Kornelija Miše

Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995–2006

BackgroundTracheobronchial foreign body (TFB) removal in adult patients using the combined technique of flexible bronchoscopy (FBSC) through the endotracheal tube as well as using the simple FBSC has not often been described. This study reports our experience with FBSC for removal of TFBs and describes diagnosis, techniques of removal, and types of TFBs.MethodsWe retrospectively examined bronchoscopic records of adult patients performed between 1995 and 2006 and collection of foreign bodies in Clinical Department for Respiratory Diseases, University Hospital Split, Croatia.ResultsTFBs were found in 86 (0.33%) out of 26,124 patients who were submitted to bronchoscopy. The majority of the patients (90%) had some risk factor for aspiration, among which stroke (30%) was the most frequent. Patients with different neurologic and neuromuscular diseases together accounted for 58% of all patients with TFB aspiration. Medical history was suggestive of foreign body aspiration in 38.4% of the patients, while chest X-ray was indicative in 7% of the patients. TFBs were most often found in the right bronchial tree (75.6%). The most common TFBs were animal and fish bones (39.5%). In 90.7% of the patients they were successfully removed under FBSC, whereas in 8.1% of the patients a TFB was extracted with flexible bronchoscope through endotracheal tube. Surgery was needed in only one case.ConclusionsAlthough foreign bodies in the tracheobronchial tree are rare in adults, the clinician must be aware of their likelihood. Foreign body aspiration should be considered especially in the etiology of recurrent lung diseases and in the presence of risk factors for aspiration, in particular with different neurologic and neuromuscular diseases. They can be successfully and safely removed in the majority of patients under local anesthesia by using FBSC. In cases when repeated procedure is needed, endotracheal tube is recommended.

The influence of gastroesophageal reflux in the lung: A case–control study

Background and objective:  Many researchers have investigated the pH of exhaled breath condensate but direct measurement of pH in the lung has not been performed in vivo in humans. We hypothesized that the pH measured directly in the lung would differ between healthy subjects and patients with gastroesophageal reflux disease (GERD). We also wished to determine whether an acidic environment in the lung influences pulmonary function and DLCO, and whether microaspiration of gastric contents directly influences non‐specific inflammation in the lung.

A rare case of pulmonary tuberculosis with simultaneous pulmonary and skin sarcoidosis: a case report

BackgroundTuberculosis and sarcoidosis are chronic diseases that rarely occur concomitantly. Sarcoidosis is a multisystem granulomatous disorder characterized pathologically by the presence of non-caseating granulomas in involved tissues. Tuberculosis is infectious disease caused by Mycobacterium tuberculosis characterized by granulomas with caseous necrosis.Case presentationWe present a case of 43-year-old female refugee from Kosovo with microbiological confirmation of pulmonary tuberculosis and pulmonary and skin sarcoidosis at the same time. Three weeks after corticosteroid therapy for pulmonary sarcoidosis was introduced, positive finding of mycobacterium culture of bronchial aspirate was observed. Based on these results, corticosteroid therapy was excluded and antituberculous therapy was introduced for six months. In the meantime, new nodes on face and nose appeared and skin sarcoidosis was diagnosed. The patient was given corticosteroids and colchicine according to the skin and pulmonary sarcoidosis therapy recommendation.ConclusionThe authors of this study suggest that in cases when there is a dilemma in diagnosis between tuberculosis and sarcoidosis we should advance with corticosteroid therapy until we have microbiological confirmation of mycobacterium culture. This case is remarkable because this is a third described case of sarcoidosis and tuberculosis together (the first reported in Asia, the second in South Africa), and to authors knowledge, this is a first case report in Europe.

