Carla Damas

Pneumonia aguda fibrinosa e organizante

The term Acute Fibrinous and Organizing Pneumonia (AFOP) has been proposed by Beasley et al for cases that not fit into the histopathologic criteria of the recognized entities described as acute or subacute clinical presentations. The presence of intra-alveolar fibrin in the form of fibrin ‘balls’ and organizing pneumonia with patchy distribution are the main histological features of this entity. We describe the case of a male patient with the diagnostic of AFOP made by surgical lung biopsy. He had a subacute presentation of symptoms consisting of productive cough, chest pain and fever. Bilateral infiltrates with patchy and diffuse distribution were the predominant features in his chest HRCT scan. The patient had a good clinical course after a treatment with prednisone and cyclophosphamide. Our hope in reporting this case study is to add some more data to the discussion of this new entity. Rev Port Pneumol 2006; XII (5): 615-620

Hemoptysis – etiology, evaluation and treatment in a university hospital

OBJECTIVE Evaluate patients admitted for hemoptysis, its etiology, use of diagnostic tests, treatment and outcome. METHODS A retrospective analysis was done, checking clinical files of patients admitted for hemoptysis, between 1st January 2004 and 31st December 2008. RESULTS Two hundred and thirty seven patients were included in this study, with a mean age of 57.9 years. In patients under 18 years, the most frequent diagnoses were Bronchiectasis and Congenital Cardiopathy. In adults, Pulmonary Tuberculosis Sequelae and Bronchiectasis were the dominant diagnoses (22.2 % and 15.8 %, respectively), followed by Lung Cancer. Active infection was responsible for bleeding in 51 patients, especially Pulmonary Tuberculosis, Pneumonia and Tracheobronchitis. The etiology of hemoptysis was not established in 6.3 %. All patients performed chest X-Ray. Chest CT was performed in 81.4 % of patients and Fiberoptic bronchoscopy in 52.7 %, the latter locating the source of bleeding in 38.4 % and establishing a final diagnosis in 17.6 %. In most patients, effective control of bleeding was achieved by medical treatment (90.7 %). During these 5 years, arterial embolization was performed in 11.8 % of patients. The main reason for embolization was recurrence prevention. There were 14 deaths (5.9 %), being identified as poor prognostic factors, hemodynamic instability and malignancy. CONCLUSION Hemoptysis is still a frequent symptom, being chronic infection sequelae and lung cancer their main causes. In this study, factors associated with a worse prognosis were hemodynamic instability and malignancy.

Hemoptises-etiologia. avaliação e tratamento num hospital universitário

Resumo Objectivo Avaliar doentes admitidos por hemoptises quanto a etiologia, meios diagnosticos, tratamento e evolucao. Material e metodos Realizou-se um estudo retrospectivo dos doentes admitidos no Hospital de Sao Joao, por hemoptises, entre 01 de Janeiro de 2004 e 31 de Dezembro de 2008. Resultados Foram estudados 237 doentes, com idade media de 57.9 anos. Nos doentes com idade inferior a 18 anos, os diagnosticos mais frequentes foram Bronquiectasias e Cardiopatia congenita. Nos adultos, as Sequelas de Tuberculose Pulmonar e as Bronquiectasias foram os diagnosticos predominantes (22.2% e 15.8%, respectivamente), seguidos pela neoplasia pulmonar. A infeccao foi responsavel pelas perdas hematicas em 51 doentes, essencialmente Tuberculose Pulmonar, Pneumonia e Traqueobronquite. A etiologia ficou por esclarecer em 6.3%. Todos os doentes realizaram radiografia de torax. A TAC foi realizada em 81.4% dos doentes e a Broncofibroscopia em 52.7%, esta ultima localizando a fonte da hemorragia em 38.4% e estabelecendo diagnostico definitivo em 17.6%. Na maioria dos casos (90.7%), a hemorragia foi controlada com tratamento medico. Ao longo destes 5 anos, 11.8% dos doentes foram submetidos a embolizacao arterial, sendo a prevencao de recidiva o principal motivo da sua realizacao. Foram registados 14 obitos (5,9%), sendo identificados, como factores de mau prognostico, a instabilidade hemodinâmica e a etiologia neoplasica. Conclusao As hemoptises continuam a ser um sintoma frequente, sendo actualmente as sequelas associadas a infeccoes cronicas e as neoplasias as principais etiologias. Neste estudo, os factores de pior prognostico foram a instabilidade hemodinâmica e a etiologia neoplasica.

