Fernando Uliana Kay

Traqueobronquite aguda causada por Aspergillus: relato de caso e achados de imagem

Acute tracheobronchitis is a rare manifestation of invasive aspergillosis, generally occurring in severely immunocompromised patients. The authors report the case of a patient presenting with this condition after bone-marrow transplantation, with emphasis on tomographic findings.Acute tracheobronchitis is a rare manifestation of invasive aspergillosis, generally occurring in severely immunocompromised patients. The authors report the case of a patient presenting with this condition after bone-marrow transplantation, with emphasis on tomographic findings.

Differences between postmortem computed tomography and conventional autopsy in a stabbing murder case

OBJECTIVE: The aim of the present work is to analyze the differences and similarities between the elements of a conventional autopsy and images obtained from postmortem computed tomography in a case of a homicide stab wound. METHOD: Comparison between the findings of different methods: autopsy and postmortem computed tomography. RESULTS: In some aspects, autopsy is still superior to imaging, especially in relation to external examination and the description of lesion vitality. However, the findings of gas embolism, pneumothorax and pulmonary emphysema and the relationship between the internal path of the instrument of aggression and the entry wound are better demonstrated by postmortem computed tomography. CONCLUSIONS: Although multislice computed tomography has greater accuracy than autopsy, we believe that the conventional autopsy method is fundamental for providing evidence in criminal investigations.

Reduction of poor contrast enhancement of the pulmonary artery in computed tomography angiography using an alternative respiratory maneuver.

Purpose: The aim of the study was to compare the effects of different respiratory maneuvers in computed tomography pulmonary angiography for the diagnosis of pulmonary embolism (PE) on the contrast enhancement of pulmonary circulation and on the quality of lung window images. Materials and Methods: A retrospective analysis of 520 examinations, half obtained after deep inspiration followed by breath-holding and half solely during breath-holding. Subjective quality analyses and objective measurements of pulmonary arterial enhancement and lung parenchyma attenuation were performed. Results: Elimination of deep inspiration reduced suboptimal opacification of the pulmonary artery (PA), from 7.3% to 2.7%, with 2.7% of the deep inspiration scans having attenuation values <150 Hounsfield units (HU). The prevalence of PE was similar between the groups (19% vs. 23%, respectively), with excellent interobserver diagnostic agreement (&kgr;=0.89 to 0.91). Lung windows were compromised in 6.9% of the studies with respiratory pause, and these examinations had a higher attenuation of the lung parenchyma (median: −709.8 HU) compared with deep inspiration (−794.8 HU). A positive correlation between attenuation of the PA and the ascending aorta was observed (r=0.40 to 0.56). Conclusions: Eliminating deep inspiration before image acquisition had opposite effects with the same magnitude: it caused a reduction in inadequate PA enhancement at the cost of an increased number of nondiagnostic lung images and did not compromise diagnostic consistency for PE.

Bullet embolism of pulmonary artery: a case report

The authors report the case of a patient victim of gunshots, with a very rare complication: venous bullet embolism from the left external iliac vein to the lingular segment of the left pulmonary artery. Diagnosis is made with whole-body radiography or computed tomography. Digital angiography is reserved for supplementary diagnosis or to be used as a therapeutic procedure.

Pneumomediastinum, subcutaneous emphysema, and pneumothorax after a pulmonary function testing in a patient with bleomycin-induced interstitial pneumonitis

