Olívia Meira Dias

Fatores associados à maior mortalidade e tempo de internação prolongado em uma unidade de terapia intensiva de adultos.

OBJETIVO: A unidade de terapia intensiva e sinonimo de gravidade e apresenta taxa de mortalidade entre 5,4% e 33%. Com o aperfeicoamento de novas tecnologias, o paciente pode ser mantido por longo periodo nessa unidade, ocasionando altos custos financeiros, morais e psicologicos para todos os envolvidos. O objetivo do presente estudo foi avaliar os fatores associados a maior mortalidade e tempo de internacao prolongado em uma unidade de terapia intensiva adulto. METODOS: Participaram deste estudo todos os pacientes admitidos consecutivamente na unidade de terapia intensiva de adultos, clinica/cirurgica do Hospital das Clinicas da Universidade Estadual de Campinas, no periodo de seis meses. Foram coletados dados como: sexo, idade, diagnostico, antecedentes pessoais, APACHE II, dias de ventilacao mecânica invasiva, reintubacao orotraqueal, traqueostomia, dias de internacao na unidade de terapia intensiva, alta ou obito na unidade de terapia intensiva. RESULTADOS: Foram incluidos no estudo 401 pacientes, sendo 59,6% homens e 40,4% mulheres, com idade media de 53,8±18,0 anos. A media de internacao na unidade de terapia intensiva foi de 8,2±10,8 dias, com taxa de mortalidade de 13,46%. Dados significativos para mortalidade e tempo de internacao prolongado em unidade de terapia intensiva (p 11, traqueostomia e reintubacao. CONCLUSAO: APACHE >11, traqueostomia e reintubacao estiveram associados, neste estudo, a maior taxa de mortalidade e tempo de permanencia prolongado em unidade de terapia intensiva.

Adalimumab-induced acute interstitial lung disease in a patient with rheumatoid arthritis

The use of immunobiological agents for the treatment of autoimmune diseases is increasing in medical practice. Anti-TNF therapies have been increasingly used in refractory autoimmune diseases, especially rheumatoid arthritis, with promising results. However, the use of such therapies has been associated with an increased risk of developing other autoimmune diseases. In addition, the use of anti-TNF agents can cause pulmonary complications, such as reactivation of mycobacterial and fungal infections, as well as sarcoidosis and other interstitial lung diseases (ILDs). There is evidence of an association between ILD and the use of anti-TNF agents, etanercept and infliximab in particular. Adalimumab is the newest drug in this class, and some authors have suggested that its use might induce or exacerbate preexisting ILDs. In this study, we report the first case of acute ILD secondary to the use of adalimumab in Brazil, in a patient with rheumatoid arthritis and without a history of ILD.

Tomografia por emissão de pósitrons com 18F fluordesoxiglicose como exame não invasivo para o diagnóstico de sarcomas primários de artéria pulmonar

Os sarcomas de arteria pulmonar sao tumores raros e de dificil diagnostico, simulando frequentemente o tromboembolismo pulmonar cronico. Relatamos dois casos de pacientes do sexo feminino com quadro clinico de dispneia e massas pulmonares associadas a falhas de enchimento na arteria pulmonar em angiotomografia de torax. A tomografia por emissao de positrons com 18F fluordesoxiglicose mostrou hipercaptacao das respectivas lesoes. O sarcoma de arteria pulmonar foi confirmado posteriormente por exame anatomopatologico. Ressaltamos a importância do uso desse tipo de tomografia como exame nao invasivo no auxilio diagnostico desses tumores

Lung-dominant connective tissue disease among patients with interstitial lung disease: prevalence, functional stability, and common extrathoracic features

OBJECTIVE: To describe the characteristics of a cohort of patients with lung-dominant connective tissue disease (LD-CTD). METHODS: This was a retrospective study of patients with interstitial lung disease (ILD), positive antinuclear antibody (ANA) results (≥ 1/320), with or without specific autoantibodies, and at least one clinical feature suggestive of connective tissue disease (CTD). RESULTS: Of the 1,998 patients screened, 52 initially met the criteria for a diagnosis of LD-CTD: 37% were male; the mean age at diagnosis was 56 years; and the median follow-up period was 48 months. During follow-up, 8 patients met the criteria for a definitive diagnosis of a CTD. The remaining 44 patients comprised the LD-CTD group, in which the most prevalent extrathoracic features were arthralgia, gastroesophageal reflux disease, and Raynauds phenomenon. The most prevalent autoantibodies in this group were ANA (89%) and anti-SSA (anti-Ro, 27%). The mean baseline and final FVC was 69.5% and 74.0% of the predicted values, respectively (p > 0.05). Nonspecific interstitial pneumonia and usual interstitial pneumonia patterns were found in 45% and 9% of HRCT scans, respectively; 36% of the scans were unclassifiable. A similar prevalence was noted in histological samples. Diffuse esophageal dilatation was identified in 52% of HRCT scans. Nailfold capillaroscopy was performed in 22 patients; 17 showed a scleroderma pattern. CONCLUSIONS: In our LD-CTD group, there was predominance of females and the patients showed mild spirometric abnormalities at diagnosis, with differing underlying ILD patterns that were mostly unclassifiable on HRCT and by histology. We found functional stability on follow-up. Esophageal dilatation on HRCT and scleroderma pattern on nailfold capillaroscopy were frequent findings and might come to serve as diagnostic criteria.

