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Infections of the lungs and pleura
... There can also be shaggy or irregular edges at times, causing it to mimic lung cancer. 17,18 Lung abscess, usually caused by anaerobic bacteria like Klebsiella and Pseudomonas. On CT it can be seen as single or multiple lung masses or nodules. ...
... These can be cavitatory lesions as well, which can occur within consolidatory areas. 16,17 Materials and Methods Study Design: Observational cross-sectional study. Study Setting: Department of Radio diagnosis -Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala. ...
... Наличие центральной или диффузной кальцификации в узелке диаметром 30 мм или меньше фактически является диагностическим признаком гранулемы. Иногда гистоплазмома имеет косматый или неровный край [54]. ...
The purpose of this article is to review the origins of the classic teaching on pulmonary tuberculosis, its evolution in the modern literature, and the evidence that led to its demise.
Use of molecular epidemiologic techniques that entail DNA finger-printing has led to the discovery that the radiographic appearance of pulmonary tuberculosis does not depend on the time since infection. It has been confirmed that the upper lobe cavitary disease typical in adults is the disease of the immunocompetent host, whereas lower lung zone disease, adenopathy, and effusions, which are uncommon in adults, are the hallmarks of tuberculosis in an immunocompromised host.
We present a case of pulmonary nocardiosis in an immunocompetent patient with bronchiectasis in the middle lobe and lingula. The radiologic findings were pulmonary nodules, areas of consolidation, and multiple bronchiolar impactions. The patient died and the definitive diagnosis was confirmed at autopsy. Nocardiosis should be taken into account in patients with exacerbation of bronchiectasis.
Objective:
The purpose of this article is to describe CT findings of miscellaneous pulmonary conditions that mimic lung cancers, especially primary cancers, to improve diagnosis of pulmonary lesions. Brief descriptions of patient clinical information and pathologic findings will be included and correlated with imaging findings in actual cases.
Conclusion:
A wide variety of pulmonary conditions present imaging features that mimic those of primary lung cancers and are difficult to differentiate from cancer. Awareness of these conditions with an understanding of their pathologic background and careful attention to the clinical information will help achieve correct diagnoses.
Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest x-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when >or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained.
(c) 2010 Elsevier España, S.L. All rights reserved.
We report four cases of pulmonary myco-bacterial disease (three due to Mycobac-terium malmoense and one to Myco-bacterium avium intracellulare) complicated by the development of chronic necrotising pulmonary aspergillosis. Difficulties with treatment and the potential benefits of steroids are discussed.
Pseudomonas aeruginosa was first obtained in pure culture by Gessard in 1882 from cutaneous wounds which had a blue green discolouration1 and is the major human pathogen from a large genus of strictly aerobic Gram-negative rods which are widely distributed in nature.2 The majority of P aeruginosa strains produce at least two pigments, a fluorescent yellow pigment and a blue pigment called pyocyanin, which together give the characteristic colour noted above when the bacterium is grown on agar.3 P aeruginosa is motile by means of a single flagellum and thrives in moist environments; it is extremely versatile biochemically and can grow in many habitats including soil, surface waters, plants and various foods such as vegetables eaten by man.2 4 In hospitals P aeruginosa can be found in sinks, respirators, humidifiers, etc, and is occasionally found on the hands of medical personnel.2
P aeruginosa is an opportunistic pathogen which only causes disease in patients with impaired host defences. The patient’s defences may be generally weakened by debility or cancer, or there may be specific humeral or cellular defects. Neutropenic patients are especially susceptible to pseudomonas infection and to subsequent septicaemia. Alternatively, the body’s defences may be specifically breached as in corneal ulceration or skin burns, or artificially overcome as with assisted ventilation or by an indwelling urinary catheter.4 Patients with bronchiectasis are particularly prone to chronic infection, and delayed mucociliary clearance may be responsible.5 6 The use of broad spectrum antibiotics may kill commensal flora or more antibiotic-sensitive pathogenic species causing infection, and promote colonisation by the intrinsically resistant pseudomonas.7 P aeruginosa is particularly associated with progressive and ultimately fatal chronic respiratory infection in cystic fibrosis. Clues about the biological basis of this host-bacterial interaction which occurs almost inevitably are just being discovered. …
The greatest difficulty in the CT diagnosis of perforated pulmonary hydatid cyst (PPHC) is the increase in the attenuation numbers following infection. Because of the solid density of infected hydatid cysts, the differentiation from an abscess or neoplasm is usually impossible. The aim of this study was to evaluate the value of "air bubble" as a new CT sign in the diagnosis of PPHC. Sixty-five patients (28 men and 37 women) with PPHC were included in the study. As a control group, 55 patients who had malignant (n = 36) or non-malignant (n = 19) pulmonary diseases were also examined. Radiological diagnosis with classical CT findings was made in only 38 of 65 patients (58.5 %) with PPHC. Air bubble sign was positive in 54 of the patients with PPHC (sensitivity 83.1 %) but only 3 of 55 patients in control group (specificity 94.5 %). When we analyzed the CT scans with classical CT findings including air bubble, the diagnosis of PPHC was made in 61 of patients (93.8 %). It is concluded that "air bubble sign" is a valuable CT finding in the diagnosis of PPHC.
