Hsu-Tah Kuo

Clinical and Laboratory Features of Severe Acute Respiratory Syndrome Vis-A ` -Vis Onset of Fever*

Study objectives: Severe acute respiratory syndrome (SARS) is a rapidly progressive disease caused by a novel coronavirus (CoV) infection. However, the disease presentation is nonspecific. The aim of this study was to define clearly the presentation, clinical progression, and laboratory data in a group of patients who had SARS. Design: Retrospective observational study. Setting: A tertiary care medical center with 51 negative-pressure isolation rooms in Taipei, Taiwan. Patients: Fifty-three patients with SARS seen between April 27 and June 16, 2003. Results: Fever (ie, temperature > 38°C) was the most common symptom (98%) and the earliest. When admitted to the isolation unit of the hospital for observation, most patients reported nonspecific symptoms associated with their fever. Only two patients with preexisting illnesses had cough on the same day the fever began. Eventually, 39 patients (74%) developed cough, beginning at a mean (± SD) time of 4.5 ± 1.9 days after fever onset, and 35 patients (66%) had diarrhea beginning at a mean time of 6.0 ± 3.3 days after fever onset. Thirty-one patients (59%) had abnormal findings on chest radiographs on hospital admission, and all but 1 patient (98%) eventually developed lung infiltrates that were consistent with pneumonia. The majority of patients (63%) first developed unifocal infiltrates at a mean time of 4.5 ± 2.1 days after fever onset, while in 37% of patients the initial infiltrates were multifocal, appearing at a mean time of 5.8 ± 1.3 days after fever onset. Common laboratory findings included lymphopenia (on hospital admission, 70%; during hospitalization, 95%), thrombocytopenia (on hospital admission, 28%; during hospitalization, 40%), elevated lactate dehydrogenase (on hospital admission, 58%; during hospitalization, 88%), creatine kinase (on hospital admission, 18%; during hospitalization, 32%), and aspartate aminotransferase or alanine aminotransferase levels (on hospital admission, 27%; during hospitalization, 62%). Throat or nasopharyngeal swab for SARS-CoV by reverse transcriptase polymerase chain reaction (PCR) and real-time PCR was positive in 40 of the 47 patients (85%) in whom the test was performed. Conclusions: None of the presenting symptoms or laboratory findings are pathognomonic for SARS. Even though cough developed in a majority of patients, it did not occur until later in the disease course, suggesting that a cough preceding or concurrent with the onset of fever is less likely to indicate SARS. While PCR for SARS-CoV appears to be the best early diagnostic test currently available, it is clear that better methods are needed to differentiate between SARS and non-SARS illness on initial presentation.

Effect of a Hospital-based Case Management Approach on Treatment Outcome of Patients with Tuberculosis

Background/Purpose Tuberculosis (TB) continues to pose a heavy public health burden in Taiwan. This prospective study analyzed the factors influencing treatment outcome in patients with TB treated with and without a hospital-based case management (HBCM) approach in a referral center in Taipei. Methods A register-based cohort study design was used to enroll all new cases of pulmonary or extra-pulmonary TB from February 2003 to January 2004. The case manager served as the coordinator among patients, physicians and public health nurses, to facilitate compliance with anti-TB treatment. Treatment outcomes were assessed according to the consensus recommendations of the World Health Organization and the International Union Against Tuberculosis and Lung Disease. Results Suspected or confirmed pulmonary or extrapulmonary TB was diagnosed in 524 patients in our hospital from February 2003 to January 2004. Fifty-two of these patients were excluded due to duplicate reporting, previous treatment or death before enrollment. Out of 472 patients enrolled, 103 whose original diagnosis was revised were further excluded, leaving 369 cases eligible for analysis. Patients with case management had a significantly higher rate of successful treatment (cured plus completed treatment) compared to patients without case management, (240/277, 86.6% vs. 67/92, 72.8%; p = 0.002). The overall successful treatment rate including both case and non-case management was 83.2% (307/369), which was higher than the nationwide surveillance data of 78.3% in 2002 and 69.4% in 2003. Conclusion Treatment of TB patients by a HBCM approach provides improved treatment outcomes compared to those without case management.