Reexpansion pulmonary edema after therapeutic thoracentesis

Reexpansion pulmonary edema is a rare complication resulting from rapid emptying of air or liquid from the pleural cavity performed by either thoracentesis or chest drainage. Despite being infrequent, mortality may occur in up to 20% of cases and is attributed to the abrupt reduction in pleural pressure, especially as a result of extensive pneumothorax drainage or when there is long‐term pulmonary collapse.1,2 We report the case of a young patient who experienced intense chest discomfort during thoracentesis for relief of dyspnea.

Combined pulmonary fibrosis and emphysema: an increasingly recognized condition

Combined pulmonary fibrosis and emphysema (CPFE) has been increasingly recognized in the literature. Patients with CPFE are usually heavy smokers or former smokers with concomitant lower lobe fibrosis and upper lobe emphysema on chest HRCT scans. They commonly present with severe breathlessness and low DLCO, despite spirometry showing relatively preserved lung volumes. Moderate to severe pulmonary arterial hypertension is common in such patients, who are also at an increased risk of developing lung cancer. Unfortunately, there is currently no effective treatment for CPFE. In this review, we discuss the current knowledge of the pathogenesis, clinical characteristics, and prognostic factors of CPFE. Given that most of the published data on CPFE are based on retrospective analysis, more studies are needed in order to address the role of emphysema and its subtypes; the progression of fibrosis/emphysema and its correlation with inflammation; treatment options; and prognosis.

Gastropleural fistula from gastric perforation due to renal cell carcinoma after bevacizumab chemotherapy: a case report

A 39-year-old female was admitted for antibiotic treatment of sepsis of unknown origin, which had been empirically treated with piperacillin-tazobactam. The patient had previously (five months prior) been diagnosed with renal cell carcinoma with clear cell histological features and had undergone a left partial nephrectomy without excision of the entire tumor. Three months before admission, the patient was recruited to participate in a clinical trial investigating hepatic and pancreatic metastasis; the participants received interferon and bevacizumab in one of the protocols. The patient did not present any indication of pulmonary involvement from cancer in a tomography scan taken one month before admission. During her hospital stay, the patient presented a sudden onset of shortness of breath, tachypnea, and chest discomfort without hemodynamic repercussion. On physical examination, the patient exhibited decreased breath sounds in her left hemithorax and tympanic percussion. Trachea deviation was also observed to the right and the patient presented with bilateral jugular stasis. Her saturation was 91% despite oxygen given at a 10-l/min rate through an oxygen mask. A thoracocentesis with air escape in the second intercostal space was immediately performed by the thoracic surgeon. A left-sided hydropneumothorax was diagnosed in the chest roentgenogram with contralateral mediastinal shift (Figure 1). The patient was transferred to the intensive care unit (ICU) with chest discomfort despite drainage with a chest drain. A small amount of odorless, turbid brownish fluid came from the pleural space just after the drainage. After non-invasive mechanical ventilation, the chest discomfort progressively improved, and both lungs were expanded. Upon discharge from the ICU, a liquid resembling nasogastric feed started to emerge from the chest drain in increasing amounts and shortly after commencing feeding with an output of more than 2300 ml per day. Biochemical analysis of the pleural effusion revealed a neutrophilic exudate with a low pH (6.32), low protein (1.5 g/dl), normal glucose (103 mg/dl), and high levels of lactate dehydrogenase (DHL) and amylase (16864 U/l and 873 U/l, respectively). The level of serum amylase was 23 U/l. The cytological exam was inconclusive. Because of the high levels of amylase, an esophageal perforation was initially suspected. A methylene blue test was performed at the bedside with a positive result, indicating leakage of this substance in the chest drain insertion after oral administration. Computed tomography with oral contrasted medium through the feeding tube showed a gastropleural fistula originating from the greater curvature and extending to the left subphrenic space (Figure 2). The patient was submitted to parenteral nutrition. Two days after the diagnosis, the patient presented sudden bleeding exteriorized by the chest tube (approximately 1800 ml of sanguineous pleural effusion) and hypovolemic shock. The patient was transferred again to the ICU where the patient received fluid, blood, and vasopressor support and recovered from the shock. Upper gastrointestinal endoscopy revealed a large blood clot in the greater curvature and fundus, which impeded further exploration. The patient was submitted to embolization of the splenic arteries in the interventional radiology service with success, and no further bleeding episodes occurred. After discussion with the Gastro Surgery team and considering the surgical risk due to the patient’s poor status, the patient was transferred to a palliative care facility. The patient died ten days after the embolization, due to shock and acute respiratory insufficiency.