Our aim was to evaluate the effect of human immunodeficiency virus (HIV) disease stage on chest radiographic (CXR) findings
among patients with HIV-related pulmonary tuberculosis (TB). Data are from a prospective multicenter treatment trial for HIV-related
TB. Baseline CXR findings and CD4+ lymphocyte counts were compared among patients with HIV-related TB. Data from published studies describing CXR findings in
HIV-infected patients were reviewed and a pooleddata analysis was conducted. Of 135 patients with culture-confirmed HIV-related
TB, 128 had both CXR and CD4+ lymphocyte data. CD4+ lymphocyte counts of <200/mm3 (n = 98) were significantly associated with hilar/mediastinal adenopathy on CXR (30%, vs. 7% with counts ⩾200/mm3; P = .01); counts of ⩾200/mm3 (n = 30) more frequently were associated with cavitation (20% vs. 7%; P = .08). Analyses of these results, pooled with other published data, confirmed these findings. This study demonstrates associations
of certain CXR findings with HIV disease stage. Knowledge of the degree of immunosuppression is important when evaluating
CXR findings in HIV-infected patients.
Obligate anaerobes are the predominant constituents of normal oropharyngeal flora and produce pleuropulmonary infection in patients who are prone to aspirate. Obtaining material from these patients for culture from the site of infection that is uncontaminated by normal flora is problematic. In-vitro cultivation of obligate anaerobes requires rigorous anaerobic techniques and susceptibility testing of obligate anaerobes is not standardized in many clinical microbiology laboratories. Few clinical trials of drugs have been done in patients with laboratory documented or putative anaerobic pulmonary infection. For these reasons the diagnosis and therapy of anaerobic pulmonary infection are frequently empirical and guided by published studies of in-vitro activity against collected clinical isolates. Several new drugs that have in-vitro activity against obligate anaerobes have recently become available for empirical treatment of pneumonia. Curr Opin Infect Dis 14:187-191. (C) 2001 Lippincott Williams & Wilkins.
Four hundred and fifty-three adults in 25 British hospitals entered a prospective study of community-acquired pneumonia. A microbiologica] diagnosis was established in 67 per cent; Streptococcus pneumoniae (34 per cent). Mycoplasma pneumoniae (18 per cent) and Influenza A virus (7 per cent) were the commonest microorganisms. Our observations support the view that most of those in the microbiologically negative group (33 per cent) had 5. pneumoniae infection. In addition to cultures of blood and sputum the most useful initial tests were for sputum pneumococcal antigen and serum mycoplasma specific IgM. Twenty-six patients (5.7 per cent) died, seven within 48 h of admission. Multivariate analyses showed age, absence of chest pain, absence of vomiting, previous treatment with digoxin, tachypnoea, diastolic hypotension, confusion, leucopenia, leucocytosis, and raised blood urea levels were significantly correlated with death. Patients had a 21-fold increased risk of death if they had two of the following: admission respiratory rate ≥ 30/min, admission diastolic BP≤60 mmHg, urea>7 mmol/1 during admission. Mortality was not related to aetiology except that all three patients with combined Influenza A virus and Staphylococcus aureus infection died. Nine patients had legionella pneumonia; none died. No patients who died from pneumococcal pneumonia, mycoplasma pneumonia or staphylococcal pneumonia had received an appropriate antibiotic before admission. Such deaths are possibly preventable. Assisted ventilation was used in 22 patients of whom 14 survived. Hospital stay in survivors averaged 10.8 days; after six weeks 79 per cent were fit for normal activities, and 55 per cent showed resolution of radiographic signs of pneumonia. We recommend that antibiotics should be given as early as possible and chosen always to cover 5. pneumoniae, and in addition M. pneumoniae during outbreaks, and S. aureus during influenza epidemics.
The authors present five cases of untreated progressive multinodular pulmonary histoplasmosis followed from four to nine years. The disease represents a distinct clinical and radiological entity and should be added to the spectrum and classification of histoplasmosis. Recognition of similar cases in the future will permit avoidance of needless risks of surgery or administration of amphotericin B.
