José Echave-Sustaeta

Interferon gamma levels in pleural fluid for the diagnosis of tuberculosis

PURPOSE To assess the utility of interferon gamma levels, including identification of the best cutoff for the diagnosis of tuberculosis. METHODS We prospectively studied consecutive patients in a tertiary care, university-affiliated hospital who had pleural effusions. Interferon gamma levels were measured blindly by radioimmunoassay. The diagnosis of tuberculosis was established using prespecified standard criteria. RESULTS Of the 595 patients with pleural effusions, 82 patients (14%) had tuberculosis. The area under the receiver operating characteristic (ROC) curve for elevated interferon gamma levels in the diagnosis of tuberculosis was 0.99 (95% confidence interval [CI]: 0.97 to 1.00). A cutoff of 3.7 IU/mL yielded a sensitivity of 0.98 (95% CI: 0.91 to 1.00) and a specificity of 0.98 (95% CI: 0.96 to 0.99). The areas under the ROC curves, and the tests sensitivity and specificity, were similar among patients of different ages and by percentage of lymphocytes in the pleural fluid. In 5 of the 28 patients with hematologic malignancies, interferon gamma levels were slightly above the cutoff; no patient with vasculitis or granulomatous diseases had levels higher than 3.7 IU/mL. The 14 immunocompromised patients and the 3 transplantation patients with tuberculosis had interferon gamma levels greater than the cutoff. CONCLUSION Elevated pleural interferon gamma levels (>3.7 IU/mL) are very valuable in diagnosing pleural tuberculosis. Patients with pleural effusion due to hematologic neoplasms occasionally have levels slightly above the cutoff.

Diagnostic value of CA 549 in pleural fluid. Comparison with CEA, CA 15.3 and CA 72.4

Several tumor markers have been evaluated in pleural fluid, but their clinical role has not been firmly established. The aim of this study is to determine the diagnostic value of carbohydrate antigen 549 (CA 549) levels in pleural fluid, and to compare it with another previously studied tumor markers: carcinoembryonic antigen (CEA), CA 15.3 and CA 72.4. We prospectively studied 252 patients with pleural effusion: 101 malignant (20 mesothelioma) and 151 of several benign diseases. The levels of the tumor markers were measured by immunoradiometric assays (RIA). CA 549 in pleural fluid has an acceptable sensitivity (0.49), with high specificity (0.99). The best combination of tumor markers for differentiating malignant from benign effusions was CA 549+CEA+CA 15.3, with a sensitivity of 0.65, specificity of 0.99 and accuracy of 0.85. The addition of any one tumor marker assay consistently improved the diagnostic value of cytology. In our study, none of the tumor markers was organ-specific. When mesothelioma and hematological malignancy were ruled-out, the combination of CA 549+CEA+CA 15.3, improved the results up to a sensitivity of 0.77, specificity of 1 and accuracy of 0.92. In conclusion, CA 549 assay has an acceptable sensitivity with high specificity. The best combination of tumor markers in this series with a high relative frequency of mesothelioma and low frequency of breast carcinoma was CA 549+CEA+CA 15.3. Individual tumor markers or their combination increased the sensitivity of pleural cytology.

