Ahmed Fahim

Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis: A Review

The histological counterpart of idiopathic pulmonary fibrosis is usual interstitial pneumonia, in which areas of fibrosis of various ages are interspersed with normal lung. This pattern could be explained by repeated episodes of lung injury followed by abnormal wound healing responses. The cause of the initiating alveolar epithelial injury is unknown, but postulated mechanisms include immunological, microbial, or chemical injury, including aspirated gastric refluxate. Reflux is promoted by low basal pressure in the lower oesophageal sphincter and frequent relaxations, potentiated by hiatus hernia or oesophageal dysmotility. In susceptible individuals, repeated microaspiration of gastric refluxate may contribute to the pathogenesis of IPF. Microaspiration of nonacid or gaseous refluxate is poorly detected by current tests for gastroesophageal reflux which were developed for investigating oesophageal symptoms. Further studies using pharyngeal pH probes, high-resolution impedance manometry, and measurement of pepsin in the lung should clarify the impact of reflux and microaspiration in the pathogenesis of IPF.

Serum carcinoembryonic antigen correlates with severity of idiopathic pulmonary fibrosis

Background and objective:  Idiopathic pulmonary fibrosis (IPF) is the commonest idiopathic interstitial pneumonia and carries a poor prognosis. Epidemiological evidence suggests that patients with IPF have an increased risk of developing lung cancer. Carcinoembryonic antigen (CEA) has a close association with epithelial malignancy. The aim of this study was to evaluate serum CEA concentrations in patients with IPF and to perform correlation with pulmonary function.

Comparison of the effect of high-dose inhaled budesonide and fluticasone on adrenal function in patients with severe chronic obstructive pulmonary disease

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a leading cause of respiratory-related morbidity and mortality. Inhaled steroids are frequently used in patients with moderate to severe disease and may lead to adrenal suppression. OBJECTIVES: The aim of this study was to compare the effect of inhaled budesonide/formoterol with inhaled fluticasone/salmeterol in severe COPD. METHODS: It was a prospective open-label crossover study of 22 patients. Adrenal suppression was measured by overnight urinary cortisol/creatinine ratio. The measurements were taken while patients were on either combination for at least 4 weeks. RESULTS: A total of 12 patients completed the study. The mean age was 64 years (8 males, 4 females). The mean FEV1 was 1 L (range, 0.5-1.8). There was no significant difference in adrenal suppression measured by overnight urinary cortisol/creatinine ratio (budesonide 5.2 ± 4.3, fluticasone 4.7 ± 3.1; 95% CI -2.2 to 1.2; P = 0.52) and urinary cortisol concentration (budesonide 51 ± 53, fluticasone 43 ± 31 [nmol/l]; 95% CI -35 to 20; P = 0.56). CONCLUSION: Inhaled budesonide and fluticasone have no significantly different effect on adrenal function in moderate to severe COPD. The adverse event profile of high-dose inhaled steroids should not influence the choice of medication.

Increased Platelet Reactivity in Idiopathic Pulmonary Fibrosis Is Mediated by a Plasma Factor

Introduction Idiopathic Pulmonary Fibrosis (IPF) is a progressive, incurable fibrotic interstitial lung disease with a prognosis worse than many cancers. Its pathogenesis is poorly understood. Activated platelets can release pro-fibrotic mediators that have the potential to contribute to lung fibrosis. We determine platelet reactivity in subjects with IPF compared to age-matched controls. Methods Whole blood flow cytometry was used to measure platelet-monocyte aggregate formation, platelet P-selectin expression and platelet fibrinogen binding at basal levels and following stimulation with platelet agonists. A plasma swap approach was used to assess the effect of IPF plasma on control platelets. Results Subjects with IPF showed greater platelet reactivity than controls. Platelet P-selectin expression was significantly greater in IPF patients than controls following stimulation with 0.1 µM ADP (1.9% positive ±0.5 (mean ± SEM) versus 0.7%±0.1; p = 0.03), 1 µM ADP (9.8%±1.3 versus 3.3%±0.8; p<0.01) and 10 µM ADP (41.3%±4.2 versus 22.5%±2.6; p<0.01). Platelet fibrinogen binding was also increased, and platelet activation resulted in increased platelet-monocyte aggregate formation in IPF patients. Re-suspension of control platelets in plasma taken from subjects with IPF resulted in increased platelet activation compared to control plasma. Conclusions IPF patients exhibit increased platelet reactivity compared with controls. This hyperactivity may result from the plasma environment since control platelets exhibit increased activation when exposed to IPF plasma.

Chronic cough and obstructive sleep apnoea: reflux-associated cough hypersensitivity?