Acute Q fever is the generic name for febrile diseases such as pneumonia and bronchitis mainly occurring after transtracheal infection of Coxiella burnetii, an obligate intracellular parasite of Coxiella belonging to the Rickettsia family, in a broad sense, and difficult to differentiate from other respiratory infections by clinical features alone. In addition to respiratory ailments, diseases including hepatitis and fever of unknown origin are also observed. In many cases, acute Q fever is transient and febrile, showing influenza-like symptoms such as fever, malaise, and arthralgia mainly in summer, and is self-limiting with a good prognosis. Because it may lead to chronic Q fever and a poor prognosis in the form of endocarditis, it is desirable to progressively treat patients upon strong suspicion or definite diagnosis of the disease. Definite diagnosis is currently based on a significant increase in serum antibody titer, but many cases take a long time to achieve a sufficient increase in antibody titer, so it must be determined several times. The results of PCR using respiratory tract specimens in the acute phase are also very useful for diagnosis, but development of a rapid, highly sensitive, simple diagnostic method is much desired. In treatment, β-lactam antibiotics with low cell penetration are ineffective and tetracyclines is the drug of first-choice. Macrolides, new-quinolones, and rifampicin are also effective, but treatment must be continued one or two weeks after fever subsides in a few days after treatment is started.
Eighteen well-documented cases of pulmonary gangrene as a complication of bacterial pulmonary infections have been reported in the literature. These infections were due to Klebsiellapneumoniae, Streptococcus pneumoniae, and Hemophilus influenzae. We describe four patients with pulmonary tuberculosis who developed pulmonary gangrene. Vascular thrombosis and arteritis were found in three of these four patients, and this vascular complication seems to be necessary for the development of pulmonary gangrene.
Measles occurred in 3,220 Air Force recruits between January 1976 and July 1979 and was complicated by pneumonia in 106 cases (3.3 percent). Although no deaths occurred, the illness was characterized as clinically severe with high fever and prolonged hospitalization (mean, 14.5 days). Bacterial superinfection as documented by transtracheal aspiration occurred in 35 cases (30.3 percent) and was caused by Hemophilus influenzae (18), Hemophilus parainfluenzae (two), Neisseria meningitidis (nine), Streptococcus pneumoniae (three), Streptococcus pyogenes (two) and Moraxella kingae (one). Clinical evidence of bronchospasm was present in 18 patients (17 percent) and required bronchodilators in six. Other complications included liver function abnormalities (31 percent), otitis media (29 percent) and sinusitis (25 percent). Measles pneumonia in adolescents is clinically severe with a generally benign outcome.
Spontaneous lysis of an aspergilloma occurred in four patients out of a consecutive series of 41 aspergillomata in 37 patients. The occurrence of spontaneous lysis in approximately 10 percent of aspergillomata is significant and should be considered when evaluating claims of effective medical treatment.
BACKGROUND—A national survey of tuberculosis was conducted in England and Wales in 1998 to obtain detailed information on the occurrence of the disease and recent trends. This survey also piloted the methodology for enhanced tuberculosis surveillance in England and Wales and investigated the prevalence of HIV infection in adults with tuberculosis.
METHODS—Clinical and demographic data for all cases diagnosed during 1998 were obtained, together with microbiological data where available. Annual incidence rates in the population were estimated by age, sex, ethnic group, and geographical region using denominators from the 1998 Labour Force Survey. Incidence rates in different subgroups of the population were compared with the rates observed in previous surveys. The tuberculosis survey database for 1998was matched against the Communicable Disease Surveillance Centre HIV/AIDS database to estimate the prevalence of HIV co-infection in adult patients with tuberculosis.
RESULTS—A total of 5658 patients with tuberculosis were included in the survey in England and Wales (94% of all formally notified cases during the same period), giving an annual rate of 10.93per 100 000 population (95% CI 10.87 to 10.99). This represented an increase of 11% in the number of cases since the survey in 1993 and 21% since 1988. In many regions case numbers have remained little changed since 1988, but in London an increase of 71% was observed. The number of children with tuberculosis has decreased by 10% since 1993. Annual rates of tuberculosis per 100 000 population have continued to decline among the white population (4.38) and those from the Indian subcontinent, although the rate for the latter has remained high at 121 per 100 000. Annual rates per 100 000 have increased in all other ethnic groups, especially among those of black African (210) and Chinese (77.3) origin. Over 50% of all patients were born outside the UK. Recent entrants to the UK had higher rates of the disease than those who had been in the country for more than 5 years or who had been born in the UK. An estimated 3.3% of all adults with tuberculosis were co-infected with HIV.