Mesotelioma pleural: experiencia durante 9 años y descripción de 62 casos

Objetivo Describir las caracteristicas clinicas, radiologicas, el metodo diagnostico y la evolucion de los pacientes con mesotelioma pleural estudiados en nuestro hospital durante 9 anos Pacientes y Metodo Se ha incluido a todos los pacientes diagnosticados de mesotelioma pleural en nuestro hospital entre enero de 1992 y diciembre de 2000 Resultados Se ha incluido a 62 pacientes (49 varones), con una edad media de 65 anos (rango: 45-85). De ellos, 41 (66%) tenian antecedentes de contacto con asbesto seguro o probable. El 94% presentaba dolor toracico o disnea al comenzar el estudio; el tumor era derecho en 33 pacientes, en 59 habia derrame pleural y en 3 solo engrosamiento pleural. El liquido pleural era hematico en el 19% de los pacientes. El 44% tenia concentraciones de glucosa inferiores a 60 mg/dl, y en el 19% el pH pleural era inferior a 7,20. El diagnostico se realizo en el 52% de los pacientes mediante biopsia pleural, y en el 44% mediante toracoscopia o toracotomia. La mediana de supervivencia fue de 11 meses (intervalo de confianza del 95%, 8-15); la probabilidad de supervivencia fue de 0,22 a los 2 anos, y del 0,09 a los 5 anos. Para los tumores epiteliales la probabilidad de supervivencia era de 0,31 a los 2 anos y de 0,16 a los 5 anos. En el analisis univariante se asociaron al pronostico de supervivencia el estado clinico general (escala de Karnofsky), el numero de plaquetas, la albumina serica, asi como el pH, la glucosa y la lactatodeshidrogenasa pleurales y el tipo histologico Conclusiones Se describen las caracteristicas clinicas, radiologicas, del liquido pleural y la supervivencia de los pacientes con mesotelioma pleural

Diagnóstico ambulatorio de los pacientes que precisan biopsia pleural. Estudio de 100 casos consecutivos

El objetivo de este trabajo ha sido describir nuestra experiencia con la realizacion del estudio ambulatorio de los pacientes que precisan biopsia pleural. Se han incluido en el estudio prospectivamente y de forma consecutiva los 100 primeros pacientes con exudado pleural en los que durante su proceso diagnostico se realizo al menos una biopsia pleural en nuestro servicio, desde enero de 1993, habiendose llevado a cabo el estudio de forma ambulatoria. De todos los pacientes se recogieron las caracteristicas clinicas y radiologicas. Se analizaron tambien las complicaciones, la frecuencia de utilizacion de otras pruebas diagnosticas y el tiempo precisado hasta el diagnostico. Se han estudiado 100 pacientes (64 varones), con una edad media de 56 anos. La edad avanzada, con 35 pacientes mayores de 70 anos, el tamano grande del derrame con 23 derrames grandes, o el diagnostico de patologias de mal pronostico, con 43 derrames neoplasicos, no impidieron el estudio ambulatorio de los pacientes. Las complicaciones de la biopsia pleural fueron similares a otras series. El tiempo medio empleado hasta la consecucion del diagnostico fue de 7,4 dias. El diagnostico de los pacientes con derrame pleural que precisen la realizacion de biopsia pleural se puede realizar frecuentemente de forma ambulatoria, incluyendo pacientes con un amplio espectro de condiciones clinicas, sin incrementarse el numero de complicaciones, con una demora aceptable en la consecucion del diagnostico.

Persistent cavitations in pulmonary mucormycosis after apparently successful amphotericin B

A 67-year-old diabetic male developed bilateral pulmonary mucormycosis (PM). After long-term treatment with amphotericin B (cumulative dose of 30.6 g), clinical resolution was obtained, but small radiographic cavitations persisted. A late relapse occurred and bilateral lobectomy led to a definitive cure. Amphotericin B is not able to penetrate properly into PM cavitations. We suggest that persistence of cavitations should lead to consideration of surgery, even after a good response to amphotericin B.

Ventilación mecánica en hospitalización neumológica. Evolución en el período 1994-2000

OBJECTIVE: To investigate the absolute and relative frequency of mechanical ventilation in the management of patients on a respiratory medicine ward between 1994 and 2000. To describe reasons for admission, mean hospital stay and outcomes. SETTING: A tertiary-care university hospital. METHODS: Observational, descriptive study of a case series. RESULTS: During the study period, 257 admissions involved mechanical ventilation of 132 patients. During that time, there was a progressive increase in the total number of ventilated patients as well as in the relative frequency, such that ventilated patients eventually accounted for 6.1% of all admissions for respiratory care in 2000. Nearly 80% of admissions were related to the services home mechanical ventilation program, either to initiate and adapt ventilation for new patients or to treat exacerbations or diagnose and treat other medical or surgical problems in already-ventilated patients. Patients transferred from the intensive care unit (ICU) because of weaning difficulties (median ventilation, 31 days) had the highest mean stay. Nine of the 132 patients had to be transferred to the ICU and 18 died while hospitalized (7% of admissions and 13.6% of patients). The patients who died were those who were more acutely and severely ill (acute exacerbation in home-ventilated patients, patients with acute respiratory failure treated initially with non-invasive ventilation and patients transferred from the ICU due to weaning difficulties). CONCLUSIONS: Admissions requiring mechanical ventilation have increased and most are related to the home mechanical ventilation program. The mean stay and the mortality rate were related to the reason for admission.