Spontaneous pneumomediastinum is an uncommon event, the clinical picture of which includes retrosternal chest pain, subcutaneous emphysema, dyspnea, and dysphonia. The pathophysiological mechanism involved is the emergence of a pressure gradient between the alveoli and surrounding structures, causing alveolar rupture with subsequent dissection of the peribronchovascular sheath and infiltration of the mediastinum and subcutaneous tissue with air. Known triggers include acute exacerbations of asthma and situations that require the Valsalva maneuver. We described and documented with HRCT scans the occurrence of pneumomediastinum after a patient with bleomycin-induced interstitial lung disease underwent pulmonary function testing. Although uncommon, the association between pulmonary function testing and air leak syndromes has been increasingly reported in the literature, and lung diseases, such as interstitial lung diseases, include structural changes that facilitate the occurrence of this complication.Spontaneous pneumomediastinum is an uncommon event, the clinical picture of which includes retrosternal chest pain, subcutaneous emphysema, dyspnea, and dysphonia. The pathophysiological mechanism involved is the emergence of a pressure gradient between the alveoli and surrounding structures, causing alveolar rupture with subsequent dissection of the peribronchovascular sheath and infiltration of the mediastinum and subcutaneous tissue with air. Known triggers include acute exacerbations of asthma and situations that require the Valsalva maneuver. We described and documented with HRCT scans the occurrence of pneumomediastinum after a patient with bleomycin-induced interstitial lung disease underwent pulmonary function testing. Although uncommon, the association between pulmonary function testing and air leak syndromes has been increasingly reported in the literature, and lung diseases, such as interstitial lung diseases, include structural changes that facilitate the occurrence of this complication.

Do Current Lung Cancer Screening Guidelines Apply for Populations With High Prevalence of Granulomatous Disease? Results From the First Brazilian Lung Cancer Screening Trial (BRELT1)

BACKGROUND Low-dose computed tomography (LDCT) screening for lung cancer has been demonstrated to be effective in reducing cancer mortality. However, these studies have not been undertaken in countries where the incidence of granulomatous disease is high. The First Brazilian Lung Cancer Screening Trial (BRELT1) has completed initial accrual and is now in the follow-up phase. We present results from the initial prevalence round of screening. METHODS The inclusion criteria were the same as those for the National Lung Cancer Screening Trial (NLST). Pulmonary nodules larger than 4 mm were considered positive and required evaluation by a multidisciplinary team. Indeterminate nodules were evaluated with fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) or biopsy when indicated. Statistical analysis was performed with Fishers exact test to compare our positive findings with those of the NLST. RESULTS From January 2013 to July 2014, 790 participants were enrolled. Positive LDCT scans were reported in 312 (39.4%) participants, with a total of 552 nodules larger than 4 mm. The comparison between positive findings in the NLST (7,191 of 26,722 cases) and those in the BRELT1 (312 of 790 cases) showed a significant difference (p < 0.001). The positive predictive value was lower in BRELT1 than in the NLST (3.2% versus 3.8%, respectively). Follow-up imaging was indicated in 278 of 312 (89.1%) participants; 35 procedures were performed in 25 participants. In 15 cases, benign lesions were diagnosed. Non-small-cell lung cancer (NSCLC) was diagnosed in 10 patients (prevalence of 1.3%). In 8 patients (stage IA/IB disease), treatment was by resection only, in 1 patient neoadjuvant chemotherapy was used (stage IIIA), and in 1 patient advanced disease was diagnosed (stage IV). CONCLUSIONS Using NSLT criteria, a larger number of patients had positive scans (nodules), compared with previous lung cancer screening studies. However, the number of participants requiring surgical biopsy procedures and who were ultimately identified as having cancer was similar to other reports. This supports the role of screening in patient populations with a high incidence of granulomatous inflammation.

Transdiaphragmatic intercostal hernia: imaging aspects in three cases

Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or penetrating trauma. We report three similar cases of cough-induced transdiaphragmatic intercostal hernia, highlighting the anatomic findings obtained with different imaging modalities (radiography, ultrasonography, CT, and magnetic resonance) in each of the cases.Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or penetrating trauma. We report three similar cases of cough-induced transdiaphragmatic intercostal hernia, highlighting the anatomic findings obtained with different imaging modalities (radiography, ultrasonography, CT, and magnetic resonance) in each of the cases.