CONCLUSIONS—The epidemiology of tuberculosis continues to change in England and Wales and the annual number of cases is rising. More than one third of cases now occur in young adults and rates are particularly high in those recently arrived from high prevalence areas of the world. The geographical distribution is uneven with urban centres having the highest rates. The increase in the number of cases in London is particularly large. Tuberculosis in patients co-infected with HIV makes a small but important contribution to the overall increase, particularly in London. To be most effective and to make the most efficient use of resources, tuberculosis prevention and control measures must be based on accurate and timely information on the occurrence of disease. A new system of continuous enhanced tuberculosis surveillance was introduced in 1999, based on the methodology developed in this national survey.
Pneumococcal parapneumonic effusions are thought to be uncommon. Considering the frequency off pleuritic pain and the proposed pathogenesis off pneumococcal pneumonia, a higher incidence was suspected. Thirty-five consecutive patients with pneumonia due to Streptococcus pneumoniae were studied prospectively utilizing frequent chest x-ray films, including lateral decubitus views. Twenty (57 percent) of the 35 patients had parapneumonic effusions. The presence of parapneumonic effusions correlated significantly with the duration of symptoms before admission, bacteremia, and prolonged fever after therapy (P
A rare example of an intralobar sequestration (ILS) containing a fungal mycetoma is reported. This finding indicates the presence of a communication between the ILS and the airways, thus supporting the theory that ILSs are acquired lesions, rather than congenital malformations.
Study objectives
Patients with HIV-1 infection or AIDS may present with abnormal chest radiograph (CXR) findings in the absence of symptoms specific to the lung. The objective was to determine the spectrum of disease and the diagnostic modalities employed in these patients.
Methods
From 1996 to 1998, we identified patients with HIV-1 infection presenting to the Bellevue Hospital Chest Service with abnormal CXR findings, and absence of specific pulmonary symptoms. Charts were reviewed for presence of constitutional symptoms, CD4 lymphocyte count, use of Pneumocystis carinii pneumonia (PCP) prophylaxis, eventual diagnosis, and all diagnostic modalities employed. CXR findings were classified according to their predominant abnormalities: nodules, infiltrates, cavity, mass, adenopathy, or effusion.
Results
Forty-four patients were eligible for inclusion. Eight-six percent of patients had a CD4 lymphocyte count < 200 cells/μL, and 57% were receiving PCP prophylaxis. Nodular disease was the most common radiographic abnormality (57%), followed by adenopathy (17%). A definitive diagnosis was obtained in 86% of the patients. The most common diagnosis was tuberculosis (26%), followed by nontuberculous mycobacteria (NTM; 23%) and Kaposi sarcoma (12%). No patients had PCP or bacterial pneumonia. Sixty-two percent of patients required an invasive modality to establish a diagnosis. Only 18% of patients with tuberculosis (2 of 11 patients) received diagnoses by sputum analysis.
Conclusions
Patients with HIV-1 infection, abnormal CXR findings, and lack of pulmonary symptoms have a high incidence of infectious disorders, especially pulmonary tuberculosis and infection due to NTM. The high prevalence of treatable and potentially communicable disorders warrants an aggressive diagnostic approach in these patients.
The endemic mycoses are restricted geographically based on environmental and other factors that favor the growth of these organisms in the soil. Histoplasmosis and blastomycosis mostly afflict patients in the Mississippi and Ohio River Valleys whereas coccidioidomycosis occurs primarily in the dessert south-west United States. Cryptococcosis also may present as pulmonary disease, particularly in persons with cellular immune impairment. These mycoses are increasing in importance as causes for opportunistic disease in immunocompromised patients, especially those with acquired immune deficiency syndrome (AIDS). Aspergillus is a common cause of serious invasive fungal infection in granulocytopenic patients, and may cause lung infection in persons with pre-existing pulmonary diseases or atopy. Infections with less virulent fungi, such as Trichosporon, Fusarium, Alternaria, Pseudallescheria, and dematiaceous fungi, are being recognized more frequently. The lung is the portal of entry for most of these pathogens, and often is prominently involved in the clinical syndrome. This article focuses on the recognition, diagnosis, and management of these important pulmonary mycoses.
