Ganesan Murali

Nonresolving pneumonia and mimics of pneumonia

Physicians caring for patients with community-acquired pneumonia are often faced with the dilemma of how to approach a patient with slowly resolving or even nonresolving pneumonia. When the radiograph has failed to resolve by 50% in 2 weeks or completely in 4 weeks, the pneumonia should be considered to be nonresolving or slowly resolving. The causes of a nonresolving pneumonia and an approach to the work-up are presented.

Life-Threatening Hemoptysis With Thoracic Actinomycosis: Two Case Reports and Review of the Literature

Massive hemoptysis occurs most frequently in bronchiectasis, tuberculosis, or lung cancer. The amount of hemoptysis is typically over 600 mL in a 24- to 48-hour period and requires active resuscitation and close observation in an intensive care unit. It may require aggressive controlling measures such as selective bronchial arterial embolization or surgery. Massive hemoptysis due to actinomycosis is extremely uncommon. We recently evaluated 2 patients with massive hemoptysis due to actinomycosis requiring surgery. To gain a better understanding of the relationship between actinomycosis and hemoptysis, we reviewed published cases in the English literature of hemoptysis associated with actinomycosis.

Effect of obstructive sleep apnea on mitral valve tenting.

Obstructive apneas produce high negative intrathoracic pressure that imposes an afterload burden on the left ventricle. Such episodes might produce structural changes in the left ventricle over time. Doppler echocardiograms were obtained within 2 months of attended polysomnography. Patients were grouped according to apnea-hypopnea index (AHI): mild/no obstructive sleep apnea (OSA; AHI <15) and moderate/severe OSA (AHI ≥15). Mitral valve tenting height and area, left ventricular (LV) long and short axes, and LV end-diastolic volume were measured in addition to tissue Doppler parameters. Comparisons of measurements at baseline and follow-up between and within groups were obtained; correlations between absolute changes (Δ) in echocardiographic parameters were also performed. After a mean follow-up of 240 days mitral valve tenting height increased significantly (1.17 ± 0.12 to 1.28 ± 0.17 cm, p = 0.001) in moderate/severe OSA as did tenting area (2.30 ± 0.41 to 2.66 ± 0.60 cm(2), p = 0.0002); Δtenting height correlated with ΔLV end-diastolic volume (rho 0.43, p = 0.01) and Δtenting area (rho 0.35, p = 0.04). In patients with mild/no OSA there was no significant change in tenting height; there was a borderline significant increase in tenting area (2.20 ± 0.44 to 2.31 ± 0.43 cm(2), p = 0.05). Septal tissue Doppler early diastolic wave decreased (8.04 ± 2.49 to 7.10 ± 1.83 cm/s, p = 0.005) in subjects with moderate/severe OSA but not in in those with mild/no OSA. In conclusion, in patients with moderate/severe OSA, mitral valve tenting height and tenting area increase significantly over time. This appears to be related, at least in part, to changes in LV geometry.