Serhat Findik

Pulmonary Involvement in Behçet’s Disease

Background: Behçet’s disease (BD) is a multisystem vasculitis and pulmonary involvement in BD is reported to indicate poor prognosis and high mortality. Objectives: The aims of this study were to report on patients with pulmonary involvement and to discuss pulmonary artery thrombus and small-sized vasculitis associated with BD, with respect to previously published cases. Methods: Fifteen patients with BD and pulmonary involvement were included in this study. Massive hemoptysis was observed in all patients having pulmonary artery aneurysm (PAA). Results: Eleven patients had macroscopic pulmonary vascular disease (2 PAA, 3 PAA and thrombi and 6 only thrombi) and 3 patients had microscopic pulmonary vascular disease. The remaining patient had pulmonary cryptococcosis. Conclusions: Data regarding treatment and outcomes of patients having BD-related pulmonary emboli/infarct and small-sized vasculitis are limited. Pulmonary vasculitis affects different levels of the pulmonary artery in BD and should be classified as macroscopic and microscopic vascular disease. ‘Pulmonary artery thrombosis’ should be used instead of ‘pulmonary emboli’. Spiral CT angiography is the best radiological tool for evaluation of pulmonary problems in BD. Treatment of vasculitis should be based on the type of vascular disease and may vary among different types of vascular disease. Anticoagulation can be used in patients with microscopic vascular disease and nonaneurysmal macroscopic vascular disease. More studies are needed to clarify this issue.

What's Your diagnosis?

History A 49-year-old, nonsmoking female was adm itted to our clinic on 20 June 2001 with a one-year history of progressive dyspnea and dry cough. She denied sputum production, hemoptysis, night sweats and fever. At the time of her evaluation, she had been taking antituberculous drugs for two months. She had been noted to have abnormal shadows on a chest radiograph in 1990, but she had not been treated for it due to her good clinical status. She was treated for tuberculosis for about one year in 1993. Her family history was negative for any lung disease. Vital signs were within normal limits. Examination o f the chest indicated bibasilar end-inspiratory fine rales. Extremities showed digital clubbing of grade V with slight cyanosis. Although the patient appeared well at rest, she became dyspneic after walking about twenty to thirty meters. Laboratory findings are shown in the table. Plain chest x-ray and thorax C T are shown in Figures 1 and 2, respectively.

Computed tomographic pulmonary angiography in the assessment of severity of acute pulmonary embolism and right ventricular dysfunction

Background: The distinction between severe pulmonary embolism (PE) and right heart dysfunction is important for predicting patient mortality. Purpose: To identify the role of computed tomographic pulmonary angiography (CTPA) in the assessment of the severity of acute PE and right ventricular dysfunction. Material and Methods: Eighty-five patients suspected of having PE, as diagnosed by CTPA and scintigraphy, were divided into three groups: hemodynamically unstable PE (HUPE) (n = 20), hemodynamically stable PE (HSPE) (n = 33), and no PE (n = 32). For each patient, obstruction scores, including short-axis diameters of the right ventricle (RV) and left ventricle (LV), main pulmonary artery, and superior vena cava (SVC), were measured. The RV/LV short-axis ratios were calculated. The shapes of the interventricular septum and the reflux of the contrast medium into the inferior vena cava (IVC) were evaluated. The mortality due to PE within a 1-month follow-up period was recorded. Results: The median CTPA obstruction score (HUPE 64%, HSPE 28%, P < 0.001), median RV/LV short-axis ratio (HUPE 1.4, HSPE 1.0, P < 0.01), median RV diameter (HUPE 55 mm, HSPE 42 mm, P < 0.001), median SVC diameter (HUPE 23 mm, HSPE 19 mm, P < 0.01), interventricular septum convex toward the LV (HUPE 70%, HSPE 18%, P < 0.001), and reflux of the contrast medium into the IVC (HUPE 65%, HSPE 33%, p < 0.05) were significantly different between the HUPE and HSPE groups. With ROC analysis, the CTPA obstruction score and RV/LV short-axis ratio threshold values for the HUPE patients were calculated to be 48% (95% sensitivity, 76% specificity) and 1.1 (85% sensitivity, 76% specificity), respectively. Three patients in the HUPE group died within the first 24 hours. Logistic regression methods revealed only the RV diameter as a significant predictor of death (odds ratio 1.24; 95% CI 1.04–1.48; P = 0.01). Conclusion: This study found that the parameters useful for distinguishing HUPE and HSPE included CTPA obstruction score, RV and SVC diameters, RV/LV short-axis ratio, interventricular septum shape, and reflux into the IVC. RV dilatation may be a significant predictor for mortality.