Melioidosis is a disease caused by a motile, pleomorphic, Gram-negative bacillus, Pseudomonas pseudomallei. The clinical manifestations were first described in 1912 by Whitmore and Krishnaswami (17). Clinically as well as bacteriologically related to glanders, melioidosis is characterized by a fulminating septicemia with extreme prostration and a high mortality rate. Over 300 cases of this disease have been reported, 2 in persons who had never been outside the United States (2, 11). The 7 pathologically proved cases in this series were in United States servicemen in South Vietnam. The clinical manifestations, pathologic findings, and radiologic correlation will be considered in an attempt to establish an approach for early diagnosis. All the 7 cases in our experience occurred in individuals who were in excellent health prior to their illness. They had been engaged in widely varied activities; therefore, from an initial epidemiologic search, the only common factor is general location. Six of the 7 patients...
In order to describe the clinical features and the epidemiologic findings of 1,383 patients hospitalized in France for acute or chronic Q fever, we conducted a retrospective analysis based on 74,702 sera tested in our diagnostic center, National Reference Center and World Health Organization Collaborative Center for Rickettsial Diseases. The physicians in charge of all patients with evidence of acute Q fever (seroconversion and/or presence of IgM) or chronic Q fever (prolonged disease and/or IgG antibody titer to phase I of Coxiella burnetii > or = 800) were asked to complete a questionnaire, which was computerized. A total of 1,070 cases of acute Q fever was recorded. Males were more frequently diagnosed, and most cases were identified in the spring. Cases were observed more frequently in patients between the ages of 30 and 69 years. We classified patients according to the different clinical forms of acute Q fever, hepatitis (40%), pneumonia and hepatitis (20%), pneumonia (17%), isolated fever (17%), meningoencephalitis (1%), myocarditis (1%), pericarditis (1%), and meningitis (0.7%). We showed for the first time, to our knowledge, that different clinical forms of acute Q fever are associated with significantly different patient status. Hepatitis occurred in younger patients, pneumonia in older and more immunocompromised patients, and isolated fever was more common in female patients. Risk factors were not specifically associated with a clinical form except meningoencephalitis and contact with animals. The prognosis was usually good except for those with myocarditis or meningoencephalitis as 13 patients died who were significantly older than others. For chronic Q fever, antibody titers to C. burnetii phase I above 800 and IgA above 50 were predictive in 94% of cases. Among 313 patients with chronic Q fever, 259 had endocarditis, mainly patients with previous valvulopathy; 25 had an infection of vascular aneurysm or prosthesis. Patients with endocarditis or vascular infection were more frequently immunocompromised and older than those with acute Q fever. Fifteen women were infected during pregnancy; they were significantly more exposed to animals and gave birth to only 5 babies, only 2 with a normal birth weight. More rare manifestations observed were chronic hepatitis (8 cases), osteoarticular infection (7 cases), and chronic pericarditis (3 cases). Nineteen patients were observed who experienced first a documented acute infection, then, due to underlying conditions, a chronic infection. To our knowledge, we report the largest series of Q fever to date. Our results indicate that Q fever is a protean disease, grossly underestimated, with some of the clinical manifestations being only recently reported, such as Q fever during pregnancy, chronic vascular infection, osteomyelitis, pericarditis, and myocarditis. Our data confirm that chronic Q fever is mainly determined by host factors and demonstrate for the first time that host factors may also play a role in the clinical expression of acute Q fever.
Respiratory syncytial virus disease was documented in 11 immunocompromised adults, aged 21 to 50. Underlying conditions included bone marrow transplant (6 patients), renal transplant (3 patients), renal and pancreas transplants (1 patient), and T-cell lymphoma (1 patient). Diagnosis of infection was based on specimens from bronchoalveolar lavage, sputum, throat, sinus aspirate, and lung biopsy. The virus was detected simultaneously by antibody in either an immunofluorescence or enzyme-linked immunosorbent assay in 3 of 4 patients whose culture results were positive for respiratory syncytial virus. The virus was an unexpected finding, despite widespread infection in the community. Clinical symptoms included low-grade fever, nonproductive cough, rhinorrhea or nasal congestion, and radiographic evidence of interstitial infiltrates and sinusitis. Aerosolized ribavirin therapy was used in the 6 recipients of bone marrow transplants, 3 of whom required assisted ventilation but died. Death caused by virus infection was documented in 4 of 11 patients. Respiratory syncytial virus disease must be considered in the differential diagnosis of fever and pulmonary infiltrates in immunocompromised adults.
Coccidioidomycosis is a regionally common fungal infection, primarily affecting the lung. While in the majority of cases the tempo of the disease allows for a more leisurely diagnostic plan, including multiple serologic tests and culture of respiratory secretions, occasionally, patients will present with rapidly progressive, life-threatening pulmonary illness, in whom there is an urgent need for rapid diagnosis. Evaluation of respiratory secretions including expectorated sputum as well as bronchial washings are frequently available or obtained for diagnosing pulmonary infiltrates. We compared the sensitivity of the Papanicolaou stain with 10% potassium hydroxide digestion (10% KOH) and with calcofluor white (cw). The Papanicolaou test performed the best and should be used in the evaluation of suspected patients with coccidioidomycosis.