Angiotomografia computadorizada de coronárias com tomógrafo com 320 fileiras de detectores e utilizando o AIDR-3D: experiência inicial

ABSTRACT Coronary computed tomography angiography (coronary CTA) is a powerful non-invasive imaging method to evaluate coronary artery disease. Nowadays, coronary CTA estimated effective radiation dose can be dramatically reduced using state-of-the-art scanners, such as 320-row detector CT (320-CT), without changing coronary CTA diagnostic accuracy. To optimize and further reduce the radiation dose, new iterative reconstruction algorithms were released recently by several CT manufacturers, and now they are used routinely in coronary CTA. This paper presents our first experience using coronary CTA with 320-CT and the Adaptive Iterative Dose Reduction 3D (AIDR-3D). In addition, we describe the current indications for coronary CTA in our practice as well as the acquisition standard protocols and protocols related to CT application for radiation dose reduction. In conclusion, coronary CTA radiation dose can be dramatically reduced following the “as low as reasonable achievable” principle by combination of exam indication and well-documented technics for radiation dose reduction, such as beta blockers, low-kV, and also the newest iterative dose reduction software as AIDR-3D.

Pulmonary involvement in rheumatoid arthritis: evaluation by radiography and spirometry

Abstract Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA). Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry. Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure. Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA).Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry.Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure.Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.

The role of magnetic resonance imaging-T2* in the evaluation of iron overload early in hereditary hemochromatosis. A cross-sectional study with 159 patients