Lung and renal transplantation

UNLABELLED Renal transplantation is the most common type of solid organ transplantation and kidney transplant recipients are susceptible to pulmonary complications of immunosuppressive therapy, which are a diagnostic and therapeutic challenge. AIM To evaluate patients admitted to the Renal Transplant Unit (RTU) of Hospital de S. João with respiratory disease. SUBJECT AND METHODS We performed a retrospective study of all patients admitted to RTU with respiratory disease during a period of 12 months. RESULTS Thirty-six patients were included. Mean age 55.2 (+/-13.4) years; 61.1% male. Immunosuppressive agents most frequently used were prednisolone and mycophenolate mofetil associated with ciclosporin (38.9%) or tacrolimus (22.2%) or rapamycin (13.9%). Thirty-one patients (86.1%) presented infectious respiratory disease. In this group the main diagnoses were 23 (74.2%) pneumonias, 5 (16.1%) opportunistic infections, 2 (6.5%) tracheobronchitis, and 1 case (3.2%) of lung abscesses. Microbiological agent was identified in 7 cases (22.6%). Five patients (13.9%) presented rapamycin-induced lung disease. Fibreoptic bronchoscopy was performed in 15 patients (41.7%), diagnostic in 10 cases (66.7%). Mean hospital stay was 17.1 (+/-18.5) days and no related death was observed. CONCLUSION Respiratory infections were the main complications in these patients. Drug-induced lung disease implies recognition of its features and a rigorous monitoring of drug serum levels. A more invasive diagnostic approach was determinant in the choice of an early and more specific therapy.

Toxicidade pulmonar induzida pela rapamicina

Resumo As doencas pulmonares induzidas por farmacos constituem uma causa crescente de morbilidade, tendo sido descritas diferentes formas de toxicidade associadas a inumeras substâncias. O sirolimus (rapamicina) e um farmaco imunossupressor usado de forma crescente no contexto do transplante de orgaos solidos, nomeadamente no transplante renal. A toxicidade pulmonar tem sido descrita como um dos potenciais efeitos laterais, nomeadamente causando formas de pneumonite intersticial ou, mais raramente, hemorragia alveolar. Os autores descrevem os casos de quatro doentes (3 do sexo masculino, 1 do sexo feminino) com idades compreendidas entre os 46–71 anos, recipientes de transplante renal (rim cadaver) ha 3 anos (1 doente) e 7 anos (3 doentes). A imunosupressao consistia em micofenolato mofetil, prednisolona e rapamicina. Os quatro doentes foram admitidos por febre, tosse produtiva (2) e dispneia (3). Apresentavam imagem radiologica de infiltrados pulmonares bilaterais de predominio basal. O LBA mostrou alveolite linfocitica em 3 doentes, tendo-se observado no entanto diferentes relacoes CD4/CD8., para alem de neutrofilia em 2 deles. No restante doente, observou- se hemorragia alveolar grave. Nao houve em nenhum dos casos qualquer isolamento de micro organismos patogenicos no LBA. As queixas apresentadas, bem como as alteracoes radiologicas regrediram com a suspensao do farmaco. Estes quatro casos revelaram alguma variedade, quer na apresentacao clinica, quer nos achados dos exames subsidiarios efectuados, nomeadamente no LBA. Este facto pode ter como causa diferentes mecanismos fisiopatologicos a nivel do pulmao induzidos pelo sirolimus.

Avaliação de hábitos tabágicos em alunos do ensino secundário

Background: Smoking is an important health risk in general, and responsible for diseases with significant mortality and morbidity. Smoking habits start early and adolescence is a notorious time for starting smoking. Aim and Methods: To assess knowledge on smoking and smoking habits in a population of adolescents in four Porto schools, using a confidential self administered questionnaire. Collected data were evaluated using the SPSS 1.2 statistics program (2004 version). Results: A total of 1770 students aged 11 - 21 (median 15.1 years), mainly female, (58%), answered. Most students (n = 952, 54.6%) were unaware of signs or warnings against smoking in their schools. The great majority (n = 1639, 92.7%) considered themselves well informed on the harmful effects of smoking, but only 6.7% could list three or more tobacco-associated health consequences, however. Parents and friends were seen as privileged sources of information. Among these students, 194 (11.1%) were smokers and the average started to smoke at the age of 15. The majority of these (n = 111, 57.2%) had parents who smoked and 96.4% had friends who smoked, versus 83.1% of non-smokers, a statistically significant difference (p < 0.001). Pocket money was the means of acquiring cigarettes in 34.8%. Most (60.8%) considered themselves able to stop smoking at any time, while 11.4% of the smokers smoked more than one pack a day and 9.8% smoked the first cigarette within 5 minutes of waking, however. Conclusions: The percentage of smokers in this group of teenagers was considerable and indicators of nicotine dependence were found. Knowledge of the risks of smoking was poor and information on smoking given by schools had an apparently low and variable impact. Parents’ and friends’ behaviour may have a weighty impact on the decision to start smoking. Rev Port Pneumol 2009; XV (1): 43-53