Objective
To assess the utility of CT in the evaluation of pulmonary tuberculosis in patients without AIDS.
Patients and methods
Thin-section CT scans for suspicion of pulmonary tuberculosis were obtained from 226 patients. A total of 38 patients were excluded; the reasons were unavailability of final results (n=18), patient unavailability for follow-up (n=13), and coexistence of tuberculosis and aspergilloma (n=7). The results from 188 patients were used for this study. After assessing the patterns of parenchymal lesion, involved segments, and presence of cavity, bronchiectasis, and bronchogenic spread of the lesion with CT, tentative diagnosis and disease activity were recorded.
Results
With CT, 133 of 146 patients (91%) with tuberculosis were correctly diagnosed as having pulmonary tuberculosis whereas 32 of 42 patients (76%) without tuberculosis were correctly excluded. CT diagnosis of lung cancer (n=8), bacterial pneumonia (n=2), pulmonary metastasis (n=1), chronic hypersensitivity pneumonia (n=l), and diffuse panbronchiolitis (n=l) turned out to be tuberculosis. Conversely CT diagnoses of tuberculosis appeared pathologically as lung cancer (n=5), bacterial pneumonia (n=4), and pulmonary paragonimiasis (n=l). Active (71/89, 80%) and inactive state (51/57, 89%) of disease respectively could be correctly differentiated by CT.
Conclusion
CT can be helpful in the diagnosis of pulmonary tuberculosis in most cases. On the basis of CT findings, distinction of active from inactive disease can be made in most cases.
A previously healthy young asthmatic patient developed fatal disseminated aspergillosis where the only identifiable risk factor was a short course of corticosteroid therapy. Physicians are cautioned to be alert for evidence of invasive fungus infection in asthmatic patients receiving corticosteroid therapy.
Hospital-acquired pneumonia was studied prospectively for 3½ years in a 549-bed facility with acute medical-surgical care wards, convalescent wards, and a chronic care unit. Bacteriological studies were limited to transtracheal aspirates, pleural fluid, and blood cultures. The predominant isolates in 159 patients were gram-negative bacilli (47%), anaerobic bacteria (35%), Staphylococcus aureus (31%), and Streptococcus pneumoniae (26%). Nearly half of all specimens yielded a polymicrobial flora with more than one potential pathogen. Distribution of pathogens was similar with analysis of all patients, including patients with a monomicrobial infection and patients with bacteremic pneumonia. The prevalence of cases and distribution of bacteria were similar for patients located on acute medical-surgical wards and those in the nursing home care unit. Nosocomial pneumonia was judged directly responsible for lethal outcome in 19% of patients and a contributing factor to death in another 13%.
(Arch Intern Med 1986;146:868-871)
PULMONARY nocardiosis presents with a highly variable clinical and roentgenographic picture that can often mimic granulomatous disease or neoplasm.1-4 A review of the literature describes only one previous report of pulmonary nocardial infection with an associated endobronchial mass.5 We report the second case, to our knowledge, of this unusual manifestation of pulmonary nocardiosis.Report of a Case
A 56-year-old man saw his local physician on Aug 28, 1984, for malaise, cough productive of small amounts of sputum, and occasional night sweats of several days' duration. He denied fever, chills, recent weight loss, chest pain, hemoptysis, joint pains, headache, or skin lesions. Several days prior to the onset of his symptoms, he experienced significant dust exposure while raking his yard. There was no prior history of pulmonary illness. The patient had lived in Arizona for six years in an area endemic for coccidioidomycosis. He had a 20 pack-year history
Psittacosis may present with a wide variety of clinical manifestations. This fact has received attention in the literature1-4 but, in our experience, is not generally appreciated by either house officers or practicing physicians. Unless a high level of suspicion is maintained, those cases occurring in other than epidemic situations may be missed.Recent experience with several patients prompted a review of the cases of psittacosis seen at the Vanderbilt University Hospital during the past decade. This review reinforced the impression that the sporadic form of psittacosis is diverse in its presentation and is often overlooked as a diagnostic possibility. This paper summarizes our experience with endemic psittacosis and emphasizes its clinical variability, the frequency with which it mimics bacterial pneumonia, and its occasional failure to respond promptly to tetracycline therapy.Summary of Cases
Nine cases have been observed at the Vanderbilt University Hospital since 1955, when facilities for the
A case of pericardial actinomycosis mimicking a pericardial tumour is reported. After the appearance of non-specific subpleural pulmonary nodules, a 48 year old woman presented with fever and clinical signs of pericardial tamponade. Subxiphoid pericardiotomy yielded a culture negative fluid and inflammatory reactive histopathology in the pericardial biopsy specimen. Because of suspected infection cefamandole was administered for 10 days and the patient became afebrile. The pericardial effusion recurred with no clinical signs two weeks later. Steroid medication resulted in rapid regression of the pericardial effusion. Subsequent echocardiography controls showed a tumour-like pericardial mass, confirmed by cardiac magnetic imaging. Surgical exploration led to the final histological diagnosis of actinomycosis. After high dose and long term penicillin G treatment the patient recovered fully with no recurrence during two years’ follow up.