Pulmonary Infection after Appendectomy: A Rare Case Report and Literature Review

We describe an unusual case of a lung abscess and empyema after an open appendectomy for a perforated appendix. A previously healthy 52-year-old man was admitted complaining of fever and abdominal pain. Open appendectomy and drainage of an extraperitoneal abscess were performed. Four weeks later, he developed pleuritic chest pain, and an air-fluid level was seen on the chest X-ray, accompanied by pleural fluid. Frank pus was aspirated from empyema on the right side via echo-guided thoracocentesis. The lung abscess and empyema resolved after surgical drainage and prolonged antibiotic therapy. The patient has since remained well on outpatient follow-up.

Posterior Mediastinal Paraganglioma: A Case Report and Literature Review

Mediastinal paragangliomas are rare tumors that are commonly benign, may be malignant. Once detected, surgical resection is always suggested. We present a rare case of an extra-adrenal paraganglioma in the posterior mediastinum. A 52-year-old previously healthy man was admitted because of mild chest pain, dry cough, and dyspnea after trauma to the chest more than 1 week prior to admission. The chest X-ray showed a large shadow in the left posterior mediastinum. The patient denied recent fever, weight loss, hoarseness, dizziness, or hemoptysis. He underwent a left posterolateral thoracotomy with complete removal of the tumor. Histopathologic examination revealed a mediastinal paraganglioma. The patients postoperative recovery was uneventful and he has remained well on outpatient follow up.

Pseudomembranous Tracheobronchitis Caused by Aspergillus in an Immunocompromised Patient-A Case Report

Invasive aspergillosis is a leading cause of death in immunocompromised patients. We herein report a case of pseudomembranous tracheobronchitis caused by Aspergillus in an immunocompromised patient. A 45-year-old woman with diabetes mellitus presented with chest pain and cough. She was found to be in diabetic ketoacidosis and was treated for that and possible respiratory sepsis. She subsequently developed airway obstruction and respiratory failure. Bronchoscopic examination revealed pseudomembranous tracheobronchitis with granulation tissue obstructing several bronchi. The pseudomembrane consisted histologically of septate hyphae branching at 45°, consistent with Aspergillus species. Despite mechanical ventilation and antifungal therapy, the patient succumbed to progressive obstructive respiratory failure. Aspergillus tracheobronchitis should be considered in immunocompromised patients presenting with cough, chest pain, fever, dyspnea and upper airway obstruction. Early bronchoscopy and histologic examination should be performed and all clinical isolate of Aspergillus spp should be identified to species level because early definitive treatment may be life-saving.

Percutaneous Stenting for Malignant Superior Vena Cava Syndrome: A Case Report and Review of the Literature

Superior vena cava (SVC) syndrome is the clinical expression for the significant narrowing or occlusion of the SVC and its branches. Malignancies (especially lung cancers) are the underlying cause in 80-85% of cases. Radiation therapy and chemotherapy are often used to treat malignant SVC syndrome. However, both result in slow and sometimes incomplete regression of the symptoms. With the refinement of endovascular stents in recent years, the percutaneous insertion of a metallic intravascular stent has improved the outcome and lessened the morbidity of SVC syndrome. We report a 74-year-old woman who had been diagnosed with squamous cell carcinoma of the lung, stage IIIB, 3 months previously, and who declined chemotherapy. She developed SVC syndrome about 2 weeks prior to admission. Her symptoms were not relieved by palliative radiotherapy. Balloon dilatation of the stricture was performed, and a 14 mm metallic stent was placed in the right subclavian vein and SVC. Symptoms improved thereafter, although she had fluctuating right arm swelling about one week later, but this was less severe and extensive than the initial event.