Obstructive sleep apnoea (OSA) is being increasingly recognised as a cause of chronic cough. The impact of continuous positive airway pressure (CPAP) therapy and the mechanism of this association are not well understood. We describe a patient with OSA and chronic cough who responded well to CPAP. Objective and subjective assessments of cough on treatment with CPAP, off CPAP and on follow-up as well as pharyngeal pH monitoring suggest a possible mechanism for this association. A 61-yr-old male who was a nonsmoker presented to the Hull Cough Clinic (Hull, UK) with a dry cough of 2 yrs’ duration. He did not complain of associated breathlessness or wheezing or a history of post-nasal drip. He did complain of heart burn and treatment with acid-suppressive therapy in the past lead to some improvement in his cough, though it continued to be a significant problem. Previous trials of inhaled and nasal corticosteroids did not improve his cough. He did not have any comorbidities and was not on regular medications. His body mass index was 31 kg·m−2. General physical examination and examination of the respiratory system were unremarkable. A chest radiograph and spirometry were normal. On further questioning, he had a history of snoring for many years. He also complained that his sleep quality was not good and he felt somewhat sleepy in the day time. His Epworth Sleepiness Scale score was 12. This raised the clinical suspicion of OSA. Treatment with lansoprazole was initiated and a sleep study was organised. At review, on treatment with lansoprazole, his cough was slightly better, although, …

Palliative care understanding and end-of-life decisions in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of respiratory morbidity and mortality with limited data on palliative care and evidence of reluctance to end‐of‐life discussions.

Chiari malformation and central sleep apnoea: successful therapy with adaptive pressure support servo-ventilation following surgical treatment

Sleep apnoea is a common disorder with significant morbidity. It is categorised into obstructive and central sleep apnoea. There are a variety of conditions associated with central sleep apnoea ranging from cardiac failure to structural brain anomalies. We herein report a case of 57-year-old woman with Chiari malformation associated with significant sleep-disordered breathing. There was a family history of Chiari malformation. Although neurosurgical intervention had a significant impact on apnoea hypopnoea index (AHI) with a reduction from 81/h preoperatively to 22.1/h after the surgical treatment, it failed to cure the sleep disorder breathing completely and adaptive non-invasive servo-ventilation had a dramatic effect on symptoms and normalised the AHI. Although, central sleep apnoea is associated with a number of common disorders, this case illustrates that there may be an unusual cause. Moreover, adaptive pressure support servo-ventilation may provide a promising treatment option following surgical correction of Chiari malformation.

Glomus vagale presenting as chronic cough

To the Editors: Chronic cough is one of the most common symptoms of medical importance with 12% of the population reporting significant symptoms on a daily or weekly basis. The differential diagnosis of chronic cough is extensive. Uncommon causes of chronic cough may be missed unless an adequate history is obtained, a detailed examination performed and appropriate investigations arranged. Herein, we present a case of chronic cough, the aetiology of which was previously unreported. A 57-yr-old female presented with a history of chronic cough for 12 months. The cough had features of reflux 1 as it was precipitated by food and phonation, and associated with frequent clearing of the throat. Moreover, the cough was worse when she was lying flat and started upon rising in the morning. In addition, she described her cough to be precipitated by upward movement of her neck, for example looking at the top shelf in a supermarket. There was no history of decreased appetite or weight loss. She was known to have a hiatus hernia. Her past medical history was otherwise unremarkable. She was a life long nonsmoker and was not on any regular medications. In view of clinical history being highly suggestive of reflux cough, she was started on treatment with lansoprazole in combination with ranitidine; however, she …

Heightened cough sensitivity secondary to latanoprost.

Chronic cough is a common symptom with significant morbidity. We report a case of a 51-year-old woman who presented with chronic cough. She recently had received a diagnosis of glaucoma and had started receiving therapy with topical latanoprost. The onset of cough coincided with the use of latanoprost. We performed a citric acid cough challenge while the patient was receiving latanoprost and repeated the challenge after therapy with the drug was stopped. The initial cough challenge revealed marked hypersensitivity of the cough reflex. After stopping therapy with latanoprost for 10 days, the cough sensitivity was reduced significantly. Within 3 days of recommending therapy with latanoprost, the cough sensitivity increased to the initial value. This case illustrates that the topical application of latanoprost can markedly increase cough sensitivity, which is reversible on stopping administration of the drug. Moreover, the case reflects the clinical manifestation of the effect of topical latanoprost therapy on cough reflex, which, to our knowledge, has never been reported in the medical literature.

A case of limbic encephalitis presenting as a paraneoplastic manifestation of limited stage small cell lung cancer: a case report

IntroductionThe differential diagnosis of altered mental status and behavioral change is very extensive. Paraneoplastic limbic encephalitis is a rare cause of cognitive impairment, which should be considered in the differential diagnosis.Case presentationA 64-year-old British Caucasian woman presented to our hospital with a 12-week history of confusion and short-term memory loss. She was hyponatremic with a serum sodium level of 128mmol/L. Moreover, there was evidence of left hilar prominence on the chest radiograph. A thoracic computed tomography scan showed left hilar opacity with confluent lymphadenopathy. A percutaneous biopsy confirmed a diagnosis of small cell lung cancer. There was no radiological evidence of brain metastasis on the computed tomography scan. In view of continued cognitive impairment, which was felt to be disproportionate to hyponatremia, a magnetic resonance imaging scan of the brain was undertaken. It showed hyperintense signals from both hippocampi, highly suggestive of limbic encephalitis presenting as a paraneoplastic manifestation of small cell lung cancer. She had a significant radiological and clinical response following chemotherapy and radiotherapy.ConclusionThis case highlights the importance of considering paraneoplastic syndromes in patients with neurological symptoms in the context of lung malignancy. If initial investigations fail to reveal the cause of cognitive impairment in a patient with malignancy, magnetic resonance imaging may be invaluable in the diagnosis of limbic encephalitis. The clinical presentation, diagnostic techniques and management of paraneoplastic limbic encephalitis are discussed in this case report.