Selma Maria de Azevedo Sias

Clinic and radiological improvement of lipoid pneumonia with multiple bronchoalveolar lavages

To assess the potential role of multiple bronchoalveolar lavages (BALs) in the treatment of children with lipoid pneumonia (LP).

Evolução da pneumonia lipoide exógena em crianças: aspectos clínicos e radiológicos e o papel da lavagem broncoalveolar

OBJECTIVE To present aspects of the evolution of lipoid pneumonia in children, based on clinical, radiological and bronchoalveolar lavage fluid findings, emphasizing the importance of bronchoalveolar lavage for the diagnosis and treatment. METHODS We included 28 children, with a mean age of 20 months (range, 1-108 months), diagnosed with chronic pneumonia refractory to antimicrobial therapy, with TB or with a combination of the two. Most of the children had at least one risk factor for aspiration, and all of them had a history of mineral oil ingestion for intestinal constipation (23/28) or complicated ascaridiasis (5/28). Clinical evaluations, tomographic evaluations and analyses of bronchoalveolar lavage fluid were carried out at the beginning of treatment and throughout a follow-up period of 24 months. RESULTS Tachypnea and cough were the most common symptoms. The most common radiological alterations were areas of consolidation (23/28), perihilar infiltrates (13/28) and hyperinflation (11/28). Chest CT scans showed areas of consolidation with air bronchogram (24/28), decreased attenuation in the areas of consolidation (16/28), ground-glass opacities (3/28) and crazy-paving pattern (1/28). In the analysis of the bronchoalveolar lavage fluid, Sudan staining revealed foamy macrophages, confirming the diagnosis of lipoid pneumonia. After treatment with multiple bronchoalveolar lavages (mean = 9.6), 20 children became asymptomatic, 18 of those presenting normal tomographic images. CONCLUSIONS A diagnosis of lipoid pneumonia should be considered in patients with chronic refractory pneumonia or TB, especially if there is a history of mineral oil ingestion. Bronchoscopy with multiple bronchoalveolar lavages was an efficient treatment for the clearance of mineral oil from the lung parenchyma and the prevention of fibrosis. This strategy contributed to reducing the morbidity of lipoid pneumonia, which remains a rare diagnosis.

Lipoid pneumonia in a gas station attendant.

The exogenous lipoid pneumonia, uncommon in adults, is the result of the inhalation and/or aspiration of lipid material into the tracheobronchial tree. This is often confused with bacterial pneumonia and pulmonary tuberculosis due to a nonspecific clinical and radiologic picture. It presents acutely or chronically and may result in pulmonary fibrosis. We describe here a case of lipoid pneumonia in a gas station attendant who siphoned gasoline to fill motorcycles; he was hospitalized due to presenting with a respiratory infection that was hard to resolve. The patient underwent bronchoscopy with bronchoalveolar lavage, which, on cytochemical (oil red O) evaluation, was slightly positive for lipid material in the foamy cytoplasm of alveolar macrophages. Due to his occupational history and radiographic abnormalities suggestive of lipoid pneumonia, a lung biopsy was performed to confirm the diagnosis. The patient was serially treated with segmental lung lavage and showed clinical, functional, and radiological improvement.

Successful treatment of lipoid pneumonia associated with bowel obstruction by Ascaris lumbricoides.

Partial bowel obstruction is a serious complication of ascariasis infestation generally treated with mineral oil. This prospective study aimed to evaluate the efficacy of multiple bronchoalveolar lavages (BAL) as a therapeutic strategy for reducing lung inflammation of lipoid pneumonia associated with ascariasis. The study included five children (mean age 25 months) with partial small-bowel obstruction by Ascaris lumbricoides, who underwent diagnostic bronchoalveolar lavage for assessment of refractory pneumonia. Routine biochemical, microbiological and cytological analysis were carried out in the BAL. Protein, lactate dehydrogenase and tumor necrosis factor-alpha (TNF-α) cytokine levels were determined in the serum before and after treatment. At admission, children consistently had respiratory symptoms, altered hematological function, increased immunoglobulin E serum level and peripheral blood eosinophilia. Chest tomography showed consolidation with air bronchogram (4/4), ground-glass infiltration (3/4) and decreased attenuation in the consolidation areas (2/4). Presence of marked pleocytosis with Sudan positive foamy alveolar macrophages, high protein and lactate dehydrogenase levels in the BAL indicated presence of mixed alveolitis. One child with extensive consolidation and air bronchogram in both lungs died before treatment. Multiple bronchoalveolar lavages efficiently removed alveolar oil deposits, restored BAL cellularity, improved clinical symptoms, radiological parameters and further reduced inflammatory reaction evidenced by marked decrease of the inflammatory cytokine, TNF-α. This study presents a therapeutic strategy for management of lung complications caused by mineral oil administration to treat intestinal bowel obstruction associated with ascariasis.

Neonatal osteomyelitis and complex nephro-ureteral duplication.

OBJECTIVE This report presents a case of femoral osteomyelitis secondary to urinary tract infection in a female neonate with bilateral urinary duplication and right ectopic ureterocele. METHODS A female neonate with a history of late perinatal sepsis presented to the emergency department and was found to have left distal femoral osteomyelitis. A complex urological malformation was diagnosed (bilateral renal duplication with right ectopic ureterocele associated with nonfunctional superior pole of the ipsilateral kidney). The baby was submitted to prolonged antibiotic therapy and upper pole nephrectomy of the right kidney. RESULTS The pathology report confirmed chronic pyelonephritis and dysplasia in the resected specimen. After 1.5 years the patient is asymptomatic and developing normally, with no apparent deformity, but manifests asymptomatic vesicoureteral reflux. CONCLUSIONS Urinary tract infections must always be excluded as the primary infection focus in neonates with sepsis. Perinatal osteomyelitis is almost always a complication of neonatal sepsis and is associated with orthopedic sequelae. This is the first report in literature of a case of osteomyelitis complicating complex urinary duplication and urinary tract infection.

