Shiu-Feng Huang

Open lung biopsy in early-stage acute respiratory distress syndrome.

IntroductionAcute respiratory distress syndrome (ARDS) has heterogeneous etiologies, rapid progressive change and a high mortality rate. To improve the outcome of ARDS, accurate diagnosis is essential to the application of effective early treatment. The present study investigated the clinical effects and safety of open lung biopsy (OLB) in patients with early-stage ARDS of suspected non-infectious origin.MethodsWe undertook a retrospective study of 41 patients with early-stage ARDS (defined as one week or less after intubation) who underwent OLB in two medical intensive care units of a tertiary care hospital from 1999 to 2005. Data analyzed included baseline characteristics, complication rate, pathological diagnoses, treatment alterations, and hospital survival.ResultsThe age of patients was 55 ± 17 years (mean ± SD). The average ratio of arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) was 116 ± 43 mmHg (mean ± SD) at biopsy. Seventeen patients (41%) were immunocompromised. Postoperative complications occurred in 20% of patients (8/41). All biopsies provided a pathological diagnosis with a diagnostic yield of 100%. Specific pathological diagnoses were made for 44% of patients (18/41). Biopsy findings led to an alteration of treatment modality in 73% of patients (30/41). The treatment alteration rate was higher in patients with nonspecific diagnoses than in patients with specific diagnoses (p = 0.0024). Overall mortality was 50% (21/41) and was not influenced by age, gender, pre-OLB oxygenation, complication rate, pathological results, and alteration of treatment. There was no surgery-related mortality. The survival rate for immunocompromised patients was better than that for immunocompetent patients (71% versus 33%; p = 0.0187) in this study.ConclusionOur retrospective study suggests that OLB was a useful and acceptably safe diagnostic procedure in some selected patients with early-stage ARDS.

Computed Tomography-Guided Core-Needle Biopsy Specimens Demonstrate Epidermal Growth Factor Receptor Mutations in Patients with Non-Small-Cell Lung Cancer

Background: Target therapy with a new class of epidermal growth factor receptor (EGFR) inhibitors shows improved clinical response in EGFR gene-mutated lung cancers. Purpose: To evaluate the use of computed tomography (CT)-guided core-needle biopsy specimens for the assessment of EGFR gene mutation in non-small-cell lung cancer (NSCLC). Material and Methods: Seventeen (nine males, eight females) patients with advanced NSCLC were enrolled in this study. All patients underwent CT-guided core-needle biopsy of the lung tumor prior to treatment with the EGFR inhibitor gefitinib. There were no life-threatening complications of biopsy. The specimens were sent fresh-frozen for EGFR mutation analysis and histopathological study. Results: There were 12 (70.6%) EGFR gene mutants and five (29.4%) nonmutants. The objective response rate to gefitinib therapy was 73.3% (11 of 15 patients), with 91.7% (11 of 12 mutants) for the mutant group and 0% for the nonmutant group. Conclusion: CT-guided core-needle biopsy of advanced NSCLC enables the acquisition of sufficient tissue for EGFR gene mutation analysis.

Histopathological and CT Features of Pulmonary Sclerosing Haemangiomas

AIMnTo demonstrate the computed tomography (CT) features of pulmonary sclerosing haemangiomas.nnnMATERIALS AND METHODSnSix pathologically proven sclerosing haemangiomas were included in this retrospective review. Patients consisted of five women and one man aged 20-54 years (mean, 34.5 years). Their CT features were recorded according to enhancement patterns and the presence of a tail sign, prominent pulmonary artery sign, air-trapping sign, presence of calcification or cystic spaces, consolidation, and interstitial infiltration. The predominant composition of an individual sclerosing haemangioma was documented by means of microscopy.nnnRESULTSnInhomogeneous enhancement was frequently present and depended on the various compositions of the tumours, especially those in sclerotic and predominantly papillary predominant types. The presence of a tail sign, intra-tumoural cystic areas, and a prominent artery sign were the frequent features in our cases.nnnCONCLUSIONnSclerosing haemangioma should be considered in young or middle-aged female patients whose CT images show them having an inhomogeneous enhancing soft tissue mass with a smooth outline and with above the aforementioned features.

