Alessandro Andreani

Use in routine clinical practice of two commercial blood tests for diagnosis of infection with Mycobacterium tuberculosis: a prospective study

BACKGROUND Two commercial blood assays for the diagnosis of latent tuberculosis infection--T-SPOT.TB and QuantiFERON-TB Gold--have been separately compared with the tuberculin skin test. Our aim was to compare the efficacy of all three tests in the same population sample. METHODS We did a prospective study in 393 consecutively enrolled patients who were tested simultaneously with T-SPOT.TB and QuantiFERON-TB Gold because of suspected latent or active tuberculosis. 318 patients also had results available for a tuberculin skin test. FINDINGS Overall agreement with the skin test was similar (T-SPOT.TB kappa=0.508, QuantiFERON-TB Gold kappa=0.460), but fewer BCG-vaccinated individuals were identified as positive by the two blood assays than by the tuberculin skin test (p=0.003 for T-SPOT.TB and p<0.0001 for QuantiFERON-TB Gold). Indeterminate results were significantly more frequent with QuantiFERON-TB Gold (11%, 43 of 383) than with T-SPOT.TB (3%, 12 of 383; p<0.0001) and were associated with immunosuppressive treatments for both tests. Age younger than 5 years was significantly associated with indeterminate results with QuantiFERON-TB Gold (p=0.003), but not with T-SPOT.TB. Overall, T-SPOT.TB produced significantly more positive results (38%, n=144, vs 26%, n=100, with QuantiFERON-TB Gold; p<0.0001), and close contacts of patients with active tuberculosis were more likely to be positive with T-SPOT.TB than with QuantiFERON-TB Gold (p=0.0010). INTERPRETATION T-SPOT.TB and QuantiFERON-TB Gold have higher specificity than the tuberculin skin test. Rates of indeterminate and positive results, however, differ between the blood tests, suggesting that they might provide different results in routine clinical practice.

Bronchopulmonary Actinomycosis Associated With Hiatal Hernia

OBJECTIVES To describe clinicoradiologic and histopathologic features of bronchopulmonary actinomycosis and to determine whether hiatal hernia (HH) is a potential predisposing factor for bronchopulmonary actinomycosis. PATIENTS AND METHODS We reviewed the medical charts of 10 patients who had bronchopulmonary actinomycosis between November 1, 2002, and January 31, 2008. Complete clinical data, radiologic studies (chest radiographs and computed tomographic scans), and histopathologic features were assessed to investigate clinical manifestations and predisposing factors related to bronchopulmonary actinomycosis. RESULTS The series consisted of 6 men and 4 women, with a mean age of 63.5 years; 8 of the patients were smokers. Cough and fever were the most common symptoms. Chest imaging showed mass-like consolidation in 4 patients, bronchial thickening or lung atelectasis with pleural thickening in 2 patients each, and perihilar irregular mass or multiple bilateral nodules in 1 patient each. Primary or metastatic lung cancer was suspected clinically in 8 of the 10 patients. Foreign body-related endobronchial actinomycosis was diagnosed in 6 patients, 5 of whom had HH; only 1 had gastroesophageal reflux-related symptoms. Because of bronchial obstruction, rigid bronchoscopy was performed in 3 patients, lobectomy in 2, and atypical resection in 1. Antibiotic therapy with amoxicillin was given to all patients, with resolution of actinomycosis. CONCLUSION Bronchopulmonary actinomycosis is a rare condition that mimics pulmonary malignancy on clinical and radiologic grounds. Diagnosis relies on an accurate patient history and histopathologic examination. Although further confirmation is required, esophageal HH appears to be a potential predisposing factor.

Bronchial fibroepithelial polyp: a clinico-radiologic, bronchoscopic, histopathological and in-situ hybridisation study of 15 cases of a poorly recognised lesion.

Bronchial fibroepithelial polyp is an uncommon, poorly recognised lesion, lacking clear diagnostic criteria at histology, but possibly mimicking neoplastic growth on clinico‐radiologic and histopathological grounds. The aim of this study was to define the clinico‐pathological features, bronchoscopic appearance and treatment of bronchial fibroepithelial polyp.

Unexpected Positron Emission Tomography-Positive Actinomyces-Related Mass of the Bronchial Stump

Pulmonary actinomycosis is a rare disease frequently misdiagnosed, even by experienced clinicians, as primary or metastatic lung cancer or as other more conventional lung infections. It is often an unexpected disease that is basically detected only on cytological⁄histological examination. A case involving a patient who presented with a mass in the bronchial stump (of a previous pulmonary lobectomy) is described. Despite a strong suspicion of recurrent lung cancer, positron emission tomography confirmed a diagnosis of a suture-related bronchial actinomycosis.