Low-molecular-weight heparin versus unfractionated heparin in the treatment of patients with acute pulmonary thromboembolism.

Background: Low-molecular-weight heparin (LMWH) appears to be as effective as unfractionated heparin (UFH) for both treatment and prophylaxis of deep vein thrombosis (DVT), but limited data are available for its use in acute pulmonary thromboembolism (PTE). Objective: To determine whether enoxaparin, a LMWH, was clinically as efficient and safe as UFH in patients with a diagnosis of acute PTE. Material and Methods: After exclusion of those with massive forms, 59 patients with acute PTE were randomly assigned to either subcutaneous enoxaparin given twice daily (1 mg/kg/dose) or adjusted dose intravenous UFH. Oral anticoagulant treatment was begun on the second day and was given for at least 6 months. We compared the treatment regimens at day 8 and day 90 with respect to a combined end point of major bleeding, recurrent venous thromboembolism (VTE), and death. Results: In the first 8 days of treatment, 1 of 30 patients assigned to receive UFH (3.3%) reached one of the end points (recurrence), as compared with none of 29 patients assigned to enoxaparin. Statistically this difference was not significant (p = 0.508). By day 90, 3 patients assigned to UFH (10%) had symptomatic recurrent VTE, as compared with 1 patient assigned to enoxaparin (3.4%). There was neither major bleeding nor death in the study groups. There was an absolute difference of 6.4 percentage points between the two treatment groups, but the difference was statistically not significant (p = 0.318). Conclusion: Initial subcutaneous treatment with enoxaparin appeared to be as effective and safe as UFH in acute PTE.

Massive Pulmonary Emboli and CT Pulmonary Angiography

Background: Massive pulmonary embolism (PE) is a devastating form of PE which usually results in acute right ventricular failure and death within 1–2 h. Objectives: To retrospectively assess pulmonary vascular, cardiac, pleural, and parenchymal findings on CT pulmonary angiography (CTPA) in patients with a diagnosis of massive PE (systolic blood pressure <90 mm Hg, syncope and/or shock). Methods: In 33 consecutive patients with proven massive PE, hemodynamic severity was assessed by the extent of right ventricular dysfunction (RVD); diameter of the main pulmonary artery; the shape of the interventricular septum; and the extent of obstruction to the pulmonary arterial circulation (CT obstruction index). Results: Central pulmonary arteries were embolized in all patients. RVD was detected in all patients (94% of them had severe RVD); the diameter of the main pulmonary artery was wider than normal in 76% of the patients; the shape of the interventricular septum was abnormal in all patients, and the CT obstruction index was higher than or equal to 50% in 85% of the patients. Wedge-shaped pleural-based consolidation was the most common parenchymal abnormality (36%). Pleural effusions were seen in 26 patients (79%). Twenty-eight patients were alive, and only the use of thrombolytic therapy was found to be statistically significant. Conclusions: In patients with acute massive PE, embolization of the central pulmonary arteries, RVD and displacement of the interventricular septum are commonly seen with CTPA. A CT obstruction index of >50% is commonly observed in massive PE. There was no association between CTPA findings and survival.

A prospective evaluation of hemoptysis cases in a tertiary referral hospital

Background and Aims:  Hemoptysis is symptomatic of a potentially serious and life‐threatening thoracic disease. The purpose of this study was to evaluate the relative frequency of the different causes of hemoptysis, the change of the frequency of diseases, the value of the evaluation process and the outcome in a tertiary referral hospital.

Role of bacteria in acute exacerbations of chronic obstructive pulmonary disease.