Draft Genome Sequence of a Community-Associated Methicillin- Resistant Panton-Valentine Leukocidin-Positive Staphylococcus aureus Sequence Type 30 Isolate from a Pediatric Patient with a Lung Infection in Brazil

ABSTRACT The sequence of methicillin-resistant Staphylococcus aureus strain B6 (sequence type 30 [ST30], spa type t433, staphylococcal chromosomal cassette mec element [SCCmec] type IVc, Panton-Valentine leukocidin [PVL] positive), isolated from a pediatric patient with a lung infection in Niterói, Rio de Janeiro, Brazil, is described here. The draft genome sequence includes a 2.8-Mb chromosome, accompanied by a 20-kb plasmid containing blaZ and two small cryptic plasmids.

Ascaridíase hepatobiliar complicada por pneumonia lipoídica

OBJETIVO: Apresentar um caso de ascaridiase hepatobiliar complicado por pneumonia lipoidica e discutir as implicacoes anestesicas envolvidas. DESCRICAO DO CASO: Menina de dois anos de idade com ascaridiase hepatobiliar complicada por pneumonia lipoidica por aspiracao e desnutricao grave, advinda de familia em condicoes sociais precarias em zona rural, com quatro irmaos. Foi tratada com sucesso por uma combinacao de lavados broncopulmonares sucessivos e cirurgia. COMENTARIOS: Ascaridiase biliar corresponde a cerca de 10% dos casos de complicacoes de ascaridiase. Apenas uma minoria precisa de tratamento cirurgico. O uso de oleo mineral por via oral e um tratamento tradicional para a suboclusao intestinal pelo Ascaris lumbricoides, mas a broncoaspiracao do oleo e a consequente pneumonia lipoidica representam um risco alto para o seu uso. Anestesia geral para laparotomia exploradora em pre-escolar desnutrido com pneumonia lipoide e ascaridiase biliar e uma situacao pouco contemplada na literatura medica, o que exigiu um planejamento terapeutico especifico.

Study of bronchoalveolar lavage in HIV-infected children

ulmonary complications are common among HIV-infected hildren. Early diagnosis and immediate care are important in rder to reduce morbidity and mortality. Bronchoscopy with ronchoalveolar lavage (BAL) have been routinely used in the iagnostic approach of pulmonary complications caused by IV-1.1,2 Due to immune defects, the risk of HIV-infected people o develop pneumonia is 10 to 100 times higher when comared to HIV-uninfected people. Infected patients present an ncreased susceptibility to pyogenic bacterial, viral, protozoal nd mycobacterial infections and about 80% of them develop ulmonary disease more frequently and more severe.1,2 Bronchoscopy with BAL has been used in the diagnosis of hese types of pneumonia in children and adults. Unlike lung iopsy, BAL is safe even in young infants, being less aggressive, nd presenting less risk of complications.3 The aim of this study was to evaluate the importance of BAL o diagnose lung disease in HIV-infected children correlating pidemiology and laboratory data. We retrospectively studied the microbiology and cytology ata of BAL specimens performed by flexible bronchoscopy n HIV-infected children with pneumonia unresponsive o empiric antibiotic therapy, referred to the Respiratory ndoscopy Service at Antonio Pedro University Hospital Universidade Federal Fluminense (APUH-UFF) from Janary 2000 to December 2009. Approval for this study was btained from the APUH-FFU and Research Ethics Committee CEP/HUAP/CAAE: 0178.0.258.000-10). Flexible bronchoscopy ith BAL was carried out as previously described.3 The recovred lavage fluid was sent for microbiological (direct Acid Fast nd Gram stain, and culture) and cytology (global and specific ytology) analysis. Using the protected catheter or quantiative culture can minimize the often contamination of the ample BAL when passing through the upper airway. We used uantitative culture in all study samples. 45 bronchoscopies ere performed in 33 patients. Age ranged from 1 month to 6 years (median = 4 years, interquartile range = 1–6.5). The indications for bronchoscopy with BAL are presented n Table 1. Ten children (four suspected of having tuberculosis TB), three with pneumonia, two with persistent radiological imaging, and another with interstitial pneumonia) had bronchoscopic signs suggestive of TB (widening of carina and/or extrinsic compression of the tracheobronchial tree), one of them was confirmed by culture. All bronchoscopy exams had a diffuse inflammatory process except one, with interstitial pneumonia which was normal. Cytological analysis in 12/45 (26.6%) of BAL showed neutrophilic (6/12), lymphocytic (4/12) and mixed cellularity, both neutrophilic and lymphocytic (2/12). The diagnosis was performed in 27/45 cases (60%): TB (15/45 = 33.3%), lymphocytic pneumonia (5/45 = 11.1%), bacterial infection (6/45 = 13.3%) and fungal infection (1/45 = 2.2%). The diagnostic yield of BAL in our study was 60.4%, similar to the literature (58%). Pneumonia was the main indication (14/45 = 31.1%) for performing BAL, and this confirms the high frequency of lung disease in immunocompromised patients. Sheikh et al.2 studied 104 HIV-infected children and found that 75 (45.7%) had pneumonia with no complications, 24 (14.6%) recurrent pneumonia, and 18 (10.9%) persistent pneumonia. Etiological confirmation of pulmonary diseases in HIVinfected children is crucial, since these patients often have severe infectious pulmonary complications that can cause death. Opportunistic bacteria, mycobacteria, viruses and fungi are pathogens that can be isolated, especially Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, Pneumocystis jiroveci and Streptococcus viridans.1,2,4