Síndrome de Pancoast secundario a linfoma no hodgkiniano

El sindrome de Pancoast habitualmente es secundario a un carcinoma broncogenico. Describimos un caso de linfoma no hodgkiniano que se manifesto clinicamente con sindrome de Pancoast, en un paciente con una toracoplastia previa.

[Pleural mesothelioma: experience with 62 cases in 9 years].

OBJECTIVES To describe the diagnostic approach, clinical and radiological characteristics, and survival of patients with pleural mesothelioma treated in our hospital over a 9-year period. PATIENTS AND METHOD All patients with a diagnosis of pleural mesothelioma diagnosed in our hospital from January 1992 through December 2000 were studied. RESULTS Sixty-two patients (49 men) with a mean age of 65 years (range, 45-85) were diagnosed. Probable or known contact with asbestos was established for 41 patients (66%). Ninety-four percent of the patients had chest pain or dyspnea at the onset of clinical assessment. The tumor was situated in the right hemithorax in 33 patients; 59 patients had pleural effusion, and 3 only had pleural thickening. The pleural fluid was bloody in 19% of patients, glucose levels were less than 60 mg/dL in 44%, and the pH of pleural fluid was less than 7.20 in 19%. The diagnosis was established by pleural biopsy for 52%, and by thoracoscopy or thoracotomy for 44%. The median survival was 11 months (95% confidence interval, 8-15); the probability of survival was 0.22 after 2 years, and 0.09 after 5. For the subgroup of patients with epithelial tumors the probability of survival was 0.31 after 2 years and 0.16 after 5 years. In the univariate analysis the predictors of survival were general clinical status (Karnofsky scale), platelet count, serum albumin level, pleural pH, glucose and lactate dehydrogenase levels, and histological type. CONCLUSIONS The clinical, radiological, and biochemical characteristics of the pleural fluid from patients with pleural mesothelioma and their survival rate were described.

Lymphoid Interstitial Pneumonia Resolved Through Antiretroviral Therapy in an Adult Infected by Human Immunodeficiency Virus

Lymphoid interstitial pneumonia (LIP) is a rare entity characterized by the infiltration of interstitial tissues and alveolar spaces by lymphocytes, plasma cells, and other lymphoreticular structures. The etiology of LIP is unknown, although associations with autoimmune and infectious factors have been described. The incidence of LIP has risen in recent years, mainly in children with acquired immunodeficiency syndrome (AIDS), while remaining less common in the adult population. No agreement has been reached regarding the diagnostic tests necessary for a firm diagnosis although suspicion is usually based on clinical and radiographic findings, with confirmation provided by examination of histological samples. The most common treatment is corticosteroids, either alone or in combination with other immunosuppressant agents although no evidence from controlled trials is available and cases have been reported in which LIP resolved in AIDS patients with antiretroviral therapy alone. We report the case of a human immunodeficiency virus-infected adult who was diagnosed with LIP by open lung biopsy and who responded to antiretroviral drugs with no need for associated corticosteroid therapy.

Toxicidad pulmonar recurrente por amiodarona tras retirada del fármaco y tratamiento con corticoides

Presentamos el caso de una recidiva de toxicidad pulmonar por amiodarona 4 meses despues de la suspension del farmaco y mientras seguia tratamiento con corticoides. Se sugieren como posibles causas la persistencia de niveles sanguineos elevados de amiodarona y el rapido descenso de la dosis de corticoides.