Background and study objective Infections are major causes of acute exacerbations of chronic obstructive pulmonary disease (COPD) which result in significant mortality and morbidity. The primary aim of the study was to determine the microbiological spectrum including atypical agents in acute exacerbations. The secondary aim was to evaluate resistance patterns in the microorganisms. Methods The sputum culture of 75 patients admitted to our clinic from January 1, 1999 to December 31, 2002 was evaluated prospectively, for aerobic Gram-positive and Gram-negative bacteria, and serologically for Chlamydophila pneumoniae and Mycoplasma pneumoniae. Sensitivity patterns in potentially pathogenic microorganisms (PPMs) were also investigated. Results An infectious agent was identified in 46 patients, either serologically or with sputum culture. Pathogens most commonly demonstrated were: Haemophilus influenzae (30%), Chlamydophila pneumoniae (17%), and Mycoplasma pneumoniae (9%). Mixed infections were diagnosed in 9 patients. PPMs showed a high resistance rate to commonly used antibiotics. Conclusion We have shown that microorganisms causing acute exacerbations of COPD are not only typical bacteria (46%) but also atypical pathogens (26%), with unpredictable high rates. Typical agents showed a high resistance to commonly used antibiotics.

Endobronchial tuberculosis: histopathological subsets and microbiological results

BackgroundEndobronchial tuberculosis (EBTB) is defined as a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence, with or without parenchymal involvement. Bronchoscopic appearances of EBTB have been divided into seven subtypes: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic. However, information for establishing a definite microbiological diagnosis in each of these categories is lacking.We aimed to present bronchoscopic appearances and percentages for the EBTB subtypes and to compare bronchoscopic appearances with microbiological positivity in bronchial lavage fluid.MethodsFrom 2003 to 2009, 23 biopsy-proven EBTB patients were enrolled in the study. Diagnosis of EBTB was histopathologically confirmed in all patients.ResultsThe commonest subtype was the edematous-hyperemic type (34.7%); other subtypes in order of occurrence were: tumorous (21.7%), granular (17.3%), actively caseating (17.3%), fibrostenotic (4.3%), and nonspecific bronchitic (4.3%). Although all patients were sputum-smear-negative for acid-fast bacilli (AFB), 26% of patients were smear-positive for AFB in the bronchial lavage fluid. The bronchial lavage fluid grew Mycobacterium tuberculosis in 39.1% of all patients.The bronchial lavage smear positivity for AFB in the bronchial lavage fluid was 75%, 25%, 20%, 12.5%, 0%, and 0% for the granular, actively caseating, tumorous, edematous-hyperemic, fibrostenotic, and nonspecific bronchitic subtypes of EBTB, respectively. Culture positivity for Mycobacterium tuberculosis in bronchial lavage fluid was 75%, 50%, 40%, 25%, 0%, and 0%, respectively.ConclusionThe commonest subtype of EBTB was the edematous-hyperemic subtype. The granular type had the highest smear positivity and culture positivity for Mycobacterium tuberculosis in bronchial lavage fluid. Bronchoscopy should be performed in all patients suspected to have EBTB.

Pulmonary and cerebral oil embolism after hysterosalpingography with oil soluble contrast medium

Abstract:  Pulmonary oil embolism (POE) is an extremely rare complication of hysterosalpingography (HSG). A case report of a 29‐year‐old woman who developed confusion and respiratory distress 12 h after HSG is presented. Intravasation of the contrast material was obvious on the HSG. High‐resolution CT revealed ground‐glass pattern predominantly in the lower lobes. The clinical picture and radiological findings improved on the tenth hospital day. It is believed that this is the first report of high‐resolution CT findings in a case complicating HSG.

The costs of hospitalization in patients with acute exacerbation of chronic obstructive pulmonary disease

Introduction: Chronic obstructive pulmonary disease (COPD) is a major public health problem. It imparts a substantial economic burden on individuals and society. Acute exacerbations are the main cause of hospital admissions and hospitalizations in patients with COPD in Turkey. Objectives: We aimed to determine the costs of hospitalization in patients with acute exacerbations of COPD (AECOPD). Results: A total of 7832 (1556 women, 6276 men) patients were hospitalized due to acute exacerbations of COPD between 2005–2009 in the Samsun Chest Diseases and Thoracic Surgery Hospital, northern Turkey. The mean age was 64.6 ± 19.8 years old and median length of hospital stay was 14.8 ± 9.5 days. The mean cost per admission was US