Kamyar Afshar

Epidemiology and Clinical Significance of Pneumocystis Colonization

Pneumocystis pneumonia has long been recognized as a cause of morbidity and mortality in immunocompromised populations, particularly those with HIV infection. Pneumocystis colonization-that is, detection of the organism or its DNA, without signs or symptoms of pneumonia-has recently been described, and accumulating evidence suggests that it may be an important clinical phenomenon. Sensitive molecular techniques such as polymerase chain reaction are frequently used to identify Pneumocystis colonization. Low levels of Pneumocystis in the lungs may stimulate pulmonary inflammation and may play a role in the development of lung diseases such as chronic obstructive pulmonary disease. In this review, we discuss evidence for the occurrence of Pneumocystis colonization in animals as well as the epidemiology and risk factors for Pneumocystis colonization in various human populations. We also evaluate the clinical significance of Pneumocystis colonization and its relationship to lung disease.

Gastric Sarcoidosis and Review of the Literature

Sarcoidosis is a systemic disease with a 90% predilection for the lungs, but any organ can be involved. Gastrointestinal involvement is rare. Within the gastrointestinal system, gastric involvement is the most common. When this organ system is involved, it can be a feature of systemic disease or an isolated case. Gastrointestinal sarcoid can resemble a broad spectrum of other disease processes; thus, it is important for health care providers to be familiar with the various gastrointestinal manifestations. Patients can have subclinical symptoms or have symptoms of epigastric pain, nausea, vomiting, and hematemesis. We present 2 cases of gastric sarcoid and a MEDLINE search of 44 reported cases of gastric sarcoid based on a compatible history and the demonstration of noncaseating granulomas. We describe the clinical manifestations of symptomatic gastric sarcoid in relation to the endoscopic findings.

Aspiration pneumonias: under-diagnosed and under-treated.

Purpose of review To examine recent advancements of the epidemiology, risk factors, bacteriology, diagnostic measures, and treatment for aspiration pneumonia. Recent findings In a large prospective study, 10.3% of community-acquired pneumonia requiring hospitalization was associated with aspiration pneumonia, as opposed to 30% when patients were admitted from long-term facilities. A murine stroke model showed increased apoptosis of cell-mediated immune cells due to overactivation of the sympathetic nervous system. Subsequent nasal inoculum of low-dose Streptococcus pneumoniae caused severe pneumonia. Another murine study showed intratracheal administration of hydrochloric acid-primed lungs more susceptible to infection with Klebsiella pneumoniae. Tracheal pH monitoring demonstrated acidification of trachea in 28% of patients with acute stroke deemed to be safe for oral feeding. Various antimicrobial agents used to treat aspiration pneumonia have comparable success rates. However, clindamycin was the only agent that did not propagate emergence of methicillin-resistant Staphylococcus aureus. Summary Aspiration pneumonia is prevalent in community-acquired pneumonia. Further studies are needed to elucidate the effects of sympathetic nervous system and aspiration pneumonitis as primers for lung infection. Predicting aspiration risk is difficult and newer diagnostic tools are necessary. Antimicrobials used in aspiration pneumonia have similar success rates although the development of resistant organisms must be monitored.

Eosinophil cell: pray tell us what you do!

Purpose of review We will review the role of the eosinophil as an innate immune cell. There have been recent advances in the regulatory mechanisms of the eosinophil, in terms of priming and migration. Additionally, we will discuss certain pulmonary diseases that are associated with eosinophilia. Recent findings Rapid binding of immunoglobulin A-coated beads can prime the eosinophil cell in the trafficking process. Tissue factor has been shown to be expressed within eosinophil granules. It is believed to serve as a critical eosinophil mediator within the peripheral bloodstream. Interleukin-8 serves as a chemoattractant through IL8RA and IL8RB receptors, but patients with an IL8RA-B ht2 have peripheral eosinophilia. Interleukin-10 and eotaxin correlate with eosinophilia and an active infection prior to therapy. After therapy, interleukin-5 and 6 correlated appropriately with eosinophilia. A wide differential diagnosis exists for peripheral eosinophilia. One study has shown that 86 out of 103 patients with unknown causes for peripheral eosinophilia had positive toxocara enzyme-linked immunosorbent assay results. Summary The effect of the cytotoxic eosinophil cell is not only harmful to foreign invaders within the body, but through an intricate immunological pathway, eosinophils can become detrimental to the host organs.