Chest radiographs of 4 patients with Dirofilaria immitis (dog heartworm) revealed solitary, small, peripheral, noncalcified nodular lesions. The pulmonary lesions were apparently produced secondary to lodging of the parasite in peripheral pulmonary vessels. None of the patients had symptoms referable to the heartworm lesions. Needle aspiration in 2 patients revealed a nonspecific inflammatory lesion.
The relatively high incidence of Eaton agent infection in military personnel and their dependents is probably the most striking revelation of this study.
Review of the roentgenograms of 34 young adults and 4 children with Eaton agent pneumonia revealed no characteristic diagnostic features. The pulmonary
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infiltrate is bronchopneumonic in type and clears without residual pleural or parenchymal scarring. Hilar lymphadenopathy is not too common and pleural effusion is so rare as to suggest a different diagnosis.
Response to broad spectrum antibiotics was satisfactory and there were no complications. No biopsy or autopsy material was available for study.
OBJECTIVE. The purpose of this study is to assess the radiographic, thin-section CT, and histologic findings of semiinvasive aspergillosis in patients with chronic obstructive pulmonary disease (COPD).
MATERIALS AND METHODS. The study included nine patients with COPD seen at the Hospital de Sant Pau during a 3-year period who had histopathologically proven aspergillosis with tissue invasion. Chest radiography and thin-section (2-mm collimation) CT of the chest were available in all cases.
RESULTS. Nine patients had semiinvasive aspergillosis proven at autopsy (n = 7) or by thoracoscopically guided lung biopsy (n = 2). The radiologic findings consisted of parenchymal consolidation (n = 6) and nodules larger than 1 cm in diameter (n = 3). Parenchymal consolidation involved the upper lobes in five patients and was bilateral in four. Cavitation was present in two of the patients with consolidation and in two of the patients with nodular opacities. Adjacent pleural thickening was revealed by CT in four patients. Histologically, the areas of consolidation represented active inflammation and intraalveolar hemorrhage containing Aspergillus organisms. In the three patients with multiple cavitated nodules, a variable degree of central necrosis was observed. The inflammatory infiltrate extended into the surrounding lung parenchyma, and adjacent areas of hemorrhage were also seen. Aspergillus colonies were identified within the lung tissue.
CONCLUSION. Upper lobe consolidation or multiple nodules in patients with COPD should raise the possibility of semiinvasive aspergillosis.
(CHEST 2004; 125:2322–2327) A 50-year-old heterosexual man presented to the emergency department for evaluation of a diffuse rash that started 10 weeks prior to hospital admission. He reported that the lesions began as small (0.3 cm), pink papules on his upper extremities, which progressed into large (3 cm), red, annular, plaque-like lesions that developed a thin scale within several days of onset. Subsequently, the lesions spread to his scalp, face, trunk, genitals, and lower extremities. He reported subjective fevers, chills, occasional drenching night sweats, and a 10-lb weight loss. Simultaneous with the onset of the skin lesions, he had an intermittent nonproductive cough, without dyspnea. Six weeks prior to presentation, he described the onset of sinus congestion with occasional epistaxis and left eye conjunctivitis, at which time he received a course of antibiotics. He denied any significant medical history. He also denied tobacco use, animal exposures, or recent travel. He worked as a cartographer in Colorado. On physical examination, he had a temperature of 38.1°C and a normal room air oximetry result. The left conjunctiva was injected with an erythematous plaque around the lateral canthus. The nasal mucosa had an area of septal ulceration. There were a number of anterior cervical, posterior cervical, and inguinal lymph nodes that were nontender and 1 cm. He had inspiratory crackles at the right base. Skin examination revealed multiple 0.2- to 0.3-cm nontender, pink papules on the lower extremities
The Legionella bacillus is a relatively common pulmonary pathogen that has been responsible for a number of outbreaks of respiratory illness this century. Not until 1976, however, after exciting epidemiologic and microbiologie investigation, was the organism isolated and identified. Legionnaires' disease does not have a characteristic radiographie appearance, but certain features may alert the clinician to its presence. It often rapidly progresses to a lobar pneumonia that may not respond immediately to treatment. The radiographie findings lag behind clinical improvement, and radiographic resolution is prolonged. Organ transplantation patients often present with ill-defined, rounded, pleura-based opacities that may simulate pulmonary infarction and can cavitate.
