David R. Trawick

Eosinophilic pneumonia as a presentation of occult chronic granulomatous disease

We present a case of invasive pulmonary aspergillosis (IPA) in a previously healthy young woman who presented with what initially appeared to be an acute eosinophilic pneumonia. A second lung biopsy taken after treatment with steroids showed invasive Aspergillus with associated necrotizing granulomas, a pattern commonly found in chronic granulomatous disease (CGD). Both siblings, and by extrapolation, the patient, were actually found to have CGD. A review of the literature revealed other cases of presumed immunocompetent patients with IPA with presentations and lung histopathology similar to that of our patient. We conclude that chronic granulomatous disease presenting in the adult may be more common than previously assumed, and that patients previously presumed immunocompetent, but with granulomatous invasive pulmonary aspergillosis, may have chronic granulomatous disease. Furthermore, and most devastatingly in this case, the presentation may simulate a recently described steroid responsive acute lung disease, acute eosinophilic pneumonia.

Bronchoscopy with bronchoalveolar lavage: determinants of yield and impact on management in immunosuppressed patients

Fibreoptic bronchoscopy with bronchoalveolar lavage (FOB/BAL) is a common modality for the evaluation of pulmonary infiltrates.1 2 We recognised there are limitations of comparison between subgroups of immunosuppressed patients, non-uniform definitions of a positive yield, suboptimal description of the impact of concurrent antimicrobial use at the time of the bronchoscopy and sometimes insufficient assessment of management decisions surrounding FOB/BAL.3–5 To address these issues, we performed a retrospective analysis of 190 immunosuppressed patients who underwent FOB/BAL for a pulmonary abnormality (clinical or radiographic) at the University of Rochester Medical Center from 2005 to 2008. A positive yield was defined as one of the following: (1) positive culture—bacterial, viral or fungal (not including Candida albicans alone); (2) positive finding on cytopathology or fungal stain; or (3) diffuse alveolar haemorrhage. Antimicrobial and corticosteroid treatment changes …

Persistent Culture-Positive Legionella Infection in an Immunocompromised Host

Legionella pneumophila is an important cause of community-acquired and nosocomial pneumonia. We describe an immunocompromised patient with severe pneumonia from whom Legionella species were isolated from sputum samples by culture for 30 days, despite administration of treatment with appropriate antimicrobial agents. However, clear improvement in the patients respiratory condition was evident, and he subsequently recovered completely.

Severe airflow obstruction and eosinophilic lung disease after Stevens–Johnson syndrome

Respiratory involvement is a frequent complication of Stevens–Johnson syndrome (SJS). However, there are very few convincing reports of persistent pulmonary sequelae, as demonstrated by spirometry, radiology and pathology. The current study presents a case of a 13-yr-old female with T-cell acute lymphocytic leukaemia who developed persistent, severe, obstructive lung disease following an episode of SJS. A lung biopsy demonstrated bronchiolar submucosal fibrosis consistent with constrictive bronchiolitis, as well as eosinophilic micro-abscesses, which, to the current authors’ knowledge, has not been previously described. The present study illustrates specific histopathological features that highlight a possible association between Stevens–Johnson syndrome, constrictive bronchiolitis and eosinophilic micro-abscesses. The eosinophils may be associated with permanent mucosal damage, as seen in the present case, by releasing mediators that have a pro-fibrogenetic role. However, further investigation is warranted.

Electromechanical dissociation following verapamil and propranolol ingestion : A physiologic profile

We present a case of combined verapamil and propranolol ingestion in a young woman with a DDD pacer from whom hemodynamic, echocardiographic, and toxicologic data were obtained simultaneously. Analysis of the data from these combined sources suggests a progression of (1) recovery of myocardial contractility, (2) return of systemic vascular resistance, and (3) return of intrinsic electrical activity of the heart. That contractility returns before intrinsic electrical activity strongly for the early use of transvenous temporary pacing wires. Furthermore, our patients complete recovery after a prolonged electromechanical dissociation arrest would again argue for very aggressive resuscitation efforts in this setting.

Breathtaking: Platypnea-orthodeoxia syndrome.

PRESENTATION A patient who was already coping with some respiratory compromise developed more extraordinary impairment. The 34-year-old woman presented with severe dyspnea and hypoxia, which improved while she was lying down. She was being treated for a recurrence of nodular sclerosing Hodgkin’s lymphoma, initially diagnosed as stage IIA. In addition, she had known bleomycin lung toxicity marked by a moderate decrease in lung-diffusing capacity as noted on pulmonary function testing. She had been taking enoxaparin for a pulmonary embolus diagnosed 3 weeks prior to her current presentation. A pulmonary arteriovenous malformation or an intracardiac shunt was suspected. Computerized tomography (CT) revealed a persistent pulmonary thromboembolism without any evidence for arteriovenous malformation.

33 – The Influence of Gender on Cough Reflex Sensitivity

Cough is an airway defense reflex mechanism to remove mucus and foreign particles from the respiratory tract by the generation of a large expiratory airflow. It is also a major mechanism by which a disease is spread and may serve as a natural defense against cardiac arrhythmia. This chapter briefly reviews the epidemiology, anatomy, physiology, and neurophysiology of cough. The chapter also discusses the initial studies that demonstrate the female preponderance in angiotensin converting enzyme inhibitor (ACEI)-related cough. Observations of higher frequency of ACEI-related cough in women than in men and tussigenic studies that demonstrate that females have a lower threshold to a variety of agents suggest that a fundamental gender difference exists in cough sensitivity. After a review of the methodology used to determine cough reflex sensitivity, the chapter examines the data demonstrating gender differences in cough reflex sensitivity. There is also some focus on studies examining whether hormones modulate cough sensitivity. The chapter also reviews molecular studies that explore the premise of a genetic predisposition to ACEI-related cough.