Ayten Filiz

Increased Pleural Fluid Adenosine Deaminase in Brucellosis Is Difficult to Differentiate from Tuberculosis

Pleural involvement in brucellosis is very rare. Current knowledge on brucella pleuritis is limited to a few case studies, and pleural adenosine deaminase (ADA) in brucellosis has not been studied previously. We report the pleural fluid characteristics, including ADA, of two cases with brucella pleurisy. Analysis of the pleural fluids revealed exudative effusions with increased ADA level, decreased glucose concentration, and lymphocyte predominance. The similarity with tuberculous pleurisy was remarkable. We suggest that brucellosis should be considered in the differential diagnosis of tuberculosis, especially in regions endemic for both diseases.

Drug-resistant tuberculosis at the University Hospital in Gaziantep, south-eastern Turkey

We aimed to determine the present status of drug resistance of Mycobacterium tuberculosis at the Gaziantep University Hospital in south-east Turkey. Data for 1995 to 1999 were retrospectively evaluated with respect to smear-positive cases, first positive culture for Mycobacterium tuberculosis for each patient and drug-susceptibility tests for the major antituberculous drugs. Cultures were done using the Bactec 460 TB method. A total of 106 (40.2%) strains were resistant to at least one drug. Single drug resistance was observed in 47 strains (17.8%) and resistance to two or three drugs was found in 28 and 29 strains (10.6 and 11.0%), respectively. Two strains (0.8%) were resistant to all four drugs. While multidrug resistance was observed in 52 (19.7%) strains, resistance to isoniazid + rifampin was observed in 20 (7.6%) strains. This retrospective study showed that combined drug resistance of M. tuberculosis is highly prevalent in southeastern Turkey. Possible reasons for the failure of current control policies were considered.

First report of pulmonary Nocardia otitidiscaviarum infection in an immunocompetent patient from Turkey

Nocardiosis is a rare disease, and worldwide, respiratory and disseminated infections are most often due to Nocardia asteroides which is recognised increasingly as an opportunistic infection in patients with underlying chronic debilitating disease or immunodeficiency. However, infection with N. otitidiscaviarum and pulmonary nocardiosis in an immune‐competent host remains very rare. We report a 65‐year‐old immune‐competent male with pulmonary N. otitidiscaviarum infection in whom complete cure was provided with a 6 months of antibiotic combination including trimethoprim‐sulfomethaxazol. This is the first report of pulmonary N. otitidiscaviarum infection in an immune‐competent patient from Turkey.

Bronchiolitis obliterans in a Case of Juvenile Rheumatoid Arthritis Presented with Pneumomediastinum

We present a case of bronchiolitis obliterans associated with juvenile rheumatoid arthritis in whom pneumomediastinum was the presenting manifestation. Diagnosis of bronchiolitis obliterans was made on the basis of the clinical history, pulmonary function tests and high-resolution computerized tomography scan findings. Pneumomediastinum resolved in a few days following high-dose nasal oxygen. This case shows that bronchiolitis obliterans can occur in patients with juvenile rheumatoid arthritis. Complicating pneumomediastinum in such cases should be considered as an indication of underlying bronchiolitis obliterans.

Severe Asthma Attack in a Patient with Premenstrual Asthma: Hot Pepper Is the Possible Trigger

Mild to severe deterioration of asthmatic symptoms during the premenstrual period has been reported in 30–40% of female asthmatics [1]. Although most of the authors suggest that alteration of hormonal status during the menstrual cycle has an important role, none has been able to demonstrate the exact mechanisms in the etiology of this entity [2]. We present a case who was admitted to the emergency room of Gaziantep University Hospital for a severe premenstrual asthma attack which had begun after handling fresh red hot pepper for several hours. After the addition of the leukotriene receptor antagonist (LRA) montelukast to her medication, her asthma has been better controlled even during the premenstrual periods for the last 16 months. A 38-year-old asthmatic woman was brought to the emergency room for loss of consciousness following an acute dyspnea episode in July 1999. On physical examination, she had an irregular breathing pattern, cyanosis and markedly diminished breath sounds. Her blood pressure was 160/100 mm Hg and pulse rate was 140 per minute. Arterial blood gas analysis revealed acute hypercapnic respiratory failure (pH 7.08, PaO2 45 mm Hg, PaCO2 77 mm Hg, HCO3 22.8 mmol/l). Chest X-ray showed no abnormality. Initial efforts to treat the acute attack with conventional medication failed and immediate intubation was performed for mechanical ventilation. Additionally, she was given 60 mg of methylprednisolone, 0.5 mg/kg/h aminophylline by continuous infusion and a mixture of 2.5 mg of salbutamol and 0.5 mg of ipratropium bromide via nebulizer every 4 h. Her condition stabilized the next day and she was then weaned from mechanical ventilation. Reviewing her medical records showed that she had been regularly followed at our asthma clinic with the diagnosis of premenstrual asthma for the last 10 years. However, she had never been admitted to the emergency room for an acute asthma attack until that day on which she chopped almost 20 kg of hot pepper with bear hands to make a traditional pepper sauce. She was discharged from the hospital 1 week later with LRA montelukast added to her medical regimen including metered-dose inhaler forms of salmeterol (200 Ìg/day) and fluticasone (500 Ìg/day) plus oral prednisolone (30 mg/day) and oral theophylline (400 mg/day). Oral prednisolone was discontinued with tapering after 1 month. On her follow-up during the last 16 months, neither significant deterioration of her asthma nor marked drops in her PEFR measurements occurred even during her premenstrual periods. To our knowledge, there is no report in the English medical literature that stresses the provocative effect of fresh hot pepper in asthmatic subjects. However, capsaicin, which is the irritant extract of hot pepper, is known as a potent bronchoconstrictor [3]. Therefore, we suggest that it was most likely her prolonged exposure to hot pepper that triggered off this acute severe asthmatic attack in our case. To date, therapeutic strategies for premenstrual asthma (PMA) have been limited to some case studies. Besides theories on the hormonal alterations during the premenstrual period, Nakasato et al. [4] recently suggested that leukotrienes are partly involved in the pathogenesis of PMA, and that LRAs may be useful in patients with PMA. In the presenting case, similarly, asthmatic symptoms were adequately controlled with the addition of the LRA montelukast during the 16 months of follow-up. In conclusion, we suggest that preparing pepper sauce at home or working in a hot pepper processing plant may be dangerous for asthmatic subjects because severe asthma attacks may be provoked by prolonged handling of hot pepper. We also suggest that LRAs may be considered in subjects with premenstrual asthma before hormonal therapy (gonadal releasing hormone analogs or progesterone) to avoid the side effects, related to these drugs, such as bone loss or cardiovascular complications.