The role of macrophages in interstitial lung diseases: Number 3 in the Series “Pathology for the clinician” Edited by Peter Dorfmüller and Alberto Cavazza

The finding of collections of macrophages/histiocytes in lung biopsy and bronchoalveolar lavage is relatively common in routine practice. This morphological feature in itself is pathological, but the exact clinical significance and underlying disease should be evaluated together with clinical data, functional respiratory and laboratory tests and imaging studies. Morphological characteristics of macrophages and their distribution along the different pulmonary structures should be examined carefully by pathologists. Indeed, haemosiderin-laden macrophages are associated with smoking-related diseases when pigment is fine and distribution is bronchiolocentric, while alveolar haemorrhage or pneumoconiosis are the main concerns when pigment is chunky or coarse and the macrophages show an intra-alveolar or perilymphatic location, respectively. In the same way, pulmonary accumulation of macrophages with foamy cytoplasm is generally associated with pathologies leading to broncho-bronchiolar obstruction (e.g. diffuse panbronchiolitis, hypersensitivity pneumonia or cryptogenic organising pneumonia) or alternatively to exogenous lipoid pneumonia, some drug toxicity (e.g. amiodarone exposure or toxicity) and metabolic disorders (e.g. type B Niemann–Pick disease). This pathology-based perspectives article is aimed at concisely describing the diagnostic possibilities when faced with collection of macrophages in lung biopsy and cytology. Morphology and localisation of macrophages in the lungs is helpful in the diagnosis of interstitial lung disease http://ow.ly/7bci30bBwmQ

An uncommon cause of pneumonia: The golden diagnosis

A 28-year-old sub-Saharan African Italian non-smoker male presented with signs and symptoms of pneumonia and respiratory failure. Despite antibiotic treatment he experienced a significant worsening of respiratory conditions and admission to intensive care unit. He thus underwent chest computed tomography followed by fiberopict bronchoscopy with bronchoalveolar lavage whose macroscopic examination led to the diagnosis of acute chest syndrome. A brief literature review was conducted to discuss the first manifestation of this disease.

When Acute Respiratory Distress Syndrome is not ARDS

A 58-year-old male with Ehler–Danlos syndrome was referred to our hospital for admission to respiratory intensive care unit (RICU) as he presented with fever (38.0 C) followed by an extremely rapid onset of acute respiratory failure with a radiological pattern of acute respiratory distress syndrome (ARDS) on high-resolution computed tomography (HRCT) (Fig. 1). In the days prior to admission, he had developed progressive cognitive and motor deficits with associated mild dysphagia and swallowing impairment due to considerable enlargement of a partially thrombosed aneurysm in the basilar artery. No recent chest radiographic images were available. After RICU admission the patient was treated with invasive mechanical ventilation. Since acute respiratory infection was suspected, he underwent fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) whose sample presented with a milky appearance. A few minutes after the procedure, the different components of the sample started separating into fluid and corpuscolated parts (Fig. 2). BAL fluid resulted negative on microbiological analysis, while cytological examination showed multiple lipid-laden macrophages. Based on BAL fluid evidence, we reviewed the patient’s recent medical history and we learned that during the previous week he had been aspirating a minimum quantity of petroleum jelly used as a laxative to treat a form of transient constipation. The progressive neurological impairment due to vascular disease had probably favored the aspiration process. On this ground, the diagnosis of ARDS-like exogenous lipoid pneumonia was made. Despite a wide range of reported manifestations [1], acute respiratory failure requiring RICU admission and mechanical ventilation is a very rare presentation of the disease and it is usually due to a massive aspiration [2]. In our case, petroleum jelly served as a laxative for an intercurrent constipation and was used for only a week. We conclude that although a rare occurrence, even low amounts of oil-based laxatives may increase the risk of ARDS-like life-threatening lipoid pneumonia in patients with neurological impairment.

A 45-Year-Old Human Immunodeficiency Virus–Infected Woman With Cough

FIGURE 1. Computed tomographic scan of the thorax that shows, in the posterior wall of the trachea, the presence of a fluid and amorphous material: for the declive position, for the not solid aspect, and for the fact that it did not seem to infiltrate the mucosa CASE A 45-year-old woman with human immunodeficiency virus, taking antiretroviral therapy, presented to us with a 2-month mild dry cough not responding to aspecific treatments (bronchodilators, antireflux, and aspecific antibiotics) recommended by her primary care physician. The physical examination was unremarkable as were the laboratory studies and pulmonary function tests. Suspecting a pulmonary opportunistic infection, because the results of the chest radiograph were negative, we performed thorax computed tomography (Fig. 1) that, according to the radiologist, highlighted only the presence of tracheal formations probably compatible with secretions (as he said). Bronchoscopy showed instead the presence, along thewhole trachea (and not in other respiratory tracts), of multiple cauliflower-like neoplasms with smooth surface (Fig. 2A). What is your diagnosis?: tracheal papillomatosis. the radiologist assumed in the first instance these could be secretions (encouraging, however, to verify this hypothesis with bronchoscopy).

Eosinophilic Globules in Bronchoalveolar Lavage Fluid of Patients With Systemic Sclerosis-Related Interstitial Lung Disease : A Diagnostically Useful, Previously Unreported Finding in a Retrospective and Prospective Study, Including Differential Diagnosis With Other Idiopathic and Secondary Interstitial Lung Diseases

Bronchoalveolar lavage (BAL) is a minimally invasive method possibly representing a diagnostic tool in the evaluation of interstitial lung diseases (ILDs) of different causes. We first describe herein the morphologic, histochemical, and immunohistochemical features of previously unreported eosinophilic globular deposits of acellular amorphous material of uncertain nature in a relatively large series of 227 BAL samples obtained from patients with various ILDs. Overall, eosinophilic globules were detected in 18 cases (7.9%), 16 of which were in patients with systemic sclerosis (SSc)-related ILD (16/50 [32%]) and in 2 cases of apparently idiopathic usual interstitial pneumonia. Apart from the possible diagnostic information of this finding, in patients with SSc, the globules were significantly related to BAL neutrophilia or eosinophilia and extensive ILD in high-resolution computed tomography (P < .0001). Differential diagnosis with other types of acellular globular materials observed in BAL samples is also discussed.