Piotr Palczewski

Prognostic Value of Echocardiography in Normotensive Patients With Acute Pulmonary Embolism

OBJECTIVES The goal of the study was to evaluate the prognostic value of echocardiographic indices of right ventricular dysfunction (RVD) for prediction of pulmonary embolism-related 30-day mortality or need for rescue thrombolysis in initially normotensive patients with acute pulmonary embolism (APE). BACKGROUND There is no generally accepted echocardiographic definition of RVD used for prognosis in APE. METHODS We studied the prognostic value of a set of echocardiographic parameters in 411 consecutive patients (234 women, age 64 ± 18 years) with APE hemodynamically stable at admission. RESULTS Thirty-day APE-related mortality was 3% (14 patients), all-cause mortality was 5% (21 patients). Nine patients received thrombolysis as a result of hemodynamic deterioration, and 7 of them survived. The clinical endpoint (CE), which included APE-related death or thrombolysis, occurred in 21 patients. At univariable Cox analysis, the hazard ratio (HR) for CE of the right ventricular (RV)/left ventricular (LV) ratio was 7.3 (95% confidence interval [CI]: 2.0 to 27.3; p = 0.003). However, multivariable analysis showed that tricuspid annulus plane systolic excursion (TAPSE) was the only independent predictor (HR: 0.64, 95% CI: 0.54 to 0.7; p < 0.0001). Moreover, the area under the curve (AUC) in receiver-operating characteristic analysis for TAPSE (0.91, 95% CI: 0.856 to 0.935; p = 0.0001) in CE prediction was higher (p < 0.001) than AUC of RV/LV ratio (0.638, 95% CI: 0.589 to 0.686; p = 0.001). TAPSE ≤15 mm had a HR of 27.9 (95% CI: 6.2 to 124.6; p < 0.0001) and a positive predictive value (PPV) of 20.9% for CE with a 99% negative predictive value (NPV), whereas TAPSE ≤20 mm had a PPV of 9.2 with a 100% NPV. RV/LV ratios of >0.9 and >1.0 had a PPV of 13.2% and 14.4% and a NPV of 97% and 94.3%, respectively. CONCLUSIONS TAPSE is preferable to the RV/LV ratio for risk stratification in initially normotensive patients with APE. TAPSE ≤15 mm identifies patients with an increased risk of 30-day APE-related mortality, whereas TAPSE >20 mm can be used for identification of a very low-risk group.

Early everolimus-induced pneumonitis in a renal transplant recipient: A case report.

BACKGROUND Everolimus is a derivative of sirolimus, and is considered to be free of the latters pulmonary toxicity. Recently, a few cases of everolimus-induced lung injury have been reported. Early recognition of drug-induced lung disease is important because it can be reversed if appropriate therapy is instituted soon after the onset of symptoms. CASE REPORT We present the case of an everolimus-induced pneumonitis in a renal transplant recipient, which occurred as early as on the 5th day after everolimus introduction. Shortly after the transplant procedure, the patient presented with typical symptoms of pulmonary infection. Chest radiography and computed tomography showed bilateral patchy lung infiltrates with peribronchial distribution that were suggestive of bacterial pneumonia. However, there was no improvement with empiric antibiotic treatment. Repeated cultures from the blood, sputum, and broncho-alveolar lavage (BAL) also were negative. Tuberculosis, Pneumocystis jiroveci, and Cytomegalovirus infections were excluded. A transbronchial lung biopsy performed 9 days after the onset of symptoms revealed mild nonspecific inflammation with a fibrotic component in the bronchial walls. Withdrawal of everolimus on the third day of hospitalization and after 8 days of its usage resulted in quick clinical recovery and resolution of radiological abnormalities within 1 month. CONCLUSIONS Diagnosis of drug-induced pulmonary toxicity is difficult because it is essentially a diagnosis of exclusion. Lack of response to empiric antibiotic treatment and an imaging pattern of organizing pneumonia should raise suspicion of everolimus-induced pneumonitis in patients undergoing therapy with this drug.