Effects of positive airway pressure therapy on exercise parameters in obstructive sleep apnea.

BACKGROUND AND OBJECTIVES Obstructive sleep apnea (OSA) is common in adult population and may cause many adverse clinical results. We aimed to investigate possible changes in cardiopulmonary exercise capacity in OSA patients after positive airway pressure treatment. DESIGN AND SETTINGS Patients who were admitted to Gaziantep University Pulmonary Diseases Sleep Center and diagnosed OSA were included. Studies carried out between May 2010 and July 2011. Sixty-five consecutive patients were included in this prospective study. PATIENTS AND METHODS Sixty-five adult sleep clinic patients diagnosed with OSA by polysomnography and in whom continuous positive airway pressure (CPAP) ventilation therapy was indicated were included. Cardiopulmonary exercise capacity was assessed by bicycle ergometry during diagnostic workup and at least 4 weeks later. RESULTS There were 57 (87.7%) males. The mean age was 45.29 (10.57) years, apnea-hypopnea index 38.02 (23.19 events/h, body mass index 31.72 (4.87) kg/m2. Patients were grouped with respect to compliance with CPAP. The peak oxygen consumption (VO2) did not change in the CPAP compliant group (n=33) (22.52 [6.62] mL/[min.kg] to 21.32 [5.26] mL/[min.kg]; P=.111), and decreased from 21.31 (5.66) mL/(min.kg) to 19.92 (5.40) mL/(min.kg) (P=.05) in the CPAP noncompliant group. Work rate increased from 84.0% to 85.0% in the CPAP compliant group and decreased from 79.6% to 77.1% in the noncompliant group (P=.041). In the group that used the device, ventilation (VE)/VCO2 at anaerobic threshold (AT) declined from 28.42 to 27.36; however, it increased from 27.41 to 27.81 in the group that did not use the device (P=.033). CONCLUSIONS Decline in the exercise capacity was prevented in patients with OSA after 4 weeks of CPAP therapy. The changes in VE/VCO2 at AT suggest the reversal of pathophysiologic changes in OSA with the CPAP therapy that may improve cardiac function and cause more efficient ventilation.

Allergy skin test results of an outpatient pulmonary clinic in Gaziantep

Environmental factors play an important role in allergic sensitization. The aim of this study was to determine the spectrum of aeroallergen sensitivity of patients. The skin prick test results of patients with symptoms compatible with allergic diseases between March 2002 and December 2004 were retrospectively evaluated in Gaziantep University Pulmonary outpatient clinic. Of 1627 patients in whom skin prick tests (Stallergenes, France) were performed, 528 (32.5%) patients had at least one positive result among 8 allergens. The mean age of patients who had positive allergic skin test was 33.03 ± 11.80 (16-69), and 335 (63.4%) of those were female. Two hundred twenty five (52%) patients had positive skin prick test for one allergen tested, while 253 (48%) patients had positive skin prick test for multiple allergens. Phleum pratensis was the most common allergen found to be positive in 221 (41.8%) patients. The prevalence of positive tests were as follows; cockroach (32.9%), Dermatophagoides pteronyssinus (32.7%), Olea europea (27%), cat dander (14.9%), Parieteria officinalis (11.7%), Cladosporium (9.8%) and Alternaria (8.9%).Phleum pratensis and cockroach were the most common allergens causing a sensitivity reaction detected in our clinic.