Fibrose quística: Revisão

Resumo A fibrose quistica (FQ) e a doenca autossomica recessiva mais frequente na raca caucasiana. Caracteriza-se por mutacoes na CFTR, uma proteina transmembranar responsavel pelo transporte de cloretos. Esta proteina tem uma ampla distribuicao epitelial, o que da um caracter sistemico a esta doenca e consequentemente multiplas manifestacoes clinicas de gravidade variavel. A melhoria dos cuidados de saude, associada ao desenvolvimento do arsenal terapeutico, permitiu um aumento da sobrevida destes doentes, de tal forma que a FQ ja nao pode ser abordada como doenca da idade pediatrica. Tambem a evolucao tecnica na transplantacao abriu novas perspectivas quanto ao tratamento desta afeccao. Assim, cada vez mais esta patologia implica um envolvimento multidisciplinar no qual a pneumologia tem uma parte preponderante.

Streptococcus pneumoniae – caused CAP in hospitalised patients: mortality predictors

Probably the most important decision in the management of Community-Acquired Pneumonia (CAP) is patient site of care. Patients with Streptococcus pneumoniae-caused CAP admitted to our hospital between 1st January and 31st December 2006 were retrospectively analysed. Samples of blood, sputum, bronchial and bronchoalveolar lavage and urine were collected for microbiological testing using standard culture techniques and urine antigen detection. Pneumonia Severity Index (PSI) and British Thoracic Society (BTS) CURB-65 scoring tools were evaluated. The statistical treatment was performed using the SPSS 14.0 program. We included 104 patients, 67.3% male, median age 63 years old, mortality 13.4%. There was a significant association between the PSI and CURB-65 score and mortality. Despite advances, CAP is still an important health problem with a high attendant morbi-mortality. This study confirms the value of PSI and CURB-65 in the prediction of severe pneumonia.

End-stage silicosis and lung transplantation: A way forward

Lung transplantation is an available and accepted therapy for the management of a wide range of severe lung disorders. Silicosis is a progressive, fibrotic, occupational lung disease. End-stage silicosis is one of the accepted indications for lung transplantation, although there is little published data on this topic. The aim of our study was to investigate the selection of recipients and follow-up of lung transplantation for silicosis. Data from all lung transplant patients with silicosis followed at Centro Hospitalar São João between 2008 and 2013, were retrospectively analyzed. Six males with a mean age of 55.5 ± 6.9 years underwent lung transplantation for silicosis. Of the 6 patients, 3 subjects worked in water exploration wells, 1 was a sandblasting worker, 1 slate mine worker and 1 quarry worker. At the time of referral for lung transplant, functional lung characteristics were as follows: FVC 50.20 ± 10.8% predicted and FEV1 40.48 ± 7.9% predicted. The mean pulmonary artery pressure was 61 mm Hg estimated by echocardiography. Mean time between the first observation and lung transplant was 18.5 months. All patients underwent single lung transplantation, 4 patients underwent left lung transplantation. There was no perioperative mortality, although two patients developed primary graft dysfunction after transplant. During follow-up, two recipients had cytomegalovirus infection. All recipients are alive with a mean follow-up time of 32.8 ± 17.2 months, with a good quality of life (measured by the Portuguese version of the Medical Outcomes Study, Short Form-36, presented as the median of the subscales: physical-function 54.0 ± 39.1, general health 52.4 ± 25.7, vitality 54.0 ± 19.5, social functioning 70.0 ± 31.4, mental health 56.8 ± 19.9) and improved lung function (Table 1). Despite the global efforts of prevention, silicosis remains a worldwide occupational lung disease. There is no proven Table 1 Lung functional parameters of patients before and after lung transplant.

Exacerbação aguda da fibrose pulmonar idiopática

Resumo Alguns doentes com fibrose pulmonar idiopatica (FPI) apresentam durante a sua evolucao fases de agravamento clinico sem causa conhecida, designadas como “exacerbacao aguda” ou “fase acelerada” da doenca (EA). Caracterizam-se pelo agravamento marcado da dispneia, hipoxemia e pelo aparecimento de novas opacidades pulmonares ou pelo agravamento das ja existentes no estudo imagiologico. Os achados histologicos tipicos sao o dano alveolar difuso (DAD) sobreposto a alteracoes de pneumonia intersticial usual (UIP). Esta entidade clinica associa-se a uma mortalidade elevada, nao havendo ate ao momento nenhuma terapeutica de comprovada eficacia. Os autores descrevem os casos clinicos de cinco doentes que apresentaram alteracoes clinicas, funcionais e radiologicas sugestivas de EA-FPI, assim como o tratamento efectuado e a evolucao observada, enquadrando-os na discussao das caracteristicas normalmente apresentadas por esta entidade.