Fatores associados à maior mortalidade e tempo de internação prolongado em uma unidade de terapia intensiva de adultos

OBJETIVO: A unidade de terapia intensiva e sinonimo de gravidade e apresenta taxa de mortalidade entre 5,4% e 33%. Com o aperfeicoamento de novas tecnologias, o paciente pode ser mantido por longo periodo nessa unidade, ocasionando altos custos financeiros, morais e psicologicos para todos os envolvidos. O objetivo do presente estudo foi avaliar os fatores associados a maior mortalidade e tempo de internacao prolongado em uma unidade de terapia intensiva adulto. METODOS: Participaram deste estudo todos os pacientes admitidos consecutivamente na unidade de terapia intensiva de adultos, clinica/cirurgica do Hospital das Clinicas da Universidade Estadual de Campinas, no periodo de seis meses. Foram coletados dados como: sexo, idade, diagnostico, antecedentes pessoais, APACHE II, dias de ventilacao mecânica invasiva, reintubacao orotraqueal, traqueostomia, dias de internacao na unidade de terapia intensiva, alta ou obito na unidade de terapia intensiva. RESULTADOS: Foram incluidos no estudo 401 pacientes, sendo 59,6% homens e 40,4% mulheres, com idade media de 53,8±18,0 anos. A media de internacao na unidade de terapia intensiva foi de 8,2±10,8 dias, com taxa de mortalidade de 13,46%. Dados significativos para mortalidade e tempo de internacao prolongado em unidade de terapia intensiva (p 11, traqueostomia e reintubacao. CONCLUSAO: APACHE >11, traqueostomia e reintubacao estiveram associados, neste estudo, a maior taxa de mortalidade e tempo de permanencia prolongado em unidade de terapia intensiva.

Computed tomography in hypersensitivity pneumonitis: main findings, differential diagnosis and pitfalls

ABSTRACT Introduction: Hypersensitivity pneumonitis (HP) is a disease with variable clinical presentation in which inflammation in the lung parenchyma is caused by the inhalation of specific organic antigens or low molecular weight substances in genetically susceptible individuals. Alterations of the acute, subacute and chronic forms may eventually overlap, and the diagnosis based on temporality and presence of fibrosis (acute/inflammatory HP vs. chronic HP) seems to be more feasible and useful in clinical practice. Differential diagnosis of chronic HP with other interstitial fibrotic diseases is challenging due to the overlap of the clinical history, and the functional and imaging findings of these pathologies in the terminal stages. Areas covered: This article reviews the essential features of HP with emphasis on imaging features. Moreover, the main methodological limitations of high-resolution computed tomography (HRCT) interpretation are discussed, as well as new perspectives with volumetric quantitative CT analysis as a useful tool for retrieving detailed and accurate information from the lung parenchyma. Expert commentary: Mosaic attenuation is a prominent feature of this disease, but air trapping in chronic HP seems overestimated. Quantitative analysis has the potential to estimate the involvement of the pulmonary parenchyma more accurately and could correlate better with pulmonary function results.

Interstitial Emphysema Leading to Pneumomediastinum in a Bone Marrow Transplant Patient

A 43-year-old male patient presented with acute respiratory failure requiring mechanical ventilation in the intensive care unit. He underwent an allogeneic bone marrow transplant for acute myeloid leukemia and developed bronchiolitis obliterans syndrome as chronic graft-versus-host disease. Computer tomography scans revealed symmetrical ground-glass opacities in peripheral and basilar regions of the lungs and interstitial emphysema with pneumomediastinum. An open-lung biopsy made immediately afterward demonstrated acute interstitial pneumonitis. Despite immunosuppressive therapy, the patient died. The tomographic scans depict in detail the mechanism of pneumomediastinum. When pressure gradient between alveoli and interstitium exceeds a critical level, alveoli rupture occurs and air enters into the interstitium, causing perivascular interstitial emphysema (Figure 1A, white arrows). The pleura remains intact and air dissects the bronchovascular sheath through the inferior pulmonary veins (Figures 1B and 1C, white arrows) into the anterior mediastinum following a lower pressure gradient (Figure 1D, red star). When mediastinal pressure increases above critical levels, being insufficient to relieve the pressure tension, the mediastinal parietal pleura can rupture, causing an associated pneumothorax (1, 2), which did not occur in this case. The pneumomediastinum could possibly be explained by two mechanisms: alveolar overdistension from dynamic hyperinflation and auto–positive end-expiratory pressure caused by airway obstruction secondary to bronchiolitis obliterans syndrome; or barotrauma caused by heterogeneous ventilation and regional overdistension in normal lung areas in a patient with acute interstitial pneumonitis, even in a setting where protective lung ventilation strategies were adopted.