Acute Respiratory Distress Syndrome Caused by Leukemic Infiltration of the Lung

Respiratory distress syndrome resulting from leukemic pulmonary infiltrates is seldom diagnosed antemortem. Two 60- and 80-year-old women presented with general malaise, progressive shortness of breath, and hyperleukocytosis, which progressed to acute respiratory distress syndrome (ARDS) after admission. Acute leukemia with pulmonary infection was initially diagnosed, but subsequent examinations including open lung biopsy revealed leukemic pulmonary infiltrates without infection. In one case, the clinical condition and chest radiography improved initially after combination therapy with chemotherapy for leukemia and aggressive pulmonary support. However, new pulmonary infiltration on chest radiography and hypoxemia recurred, which was consistent with acute lysis pneumopathy. Despite aggressive treatment, both patients died due to rapidly deteriorating condition. Leukemic pulmonary involvement should be considered in acute leukemia patients with non-infectious diffusive lung infiltration, especially in acute leukemia with a high blast count.

Disseminated Nocardia Farcinica Presenting as Diffused Pulmonary Nodular Infiltration in a Patient with Pemphigus Vulgaris-A Case Report

Nocardia is a Gram-positive and weakly acid-fast stain-positive aerobic bacillus that is ubiquitous in the soil and water. It is an uncommon pathogen in humans, and found mostly in immunocompromised patients with variable etiologies. The acquisition of this infection is generally via the respiratory tract, and frequently involvs the subcutaneous tissue, lung, and central nervous system. There are some common predisposing factors associated with an immunocompromised status that cause nocardiosis. The image of pulmonary nocardiosis is variable and nonspecific, and the most common findings on chest radiography are: nodules/mass, cavitation, and consolidation/infiltrates. Disseminated nocardiosis with bacteremia is not common and may be fatal. We report a 57-year-old male non-smoker, who had pemphigus vulgaris and was receiving immuno-suppressive therapy, developed unexplained multiple pulmonary nodules 2 months later. Nocardia spp. bacteremia was identified, but responded poorly to trimethoprim-sulfamethoxazole (TMP/SMX) treatment. Finally, pulmonary nocardiosis was proved by open lung biopsy. Nocardia farcinica, a potentially multidrug resistant strain, was identified from positive blood culture. This is the 7(superscript th) case reported as pemphigus vulgaris complicated with human disseminated nocardiosis after therapy, from 1902 to 2005.

Lung Cancer with Skin Metastasis: Report of 12 Cases

Metastasis to the skin from lung cancer is less common than metastasis to other organs. Identifying the skin lesion is important because it can be an initial manifestation of the underlying malignancy. We clinically reviewed 12 cases of lung cancer with skin metastasis, from Jan 2000 to Dec 2003. The pathologic findings included adenocarcinoma in 6 patients, squamous cell carcinoma in 4, and small cell carcinoma in 2. The most common sites of skin lesions were the anterior chest wall and abdominal wall. The lesions could present as a solitary mass, multiple nodules, or a plaque. One patient developed skin metastasis in the form of cellulitis. Of the 12 patients, 11 exhibited other metastatic diseases, which were diagnosed radiologically or pathologically at the time of skin biopsy. Median survival from the diagnosis of skin metastasis was 2.9 months (95% CI, 0 to 5.8 months). Three patients lived more than 1 year after the appearance of skin metastasis. In conclusion, adenocarcinoma is the predominant cell type of skin metastasis from lung cancer. The prognosis is poor, because it always represents a terminal manifestation.

Churg-Strauss Syndrome After Corticosteroid Withdrawal in Asthma Patients: Report of Two Cases not Related to Ieukotriene Receptor Antagonists

The standard management of asthma with inhaled corticosteroids and bronchodilators is successful in most patients. Leukotriene receptor antagonists are also universally used for asthma because of their anti-inflammatory potential. In recent years, academic circles have noted that some long-standing asthma patients have developed eosinophilic lung disease after withdrawal of systemic steroids due to the prior administration of inhaled steroids with or without leukotriene receptor antagonists. It was assumed that these patients may have had underlying eosinophilic lung disease with an initial presentation of asthma, which was unwittingly suppressed by previous steroid use. Herein, we present two cases of allergic-type asthma in which the underlying Churg Strauss syndrome was discovered after systemic steroid withdrawal. The symptoms and radiographic abnormalities of Churg Strauss syndrome were improved after two weeks of resumed steroid treatment.