Bronchoalveolar pH and inflammatory biomarkers in newly diagnosed IPF and GERD patients: A case-control study

Background Several studies have suggested that idiopathic pulmonary fibrosis (IPF) may be related to repeated aspiration of gastric contents over long periods of time. We aimed to investigate differences between pH measured directly in the lung, and biomarkers of acute inflammation in patients with newly diagnosed IPF and in patients with newly diagnosed GERD. Material/Methods All subjects (N=61) underwent collection of medical history, physical examination, pulmonary function testing, bronchoscopy, endoscopy, arterial blood gas analyses, and biochemical testing. Results Previously diagnosed GERD was found in 56.7%, typical symptoms of reflux in 80%, and Helicobacter pylori in gastric biopsy specimens in 76.6% of the cases. pH in peripheral branches of bronchi in the cases was 5.32±0.44 and was 6.27±0.31 (p<0.001) in the control group. The average values of LDH, ALP, and CRP in bronchoalveolar aspirate and in serum, as well as TNF-α in bronchoalveolar aspirate, were significantly higher in IPF patients. Conclusions The more acidic environment in the bronchoalveolar aspirate of the IPF subjects could contribute to the development or progression of IPF, possibly via changes in local metabolism or by damaging local cells and tissue. However, further studies with larger numbers of patients are required to clarify the role of gastric fluid aspiration in IPF pathogenesis. Our preliminary work has identified inflammatory biomarkers LDH, ALP, and TNF-α as potentially important in the pathologic processes in IPF. Further research is needed to determine their importance in clinical intervention and patient care.

Intraregional differences in asthma prevalence and risk factors for asthma among adolescents in Split-Dalmatia County, Croatia

Summary Background Our aim was to assess the differences in intraregional prevalence of asthma in adolescents in Split-Dalmatia County to determine asthma risk factors in our population and estimate the specificity and sensitivity of the questionnaire used. Material/Methods We conducted the study using the European Community Respiratory Health Survey II short questionnaire supplemented by some questions from the International Study of Asthma in Childhood questionnaire. The participants suspected to have asthma were invited for examination by an asthma specialist who established the final diagnosis of asthma according to the medical history, physical examination, skin-prick tests, and peak flow measurements. Results A total of 4027 students (51.2% male) participated in the study. According to the prevalence of wheezing during the last 12 months, asthma prevalence was estimated at 9.7%. The total prevalence of asthma confirmed by an asthma specialist in the selected population was 5.60% (95% CI, 4.93–6.36%); 6.18% in Split (95% CI, 5.37–7.09), 5.63% in Imotski (95% CI, 3.48–8.58), and 2.90% in Sinj (95% CI, 1.67–4.68) (P=0.0028). We found sensitization to aeroallergens and peanuts, and active smoking to be independent risk factors for asthma. Conclusions Split-Dalmatia County has moderate asthma prevalence, with a significant intraregional difference. Asthma prevalence estimated by a questionnaire (9.7%) overestimates the prevalence of asthma confirmed by an asthma specialist (5.6%) in adolescents in Croatia. Our data confirmed the need of a more complex questionnaire to evaluate the accurate prevalence of current asthma or the need for subsequent clinical evaluation of the questionnaire obtained data. Allergic sensitization to aeroallergens and active smoking were important risk factors for asthma.

Sarcoidosis and tuberculosis in South Croatia: Are there epidemiological similarities or not?

OBJECTIVE Tuberculosis and sarcoidosis are chronic granulomatous diseases. Clinical, pathologic and immunologic aspects are similar although different. The authors were interested to highlight possible epidemiological similarities of these two granulomatous diseases. The objective of this study was to evaluate incidence rate as well as age, sex and geographic distribution of sarcoidosis in South Croatia and to compare it with these epidemiological characteristics of tuberculosis. STUDY DESIGN Retrospective. METHODS The study was including ten years follow up period (1997-2006), and was performed in Split-Dalmatia County, Croatia. All data were collected retrospectively and analyzed using Statistica 7 programme. RESULTS The mean annual incidence of sarcoidosis was 3.3/100,000 inhabitants with a mean of 15,6 cases per year. Woman accounted for 61% of all sarcoidosis cases. The mean sarcoidosis patient age was 44.94 ± 11.85 years. The peak age group was 40-49 years (31%). Significant difference according to incidence rate on the islands comparing to the rates on the coast and the mainland was observed (P = 0.003). The mean sarcoidosis mortality rate was 1.2/100,000. Statistically significant differences between sarcoidosis and tuberculosis were observed according the higher number of tuberculosis patients (P < 0.000), among males (P < 0.000), and females, too (P < 0.000) as well as in mortality rates (P = 0.401). Significantly more patients had tuberculosis on the mainland (P < 0.000) and on the coast (P < 0.000), but not in the islands (P = 0.260). CONCLUSIONS The results from this study showed dissimilarities in classic epidemiological patterns between sarcoidosis and tuberculosis, incidence rates, as well as sex and geographic distribution. Our findings resulted from this study might be starting point for the future epidemiological, genetic, and immunological studies.