Peritoneal and pleural sarcoidosis : an unusual association -review and clinical report

Purpose of review To examine recent reports of serosal involvement in sarcoidosis. Recent findings Peritoneal sarcoidosis continues to be a rare manifestation of the disease. Patients with peritoneal disease tend to be women between the ages of 20 and 40 years, and most commonly present with ascites and abdominal pain. Peritoneal involvement is not isolated, and sarcoid granulomas are often found elsewhere. Pleural disease is often manifested as pleural effusions. Patients with pleural disease are often older and usually have lymphocytic exudative effusions. Summary Sarcoidosis should be in the differential in a young patient presenting with unexplained effusions and ascites.

Interstitial lung disease: trials and tribulations

Purpose of review To examine recent advancements in the clinical characteristics, treatment and prognosis of diffuse parenchymal disease and pulmonary hypertension due to idiopathic pulmonary fibrosis, scleroderma and sarcoidosis. Recent findings Bosentan can be used in delaying the time to progression of disease in biopsy-proven idiopathic pulmonary fibrosis patients. There are other clinical trials for the utility of pharmaceutical control of lung fibrosis. The use of cyclophosphamide in scleroderma-associated lung fibrosis has a benefit up to 1 year but not so afterwards. Despite many case reports showing benefit, infliximab does not appear to be effective in randomized-controlled trials for the use of pulmonary sarcoidosis. The presence of pulmonary hypertension appears to be an independent risk factor for death. Unfortunately, not all pulmonary hypertension-specific agents are effective in secondary pulmonary hypertension. Summary Lung fibrosis by any cause can be a debilitating disease. Not all current medical options are equally effective under randomized-controlled trials. Further studies with novel therapies are needed to control symptoms. The compounding presence of pulmonary hypertension will further limit the patient activity, quality of life and survival. As it has been reviewed, not all pulmonary hypertension-specific agents effectively work in these three subset groups.

Exudative pleurisy of coccidioidomycosis: a case report and review of the literature.

IntroductionCommunity-acquired pneumonia is the most common manifestation in primary coccidioides infections (Coccidioides immitis, C. posadasii). It is essential that this endemic dimorphic fungus be considered in order to proceed with the most appropriate diagnostic tools and therapy.Case presentationWe present a rare case of primary pleural coccidioides and a review of the current literature for optimal diagnostic methods and therapeutic strategies.ConclusionWith increased domestic and international travel, coccidioidomycosis will likely be encountered in nonendemic regions. Recognition by physicians is critical for a timely diagnosis and therapy. Tissue culture can assist in the diagnosis and polymerase chain reaction analysis shows potential as a possible addition.

Rapidly fatal disseminated acanthamoebiasis in a single lung transplant recipient

BACKGROUND Lung transplant recipients are at great risk for developing various infectious complications. These infections portend a significant morbidity and mortality throughout their lifetime following transplantation. At times, cutaneous manifestations are the only clues to systemic infection. CASE REPORT A 62 year-old man with a history of idiopathic pulmonary fibrosis presented 6 months after receiving bilateral sequential cadaveric lung transplantation for anorexia, early satiety, weight loss, exertional dsypnea, arthralgia, and depression. On exam, two rapidly growing non-painful 1.5-3 centimeter erythematous nodules with purulent draining on the anterior chest wall were noted. On Hospital Day 7, the patent was found to be un-responsive, hypotensive, and febrile. Brain imaging revealed diffuse thick nodular enhancement of leptomeningeal surface and multiple areas of hypodenisty associated with mass effect in the bilateral vermis and cerebellar hemispheres with effacement of the fourth ventricle. CSF PCR analysis showed Acanthamoeba sp. confirmed by the Center for Disease Control. Despite multi-modal therapy, his clinical course deteriorated and resulted in brain death. CONCLUSION Acanthamoeba infection is extremely rare in thoracic organ recipients. We report the fifth case of progressive disseminated acanthamoebiasis in a lung transplant recipient.

Use of Foscarnet Therapy for EBV Infection following Control of PTLD with Enhancement of Cellular Immunity in a Lung-Transplant Recipient

Posttransplant lymphoproliferative disorder (PTLD) is a serious complication following solid organ transplantation with an annual incidence rate of 3–5% in lung-transplant recipients. Pathogenesis indicates a strong association with functional over-immunosuppression and EBV infection. Clinical improvement is generally observed with reduction in immunosuppression intensity alone. We present a case of a 24-year-old woman with EBV-associated PTLD following lung transplant where decreasing the immunosuppression improved PTLD but was ineffective against controlling the EBV infection. Foscarnet in combination with immunoglobulins was successfully administered to cause a remission of the EBV infection. This is the second case reported of a persistent EBV infection after reducing immunosuppression levels and evidence of PTLD remission that required foscarnet for EBV infection control.

Pericardial Constriction After Lung Transplantation

Pericardial constriction is extremely rare after lung transplantation. We present a case and review the potential contributing factors for pericardial constriction after lung transplantation. Treatment for this condition, irrespective of the cause, remains pericardiectomy.