Midregional proadrenomedullin (MR-proADM) in the risk stratification of patients with acute pulmonary embolism

INTRODUCTION According to current ESC guidelines not only hemodynamic parameters, but also indices of right ventricular dysfunction such as NT-proBNP have a significant prognostic value in acute pulmonary embolism (PE). MR-proADM is a significant predictor of short-term mortality in acute heart failure and adds prognostic value to NT-proBNP. We hypothesized that plasma MR-proADM is elevated in acute PE, correlates with the severity of PE and has prognostic value. We also compared prognostic values of MR-proADM and NT-proBNP for the prediction of early mortality in acute PE. MATERIAL & METHODS We studied 98 patients (51F/47M, 59.6 ± 18.4 yr) with acute PE. On admission blood samples were collected for MR-proADM and NT-proBNP. RESULTS MR-proADM reflected the severity of acute PE: 0.734 nmol/L in low-risk acute PE (0.384-1.342), 0.995 nmol/L in intermediate-risk acute PE (0.394-7.499) and 2.062 nmol/L in high-risk acute PE (0.447-3.098), p<0.001. MR-proADM was higher in non-survivors than in survivors 2.123 nmol/L (1.543-4.220), vs. 0.910 nmol/L (0.384-7.449), p=0.0003. The AUC of MR-proADM and NT-proBNP ROC curves for predicting all-cause mortality were 0.935 (95% CI 0.861-0.977) and 0.844 (95% CI 0.749-0. 913), respectively. In univariable analysis NT-proBNP and MR-proADM were significant predictors of all-cause mortality HR 1.00 (95% CI 1.000-1.0002, p=0.029) and 1.65 (95% CI 1.214 - 2.249, p=0.015). However, in multivariate analysis, MR-proADM but not NT-proBNP was a significant predictor of all-cause mortality. CONCLUSION NT-proBNP and MR-proADM are of similar predictive value in the assessment of outcome in acute PE, however MR-proADM seems to be superior in predicting all-cause mortality.

Radiological spectrum of pulmonary infections in patients post solid organ transplantation.

Summary Pneumonia remains an important source of morbidity and mortality in transplant recipients. Since clinical findings are nonspecific and cultures may be time-consuming, imaging plays an important role in establishing the probable etiology of pneumonia. Plain films are used as an initial study. However, they have a limited capacity in differentiating the causative factors. HRCT is used as a problem-solving tool in patients with unclear plain film findings and/or no response to treatment. The main advantage of HRCT is a very detailed depiction of the lung parenchyma. Even though HRCT findings are not always specific, there are several sings that are more common in certain types of pneumonia. The aim of the article is to present radiological findings suggestive of a particular causative microorganism and show how they can narrow the differential diagnosis when coupled with clinical data.

Patent foramen ovale increases the risk of acute ischemic stroke in patients with acute pulmonary embolism leading to right ventricular dysfunction

BACKGROUND Patent foramen ovale (PFO) is an established risk factor for ischemic stroke. Since acute right ventricular dysfunction (RVD) observed in patients with PE can lead to right-to-left inter-atrial shunt via PFO, we hypothesized that PFO is a risk factor for ischemic stroke in PE with significant right ventricular dysfunction. METHODS 55 patients (31 F, 24M), median age 49 years (range 19-83 years) with confirmed PE underwent echocardiography for RVD and PFO assessment. High risk acute PE was diagnosed in 3 (5.5%) patients, while 16 (29%) hemodynamically stable with RVD patients formed a group with intermediate-risk PE. PFO was diagnosed in 19 patients (34.5%). Diffusion-weighted MRI of the brain for acute ischemic stroke (AIS) was performed in all patients 4.91 ± 4.1 days after admission. RESULTS AIS was detected by MRI in 4 patients (7.3%). Only one stroke was clinically overt and resulted in hemiplegia. All 4 AIS occurred in the PFO positive group (4 of 19 patients), and none in subjects without PFO (21.0% vs 0%, p=0.02). Moreover, all AIS occurred in patients with RVD and PFO, and none in patients with PFO without RVD (50% vs 0%, p=0.038). CONCLUSION Our data suggest that acute pulmonary embolism resulting in right ventricular dysfunction may lead to acute ischemic stroke in patients with patent foramen ovale. However, the clinical significance of such lesions remains to be determined.

The value of ultrasonography in the diagnosis of varicocele

A varicocele is described as pathologically enlarged, tortuous veins of the pampiniform plexus, leading to an increased testicular temperature and adrenal metabolite reflux into the testes. Varicocele can impair spermatogenesis and is considered to be the most common cause of male infertility. Patients may palpate a thickening in the scrotum or complain of dull scrotal or inguinal pain, which increases when standing or during erection. In the case of a sudden onset of varicocele in elderly men, it is necessary to exclude renal tumor and extend diagnostic ultrasound with the assessment of the abdominal cavity. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva maneuver. Ultrasound is the imaging method of choice. The width and the number of vessels in the pampiniform plexus as well as the evaluation and measurement of regurgitation during the Valsalva maneuver are typical parameters analyzed during ultrasound assessment. However, diagnostic ultrasound is still a controversial method due to numerous and often divergent classification systems for varicocele assessment as well as its poor correlation with clinical manifestations. As a result of introduction of clear ultrasound criteria as well as the development of elastography and nuclear magnetic resonance, diagnostic imaging can play an important role in assessing the risk of damage to the testicular parenchyma, qualifying patients for surgical treatment and predicting the effects of therapy.