Interobserver Variations in Diagnosing Asbestosis According to the ILO Classification

Interobserver Variations in Diagnosing Asbestosis According to the ILO Classification Inhalation of asbestos fibres leads to asbestosis of the pleura and the lung, with possible progression to lung cancer and malignant pleural or peritoneal mesothelioma. Asbestosis remains difficult to diagnose, especially in its early stages. The most important role in its diagnosis is that of chest radiographs. The aim of this cross-sectional study was to address interobserver variations in interpreting chest radiographs in asbestos workers, which remain to be an issue, despite improvements in the International Labour Office (ILO) classification system. In our ten-year study, we investigated 318 workers occupationally exposed to asbestos, and in 210 workers with diagnosed asbestos-related changes we compared interpretations of chest radiographs according to ILO by two independent radiologists. The apparent degree of interobserver variation in classifying lung fibrosis was 26.66% for the diameter of changes and 42.2% for the profusion of the changes. In cases with diffuse pleural thickening, the interobserver variation using ILO procedures was 34.93%. This investigation raises the issue of standardisation and objectivity of interpretation of asbestosis according to the ILO classification system. This study has revealed a significant disagreement in the estimated degree of pleural and parenchymal asbestos pulmonary disease. This is why we believe high-resolution computed tomography (HRCT) should also be used as a part of international classification. Interopservacijske razlike u dijagnosticiranju azbestoze prema klasifikaciji ILO

The Role of Interferon-Gamma Release Assay in Tuberculosis Control

The Role of Interferon-gamma Release Assay in Tuberculosis Control Tuberculosis is still one of the major global public health threats. Countries with low incidence must focus on exhausting the reservoir of future cases by preventing reactivation. Therefore, it is important to identify and effectively treat those individuals who have latent tuberculosis infection and who may develop active disease. The tuberculin skin test has been the standard for detection of immune response against M. tuberculosis since the beginning of the 20th century. The new millennium has brought advancement in the diagnosis of latent tuberculosis infection. The name of the new blood test is interferon-gamma release assay (IGRA). Croatia is a middle-incidence country with a long decreasing trend and developed tuberculosis control. To reach low incidence and finally eliminate tuberculosis, its tuberculosis programme needs a more aggressive approach that would include intensive contact investigation and treatment of persons with latent tuberculosis infection. This article discusses the current uses of IGRA and its role in tuberculosis control. Uloga testova otpuštanja interferona gama u nadzoru nad tuberkulozom Tuberkuloza je i danas jedan od vodećih javnozdravstvenih problema. Zemlje s niskom incidencijom fokusiraju se na iscrpljivanje rezervoara budućih slučajeva sprječavanjem reaktivacije bolesti. To se odnosi na traženje i učinkovito liječenje inficiranih osoba, primarno onih koje su u riziku od obolijevanja nakon infekcije. Tuberkulinski test je od početka 20. stoljeća bio standard u otkrivanju imunosnog odgovora na kontakt s Mycobacterium tuberculosis. Novo tisućljeće donijelo je određeni napredak u obliku novih testova za dijagnozu latentne tuberkulozne infekcije, krvne testove otpuštanja interferona gama. Hrvatska je zemlja srednje incidencije tuberkuloze s dugogodišnjim silaznim trendom i razvijenim protutuberkuloznim aktivnostima. U težnji prema niskoj incidenciji i u konačnici eliminaciji tuberkuloze potrebne su opsežnije aktivnosti unutar državnog programa nadzora nad tuberkulozom, uključujući intenzivnu obradu kontakata i probir na postojanje latentne tuberkulozne infekcije. Ovaj rad razmatra trenutačnu uporabu IGRE (engl. interferon - gamma release assay) i njezinu ulogu u nadzoru nad tuberkulozom.