Dirofilariasis is an infestation found primarily among canine species in the United States. Humans are imperfect hosts, and in them the worm dies, is embolized to the pulmonary vasculature, and presents as a solitary lung nodule. With routine radiographic techniques, this lesion cannot be differentiated from any other lung nodule or coin lesion. However, computerized tomography (CT) demonstrates its subpleural location, presence or absence of calcification, and further narrows the differential diagnosis, among which one should consider circumscribed pleural mesothelioma, loculated pleural effusion, pleural metastasis, and tumors of bone and soft tissue of the chest wall. This is the first report of CT evaluation of Dirofilaria immitis granuloma of the lung.
Purpose: The purpose of this work was to describe CT findings of the parietal pleura and extrapleural space in patients with chronic tuberculous empyema and to compare them with histopathologic findings following decortication.
Method: Chest CT scans obtained from 13 patients with chronic tuberculous empyema who underwent decortication were retrospectively reviewed. All patients were men from 18 to 67 years old (mean 42 years old). CT findings of the parietal pleura and extrapleural space were correlated with histopathologic findings in all patients.
Results: Histopathologically, the enhanced parietal pleural peel on CT was fibrous collagenous tissue, and a low attenuated layer with 2 mm thickness within the parietal pleural peel (n = 2) was either a layer of histiocytes or caseation necrosis. The extrapleural space seen as an intermediate attenuation in six patients on CT was the proliferation of vessels, inflammatory cells, and granulomas in loose collagen background. The linear soft tissue attenuation interrupting the extrapleural fat (n = 5) on CT was a collagenous fibrous layer with proliferation of vessels and inflammatory cells.
Conclusion: A layer of low attenuation in the parietal pleural peel may be due to different episodes of infection. The extrapleural space with intermediate attenuation may indicate ongoing inflammation. Linear soft tissue attenuation interrupting the extrapleural fat represents a fibrous layer rather than the subcostalis muscle.
Streptococcus pneumoniae is the most frequent pathogen of severe community-acquired pneumonia (CAP) necessitating hospitalization. The main objective of this multicentre prospective study was to determine the value of clinical, biological, and radiological features for predicting pneumococcal etiology and to define prognostic factors. Streptococcus pneumoniae was isolated in 43/132 patients (33%) with CAP requiring ICU treatment. The mean age of the patients with pneumococcal pneumonia was 55 ± 17 (SD) yrs and 34 were male. On admission, 14 patients with pneumococcal pneumonia were in shock, 24 were mentally confused, and 27 required mechanical ventilation during their hospitalization. Among the clinical, biological, and radiological features, fever >39°C, pleuritic chest pain, lobar distribution or alveolar consolidation, and an increase in immature granulocytes ≥5% of WBC were more frequent in pneumococcal pneumonia than in other etiologies. Mortality was 35%. Fatal outcome was significantly related to the presence of impaired alertness, septic shock, mechanical ventilation, acute renal failure, and bacteremic pneumonia.
Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.
Pulmonary cryptococcosis is a very rare form of pneumonia, which is seldom seen among immunocompetent patients. We report the case of a 36-year-old man who presented with indolent pneumonia that was subsequently diagnosed to be pulmonary cryptococcosis without other systemic involvement. Contrary to formal belief, there was evidence of residual lung fibrosis 12 months after initial presentation. The features of pulmonary cryptococcosis reported in the Asian Pacific region are also reviewed.
In 352 children with acute lower respiratory infections, R. S. virus was present in 126, 94 (75%) under six months of age. Consolidation was found in approximately 25% of children with R. S. virus infection and in 70% of those with an initial clinical diagnosis of pneumonia, but if it was the only abnormality or if the shadow was larger than subsegmental there was a significant negative correlation with R. S. virus isolation. Collapse was uncommon and unrelated to R. S. virus. Peribronchial thickening was found in 39% of the children, more often in bronchiolitis or bronchitis than in pneumonia, and was unrelated to R. S. virus isolation or to age. — Air trapping, particularly as the sole abnormality showed a significant association with R. S. virus. It was found more frequently in children with bronchiolitis than in the other clinical categories, and in children under six months old.