Pneumococcal and influenza vaccination status of hospitalized adults with community acquired pneumonia and the effects of vaccination on clinical presentation

ABSTRACT Background: Previous reports have shown that vaccination rates of adult at-risk populations are low in Turkey. There are differing reports with regards to the effectiveness of the influenza and the pneumococcal polysaccharide vaccine (PPSV23) on the clinical outcomes of community acquired pneumonia (CAP). The purpose of this study was to analyze the influenza (FV) and pneumococcal vaccination (PV) status, the factors that influence the receipt of influenza/pneumococcal vaccine and the effects of prior vaccination on the clinical outcomes in adults hospitalized with CAP. Patients and Methods: Patients hospitalized with CAP between March 2009 and October 2013 and registered at the web-based Turkish Thoracic Society Pneumonia Database (TURCAP) were included in this multicentric, observational study. Of a total of 787 cases, data were analyzed for 466 patients for whom self-reported information on PV and FV was available. Results: In this adult population with CAP, the vaccination rate with both the pneumococcal and influenza vaccines was found to be 6%. Prior FV was found to be the sole variable that was associated with the receipt of PV [OR 17.8, 95% CI (25–75:8.56–37.01), p < 0.001]. Conversely, being vaccinated with PPSV23 was the only predictor of receipt of FV [OR 18.1, 95% CI (25 – 75:8.75 – 37.83), p < 0.001]. Compared to the unvaccinated cases, the chest radiograms of the vaccinated patients revealed less consolidation. The latter also reported fatigue, muscle pain and gastrointestinal symptoms less frequently. Although there was a trend for lower 30-day mortality and for lower rates of intensive care unit (ICU) admission, these did not reach statistical significance. A pneumonia severity index (PSI) score ≥ 90, CURB-65 score ≥3 and multilobar involvement, but not the vaccination status, were identified as independent determinants of ICU admission. Conclusions: This study showed that, among patients hospitalized with CAP, the FV and/or PV rates are low. Prior vaccination does not appear to significantly affect the clinical outcomes.

Prognosis of hospitalized patients with community-acquired pneumonia

INTRODUCTION The long-term prognosis of patients with community-acquired pneumonia (CAP) has attracted increasing interest in recent years. The objective of the present study is to investigate the short and long-term outcomes in hospitalized patients with CAP and to identify the predictive factors associated with mortality. PATIENTS AND METHODS The study was designed as a retrospective, multicenter, observational study. Hospitalized patients with CAP, as recorded in the pneumonia database of the Turkish Thoracic Society between 2011 and 2013, were included. Short-term mortality was defined as 30-day mortality and long-term mortality was assessed from those who survived 30 days. Predictive factors for short- and long-term mortality were analyzed. RESULTS The study included 785 patients, 68% of whom were male and the mean age was 67±16 (18-92). The median duration of follow-up was 61.2±11.8 (37-90) months. Thirty-day mortality was 9.2% and the median survival of patients surviving 30 days was 62.8±4.4 months. Multivariate analysis revealed that advanced age, the absence of fever, a higher Charlson comorbidity score, higher blood urea nitrogen (BUN)/albumin ratios and lower alanine aminotransferase (ALT) levels were all predictors of long-term mortality. CONCLUSION Long-term mortality following hospitalization for CAP is high. Charlson score and lack of fever are potential indicators for decreased long-term survival. As novel parameters, baseline BUN/albumin ratios and ALT levels are significantly associated with late mortality. Further interventions and closer monitoring are necessary for such subgroups of patients.

Vascular endothelial growth factor in pleural effusions and correlation with radiologic and biochemical parameters

Introduction: Pleural effusion is a common clinical problem with management difficulties. The aim of this study is to evaluate vascular endothelial growth factor (VEGF) in differential diagnosis of pleural effusions and the presence of correlation between radiological features and biochemical properties. Materials and Methods: The study included patients with pleural effusion. VEGF levels in the pleural fluid were measured by enzyme-linked immunosorbent assay. Results: A total of 97 patients who had exudative pleural effusion related to lung cancer (n = 17), nonpulmonary malignancies (n = 25), mesothelioma (n = 9), pneumonia (n = 14), tuberculosis (n = 8), miscellaneous causes (n = 6), and transudative effusion (n = 18) were included. Pleural VEGF levels were higher in exudative effusions with respect to transudative effusions (P < 0.001) and in effusions related to malignancies versus benign causes (P < 0.001). Pleural VEGF was inversely correlated with pleural fluid glucose and pH levels and had positive correlation with lactate dehydrogenase, protein levels (P < 0.001), hematocrit, and eosinophil values in the pleura (P < 0.05). Pleural VEGF levels were also higher in patients with massive effusions and pleural thickening (both P < 0.001). Conclusions: The overlap of pleural VEGF levels between the groups may limit the value of VEGF in discriminating between malignant versus benign and exudative versus transudative effusions; however, it may be a useful adjunct to various methods. The VEGF levels in pleural fluid seem to be related to the degree of inflammation and pleural invasion.