Undiagnosed AIDS in patients with progressive dyspnoea: an occupational risk for healthcare workers in Croatia.

Undiagnosed AIDS in Patients with Progressive Dyspnoea: An Occupational Risk for Healthcare Workers in Croatia Pulmonary diseases are well documented and diverse in many patients with HIV in clinical stages 3 and 4. It is not unusual that these patients, most of whom do not know that they are already HIV-infected, are first examined and hospitalised by respiratory medicine specialists. While HIV-infection is relatively simple to diagnose if accompanied by advanced clinical manifestations and is regularly checked in patients with increased risk, this is not the case in low-risk patients, particularly in countries with low-level HIV epidemic and therefore low index of suspicion. Regular examination involves a series of tests, often including bronchoscopy with transbronchal lung biopsy in order to identify an interstitial lung disease and/or progressive dyspnoea. It is not uncommon that patients provide false or incomplete information about their lifestyle, which can mislead the clinician. At this point, HIV-infection is usually not suspected and healthcare workers may not strictly be following the safety principles which are otherwise applied when HIV-infection is known or suspect, although universal precautions are routine practice. At this point, the risk of exposure is the highest and HIV-transmission to healthcare workers is the most likely to occur. The cases presented here indicate that patients with progressive dyspnoea, which is typical of interstitial lung diseases, should undergo HIV-testing as a part of good clinical practice, even in a country with low-level HIV epidemic. Nedijagnosticirani AIDS u bolesnika s progresivnom dispnejom: profesionalni rizik za zdravstvene djelatnike u Hrvatskoj Različiti oblici plućnih bolesti detaljno su opisani u mnogih pacijenata inficiranih HIV-om te značajno pridonose kliničkoj slici AIDS-a. Stoga takve pacijente, koji obično i ne znaju da su HIV-pozitivni, najčešće obrađuju i hospitaliziraju specijalisti za plućne bolesti. Posumnjati na AIDS i tu pretpostavku potvrditi nije problem kod pacijenata s razvijenim kliničkim manifestacijama AIDS-a, a ni u pacijenata s poznatim rizičnim čimbenicima. Teškoće u postavljanju prave dijagnoze nastaju obično u pacijenata u kojih rizični čimbenici nisu poznati ili ih pacijenti namjerno skrivaju, posebno u zemlji niske incidencije HIV-infekcije u kojoj se na AIDS ne pomišlja dovoljno u diferencijalnoj dijagnozi. Tijekom dijagnostičkog procesa pacijent prolazi niz testova i pretraga, koji često uključuje bronhoskopiju i transbronhalnu biopsiju pluća s ciljem identificiranja patologije plućnog intersticija i/ili progresivne dispneje. S obzirom na to da pacijenti često taje podatke o svojim navikama i životnom stilu, kliničar može biti zavaran glede pravog smjera u postavljanju dijagnoze. Upravo u tom razdoblju, dok se ne pomišlja na mogući AIDS, mjere opreza zbogh prijenosa infekcije, kojih se liječnik inače pridržava kad je takva dijagnoza poznata, nisu uvijek strogo poštivane, premda to mora biti dijelom uobičajene prakse. Stoga je u takvim okolnostima rizik od izloženosti i moguće HIV-transmisije na zdravstvene djelatnike velik. Ovdje prikazani slučajevi upućuju na potrebu da se pacijenti s progresivnom dispnejom, tipičnom za bolesti plućnog intersticija, testiraju na prisutnost HIV-a kao dio dobre kliničke prakse, čak i u zemlji niske razine HIV-infekcije.

Long‐term course and treatment of a cutaneous BCG infection

The authors report and discuss a rare case of the long‐term course and treatment of cutaneous BCG infection in an HIV‐negative, healthy nurse. Over 5 years we cured the wrist and lower leg cutaneous tuberculosis infection caused by an accident at work. Persistent antituberculous therapy and surgical procedure were applied, but after detection of an encapsulated abscess in the wrist followed by needle aspiration, antituberculous therapy was sufficient and our patient was cured. Failing the addition of local applications, antituberculous therapy with radical surgical treatment remains the recommended treatment in cutaneous infections.