylactoid reaction after re-exposure). All the other first-line drugs tried during the ensuing eight months evoked severe adverse reactions (INH: rash and itching; amikacin: hearing impairment and tinnitus; EMB, pyrazinamide, prothionamide, p-aminosalicylic acid: rash and itching). Treatment was nevertheless clinically and microbiologically successful, and the patient insisted upon a 2 1/2 months' rest without therapy. This period was followed by extrapulmonary spread (severe arthritis of the elbow) and recurrence of pulmonary tuberculosis. The tubercle bacilli were sensitive to all the drugs so far employed. Renewed and lasting control of the infection was achieved only by continuous administration of steroids (prednisolone 10 mg twice daily) in conjunction with an unconventional antibiotic regimen consisting of amikacin, protionamide, terizidone, clarithromycin and sparfloxacin for some five months. Because of an episode of cerebral convulsions during treatment of cytomegalovirus retinitis with ganciclovir, the terizidone was discontinued (it was suspected of interacting with ganciclovir). The patient has had no more fits and sputum culture has remained negative for six months.

[Nontuberculous mycobacteriosis as a complication of the Swyer-James syndrome]. / Nicht-tuberkulöse Mykobakteriose als Komplikation eines Swyer-James-Syndroms.

The chest radiograph of a 35-year-old man with fatigue, exertional dyspnoea and haemoptyses revealed a cavity in the left upper lobe and a shrunken left lung with radiolucency greater than that on the right. Acid-fast rods in sputum were identified as Mycobacterium kansasii on culture. Scintigraphy showed a 9% residual perfusion on the left and abnormal ventilation, compatible with Swyer-James syndrome. This had favoured the development of a mycobacterial infection. There was also a decrease in ciliary function (rate of 4-7 Hz, normal: 10-11). Treatment, begun when tuberculosis had been suspected, was after sensitivity tests changed to a combination of rifampicin (600 mg), ethambutol (1600 mg) and protionamide (500 mg) daily. There was marked regression of the findings within 4 weeks, but treatment was prematurely stopped after 11 months. Two years later there was a recurrence which again responded well to the same drug regimen with additional sulphamethoxazole (1600 mg/d).

[Benign fibrous histiocytomas as a differential diagnosis in cavitary lung disease]. / Benignes fibröses Histiozytom als Differenzialdiagnose für eine kavernöse Lungenerkrankung. Kasuistik mit Literaturübersicht.

Benign fibrous histiocytomas (BFH) are uncommon pulmonary tumours. These lesions usually present as slow-growing, solid masses. We report the rare case of a young man with cavitary BFH. The 20-year-old patient, a non-invasive drug abuser, had suffered from hemoptysis for two months. The chest X-ray showed a solitary pulmonary nodule with a diameter of 2 cm in the left lower lobe with central cavitation. Fiberoptic bronchoscopy showed a normal bronchial system, biopsies were not diagnostic and no acid fast bacilli were found. Considering the patient's history and the cavitary process, a non-specific abscess was suspected and an antimicrobial treatment was started. Since no treatment effect was observed, biopsies from a second bronchoscopy were suspicious of a malignant mesenchymal tumour. Lower lobe resection with lymphadenectomy revealed a benign fibrous histiocytoma. This is--to our knowledge--the first reported case of a BFH presenting with cavitation.

Clinical and radiologic features, lung function and therapeutic results in pulmonary histiocytosis X.

Clinical appearance, radiologic findings, lung function and results of corticosteroid therapy were analyzed in 42 adult cases of biopsy-proven pulmonary histiocytosis X. Symptoms were present in only 64%. Using the ILO classification 1980, the evaluation of chest radiographs revealed all categories of profusion, size and shape of nodules. The characteristic 'ring figures', i.e. thin-walled cysts, in the parenchyma were detected in 78% of conventional tomographies (n = 27) and in all patients examined by CT (n = 5). In patients with early disease, lung function tests (n = 26) including body plethysmography, pulmonary diffusing capacity and ergospirometry revealed that parameters of gas exchange are most sensitive (TL,CO 84%, KCO 72%). Bronchial reactivity to carbachol was significantly higher than in controls (n = 12). Lung perfusion scintigram showed an abnormal, but uncharacteristic pattern in 81% (n = 26). During corticosteroid therapy, no progression was observed (n = 36). 85% of patients with radiographic evidence of progressive disease improved after administration of corticosteroids (n = 14).

[Systemic thrombolysis with short-term streptokinase infusion in acute myocardial infarct]. / Systemische Thrombolyse mit Streptokinase-Kurzzeitinfusion bei akutem Myokardinfarkt.

Within 6 hours after the onset of acute myocardial infarction, 93 patients received a brief high-dose intravenous infusion of streptokinase, 49 patients received 500,000 IU within 30 min and 44 patients received 1,500,000 IU within 60 min. 26 patients had angiography in the acute phase, after 24 hours, and in the 4th week; 52 patients had angiography in the 4th week only; and 15 had no angiography. 7 patients died in hospital and 6 suffered a nonfatal reinfarction. There were no complications with bleeding. In 52% of cases, reopening of an occluded infarct vessel was achieved within 1 hour of the beginning of treatment. During the 4th week after infarction a patent infarct vessel was found in 84%, and 58% had a residual stenosis less than 70%. In contrast, in a control group that received no streptokinase treatment, 25% had a patent infarct vessel and 4% had a residual stenosis less than 70%. Indicative for salvage of ischemic myocardium are a significant improvement in local contraction disorders between the acute phase and the 4th week and a significant correlation between infarct size in the 4th week and beginning of treatment after onset of symptoms. 1. It may be concluded that: brief intravenous infusion of streptokinase results in restoration of blood flow in an infarcted coronary artery in a high percentage of cases; the shorter thrombus-lysis time with intracoronary streptokinase infusion could be made up for by the earlier initiation of intravenous streptokinase treatment; and a conclusive randomized trial is needed to ascertain the true impact of a brief high-dose intravenous infusion of streptokinase on mortality and morbidity following acute myocardial infarction.