cancers, where a higher degree of tumor-infiltrating lymphocytes (TIL) predicts improved survival independent of TNM (tumor, node, metastases) staging [1]. TIL have also shown prognostic value in various lymphoid hematological malignancies. In AML, evidence of immune modulation is seen in the “graft-versus-leukemia” effects post-allogeneic SCT together with promising preclinical activity of novel immune therapies. Furthermore, higher peripheral blood lymphocyte recovery after induction chemotherapy [2] and allogeneic SCT for AML [3] have predicted improved overall survival (OS). The prognostic significance of immune status at diagnosis has not been defined in AML. We therefore investigated whether degree of T lymphocyte infiltration within CN-AML diagnostic bone marrow trephines, which we have labeled the “leukemia-infiltrating lymphocyte” (LIL) index, had prognostic value. Patients diagnosed with CN-AML at an adult tertiary center between 2006 and 2013, treated with intensive chemotherapy and who had suitable stored, diagnostic bone marrow trephines were analyzed with institutional ethics approval. Trephines were formalinfixed, decalcified in EDTA, and processed through to paraffin. Immunostaining for pan-T cell marker, CD3, and cytotoxic markers, CD8 and Granzyme B (GB), was performed at the time of analysis using routine methods. CD4 immunostaining was attempted, however high levels of non-specific staining precluded quantitative analysis. Positive cells were quantified using FijiVC image analysis software (v1.48o) from photographs taken at 3200 magnification of three representative areas of each trephine, expressed as a percentage of total cells and averaged over the three images. The cohort included 53 patients (51% male, median age 51 years (range 19–78)) followed-up over a median of 25.9 months (range 0.17–102.6 months). Most patients (96%) had de novo AML, 47 patients (89%) achieved CR (29 (62%) of whom relapsed), 21 (40%) underwent allogeneic SCT (10 in second CR) and 20 (38%) died. From a mean of 13,768 cells per trephine analyzed, median CD3% was 4.64% (range 0.56–37.24%) (Fig. 1A,B), CD8% was 5.08% (range 0.43–43.5%) and GB% was 0.34% (range 0–10.11%). In univariate Cox regression analyses, significant risk factors for death were higher aspirate blast% (P5 0.006), primary refractory disease (P5 0.03), and relapse (P5 0.04). Increasing age (P5 0.093), FLT3-ITD (P5 0.099), and CD3% (P5 0.079) approached significance. Gender, preceding myelodysplastic syndrome, allograft, NPM1 mutation (NPM1), CD8%, and GB% were not significant. In Cox regression multivariate analyses, combining T cell numbers with the relevant univariate factors (i.e., P< 0.1), higher CD3 and CD8 were independent predictors of OS (CD3: hazard ratio (HR) 0.929 for death, 95% CI 0.870–0.992, P5 0.029; CD8: HR 0.920, 95% CI 0.869–0.973, P5 0.004). Patients were divided into quartiles to determine whether incremental differences in survival were present with increasing T cell number. Kaplan–Meier survival analyses demonstrated that CD3 and CD8 numbers were able to stratify patient survival, with significantly superior OS in patients with higher CD3% (Quartile 4 (>12.39%) vs. Quartile 1 (<1.63%), P5 0.042) (Fig. 1C, first panel) and a trend toward better OS with higher CD8% (Quartile 4 (>10.66%) vs. Quartile 1 (<2.2%), P5 0.057) (Fig. 1C, second panel). GB was not able to risk-stratify patients (Fig. 1C, third panel). Higher CD3% and CD8% measured by flow cytometry showed similar prognostic capability, however there was weak correlation between CD3 and CD8 numbers obtained by immunohistochemistry and flow cytometry (data not shown; correlation coefficient, r5 0.534 for CD3 and r5 0.613 for CD8). This may reflect inherent differences in the type of samples analyzed, particularly with sampling artifact and varying degrees of hemodilution in aspirates. Further survival analyses incorporated known prognostic significance of FLT3-ITD and NPM1. Forty-four patients (83%) who were tested for both mutations formed three subgroups: FLT3-ITD (n5 18; 3 year OS 37%), NPM1 without FLT3-ITD (NPM1/ FLT3-ITD; n5 9; 3 year OS 70%), and “double-negative” (NPM1/FLT3-ITD; n5 17; 3 year OS 62%). As small numbers within each subgroup precluded analysis with quartiles, groups split by the median were compared. Although there were no statistically significant differences in OS for CD3, CD8, and GB within the FLT3-ITD (Fig. 1D) and NPM1/ FLT3-ITD (data not shown) subgroups, there was a trend for better survival in the FLT3-ITD subgroup with higher T cells. This was in spite of older age in high (median age 63 years) compared with low T cell (median age 53 years) subgroups. In contrast, CD3>median (16.06%) and CD8>median (13.8%) in the NPM1/FLT3-ITD subgroup were associated with significantly superior OS (CD3: P< 0.001; CD8: P5 0.010) (Fig. 1E, first and second panels) with comparable patient characteristics between above and below median groups. GB>median (1.38%) was not related to survival (P5 0.247) (Fig. 1E, third panel). As the NPM1/FLT3-ITD group often lacks defining prognostic factors, T cell numbers may be most relevant for further risk-stratification of this group. The association of low T cell numbers with poor prognosis in our analyses may reflect the proliferative advantage of blasts gained by immune evasion mechanisms described in AML, including suppression of production and function of T lymphocytes [4]. The corollary is that retained specific T cell immune responses against leukemia-associated antigens, including NPM1, may contribute to improved prognosis [5]. In addition to prognostic implications, the baseline immune status may modify response to immune therapies. Patients with lower T cells generally had a dismal prognosis with cytotoxic therapy and may benefit from immune augmentation by immune-based therapies. Conversely, low T cells may limit response to immune therapies. In in vitro studies of chimeric antigen receptor T cells [6] and bispecific T cell engaging antibodies [7] in AML, less cytolysis was seen with lower T cells to blasts (i.e., effector to target (E:T)) ratios in a dose-dependent relationship. Whether this consideration applies in vivo requires further investigation. To the best of our knowledge, this study is the first to correlate higher baseline T cell infiltration in bone marrow trephines in CN-AML with improved survival. A noted strength of the study was the objective quantitation of large numbers of cells using image analysis software. Although our patient cohort was small, patient outcomes are consistent with larger cohort analyses. Notwithstanding the other limitations of a retrospective design and variability in post-remission therapies, our study introduces the LIL index as a novel prognostic marker in CN-AML, with greatest potential utility in the indeterminate-risk NPM1/FLT3-ITD group. This work provides rationale for further studies to explore the function of the infiltrating T cells, identify T cell subsets that portend the survival benefit, and assess the LIL index in other AML genetic subgroups.