Pei-Jan Chen

Idiopathic Inflammatory Myopathy with Diffuse Alveolar Damage

Abstract: Interstitial lung disease (ILD) in patients with myositis is defined by the presence of interstitial changes on radiographic examination. The reported prevalence of ILD varies from 0% to nearly 50%. However, only rarely has the pathological pattern of diffuse alveolar damage (DAD) associated with idiopathic inflammatory myopathy (IIM) been reported. We report five patients with IIM (one with dermatomyositis, one with polymyositis, and three with amyopathic dermatomyositis) and respiratory failure. Four underwent open lung biopsy with pathological proof of diffuse alveolar damage (DAD). Despite intensive immunosuppressive therapy, all of them died. In addition to the case reports, we discuss DAD in patients with IIM.

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.

Viral load and outcome in SARS infection: The role of personal protective equipment in the emergency department

Abstract This study was conducted to evaluate the effectiveness of personal protective equipment (PPE) against severe acute respiratory syndrome (SARS). Sixteen patients in a SARS cluster, including 4 health care workers (HCWs) and 12 non-HCWs were studied. We compared the initial viral load by nasopharyngeal swabs, clinical progression, and outcome of this cluster. The HCWs had a lower viral load. The non-HCWs had a higher mean C-reactive protein, lower oxygen saturation, and a higher incidence of intubation and death. Secondary household transmission developed in three of the non-HCWs’ families. One month after discharge, non-HCWs had more signs of fibrosis on high resolution computed tomography (HRCT) scan and an impaired pulmonary function test. Although most of the PPE do not confer absolute protection against SARS, it seems that they may lower exposure to the virus, leading to a lower risk of secondary transmission, and be associated with relatively mild disease and a better early outcome.

Intrathoracic Tracheal Obstruction Caused by a Carotid Mycotic Aneurysm in a Patient with Deep Neck Infection – A Case Report

Upper airway obstruction secondary to a carotid mycotic aneurysm has not been previously reported. We describe a patient with a mycotic aneurysm associated with a deep neck infection and presenting with acute tracheal obstruction. Recognition of this condition is important to avoid inadvertent rupture of the aneurysm in the course of diagnostic aspiration or surgical drainage. Physical findings, including a pulsating mass and an arterial bruit, in addition to appropriate imaging studies, may be helpful in suggesting the diagnosis. In particular, both neck and chest contrast-enhanced computed tomography scans may give important clues to the presence of a vascular lesion. In a patient with an infected neck mass and tracheal compression, a common carotid mycotic aneurysm should be considered in the differential diagnosis.

Effect of Respiratory Muscle Performance on Ventilatory Weaning

Background: In order to determine whether the use of pressure-support ventilation (PSV) could retrain the respiratory muscles and enhance the success rate after patients had failed a spontaneous breathing trial (SBT), we developed sequential weaning protocols and monitored the changes in respiratory muscle performance during the weaning process. Methods: A total of 103 patients requiring mechanical ventilation and admitted to a tertiary hospital were enrolled. Weaning was first attempted with a once-daily spontaneous breathing trial (OSBT). For patients who failed this trial, PSV was used until a pressure of 12 cmH2O was reached, followed by SBT. Results: Sixty-six (64%) patients were successfully weaned with the OSBT. Twenty-three (62%) of the remaining 37 patients managed with PSV were successfully weaned, yielding an 86% (89/103) success rate for those who were weaned within 78±37 hours. Compared with those who failed the OSBT, the patients who succeeded with the OSBT had a significantly higher maximal inspiratory pressure (Pimax), higher percentage of change in Plmax (△Plmax%), and lower frequency-to-tidal volume ratio (f/VT). Those who succeeded with PSV also had a significantly higher △Plmax% than those who failed. Conclusions: Initial respiratory muscle performance is predictive of early successful weaning by OSBT, but not later weaning by PSV. PSV was able to help wean those patients who failed OSBT, with a success rate comparable to that of early weaning by OSBT. PSV might not produce significant augmentation of respiratory muscle strength, but was able to delay the decrease of respiratory muscle strength in the weaning process.

Double Cancer of the Liver and Lung: A Report of Three Cases

Hepatocellular carcinoma is one of the most common malignancies and, because of the high prevalence of chronic hepatitis B and C, it is the leading cause of death in Taiwan. Lung cancer coexisting with hepatocellular carcinoma has rarely been reported in the medical literature. It might have been misdiagnosed as lung metastasis in many cases. We report three cases of double cancer of the liver and lung. All of the diagnoses were confirmed by pathology. One of the three cases was diagnosed early enough to be treated with surgical resection of both liver and lung tumors. Computed tomography may be helpful in differentiating primary from metastatic lung cancer. Thus, in patients with hepatocellular carcinoma and lung lesions, the possibility of double cancer of the liver and lung rather than lung metastasis should be kept in mind.

Microscopic Polyangiitis Caused by Propylthiouracil in a Patient with Hyperthyroidism-A Case Report

he etiology of hemoptysis can be grouped into 3 major categories: disease from the airways, the pulmonary parenchyma, and the pulmonary vasculature. Small vessel pulmonary vasculitis, such as microscopic polyangiitis (MPA), is 1 of the diseases diffusely affecting the pulmonary parenchyma in the presentation of the hemoptysis. Propylthiouracil (PTU) is 1 of the etiologies of MPA with an unclear mechanism. Herein, we describe a woman with PTU-induced ANCA-positive vasculitis who developed pulmonary hemorrhage with respiratory failure and crescentic glomerulonephritis. We initiated mechanical ventilation, and medical treatment, including highdose steroid pulse therapy and oral cyclophosphamide, and discontinued PTU. Her condition improved and she was discharged. She has been in stable condition without further sequelae.

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.