Ischiofemoral Impingement Syndrome: A Case Report and a Review of Literature.

Summary Background Ischiofemoral impingement syndrome is characterized by a hip pain associated with abnormalities in quadriceps femoris muscle and ipsilaterally reduced distance between the lesser trochanter and the ischium. Thus far, the congenital variant of this entity has been reported exclusively in women. Case Report We report a case of a 22-year old male with painful hips in whom on the basis of the imaging studies the constitutional variant of ischiofemoral impingement was diagnosed. Conclusions Ischiofemoral conflict should be taken into consideration in the differential diagnosis of hip pain, particularly among women, but also in patients with valgus hip deformity and other abnormalities leading to reduction of the space between femoral and ischial bones independent of gender.

Differentiation of ovarian cancers from borderline ovarian tumors on the basis of evaluation of tumor vascularity in multi-row detector computed tomography--comparison with histopathology.

Objective The aim of this study was to evaluate the feasibility of multi–detector row computed tomography (MDCT) in the differentiation between borderline ovarian tumors and ovarian cancer on the basis of tumor morphology and specific features of tumor vascularity in correlation with the results at pathology. Methods A triphasic MDCT protocol was used for the analysis of tumor vascularity. The following features were taken into account: (1) The number of vessels in papillary projections, solid-tissue component, and septa (2 vs >2), (2) serpentine and chaotic configuration of vessels, (3) presence of microaneurysms, and (4) presence of arteriovenous microfistulas. Masses with at least 3 of 4 features were considered ovarian cancer (group A) and masses with 2 features or less as borderline tumor (group B). Radiological findings were compared with results of postoperative pathology. Results Pathologic vessels were found in all 56 patients. Thirty-two patients were included in group A and 24 in group B. The results of pathology were as follows: in group A: 31 malignant tumors, including 31 ovarian carcinomas and 1 benign cystadenoma; in group B: 22 borderline ovarian tumors, 1 benign cystadenoma, and 1 ovarian cancer. Conclusions Morphological evaluation of tumor vascularity in MDCT seems to be an efficient method of differentiating between borderline ovarian tumors and ovarian carcinomas. Because of a small number of cases in the current study, a further research seems justified to confirm our results. The presented MDCT-angiographic criteria showed high sensitivity (97%) and specificity (96%) in differentiation of borderline ovarian tumors and ovarian cancers as compared with pathology. The presented CT-angiographic criteria of malignancy showed an excellent interobserver agreement.

Pulmonary post-transplant lymphoproliferative disorder with a CT halo sign.

BACKGROUND Post-transplant lymphoproliferative disease (PTLD) comprises a spectrum of clinically relevant lymphatic diseases that occur in patients after transplantation. The PTLD-related mortality is high and the clinical picture and location of the lesions are very variable. For these reasons, the diagnosis of PTLD is difficult and new diagnostic tools are sought. CASE REPORT A 31-year-old woman, 17 years after kidney transplantation, presented with recurrent upper respiratory tract infections, fever, and weakness and was diagnosed with pulmonary PTLD. Computed tomography appearance was not typical for lymphoma and demonstrated multiple bilateral pulmonary nodules and masses with a halo sign. Initial differential diagnosis included invasive pulmonary aspergillosis and acute Wegener granulomatosis. Since cultures from bronchoalveolar lavage and anti-neutrophil cytoplasmic antibodies were negative, videothoracoscopy with lung biopsy was performed. Pathology analysis revealed diffuse large T-cell lymphoma with histopathologic features of infiltrative growth along the lung interstitium, vessel invasion, and hemorrhagic necrosis possibly explaining the presence of a halo sign. CONCLUSIONS We suggest PTLD should always be suspected in a transplant recipient presenting with the CT halo sign. Moreover, the correlation of this radiological phenomenon with the patients clinical presentation and severe pathologic findings allows us to conclude that the thoracic halo sign in PTLD may reflect a worse prognosis.

Niezwykłe izolowane złamanie dna oczodołu typu „blow-out” powikłane rozległą rozedmą podskórną: opis przypadku i przegląd piśmiennictwa.

BACKGROUND Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event. CASE REPORT A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired. CONCLUSIONS Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.