Sinem Iliaz

Value of neutrophil/lymphocyte ratio in the differential diagnosis of sarcoidosis and tuberculosis

INTRODUCTION: The differential diagnosis of sarcoidosis creates a challange due to tuberculosis also having lung and lymph node involvement. Because both diseases show granulomatous inflammation, it may not be possible to distinguish tuberculosis and sarcoidosis in pathological specimens. As a result of the complexity in the differential diagnosis of sarcoidosis and tuberculosis, new markers for differentiation are being investigated. OBJECTIVE: The aim of our study is to investigate the value of neutrophil/lymphocyte ratio (NLR) as a possible marker in differentiating sarcoidosis and tuberculosis. MATERIALS AND METHODS: In our study, 51 acid-fast bacilli (AFB) positive and/or culture-positive patients with pulmonary tuberculosis, 40 patients with biopsy-proven sarcoidosis and a control group consisting of 43 patients were included. In our study, information was collected retrospectively based on hospital records. RESULTS: Leukocyte and neutrophil counts, NLR, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) were significantly higher, and albumin was significantly lower in the tuberculosis group compared with sarcoidosis (for all parameters P < 0.001). The most appropriate cut-off value of NLR to distinguish tuberculosis from sarcoidosis was determined as 2.55. For this cut-off value of NLR there was 79% sensitivity, 69% specificity, 73% positive predictive value (PPV), 75% negative predictive value (NPV), and area under the curve (AUC) was 0.788. For differentiation of sarcoidosis from tuberculosis, accuracy of the NLR test according to this cut-off value was found as 76%. CONCLUSION: NLR as a little known marker in respiratory medicine was found to be supportive in differentiation of tuberculosis and sarcoidosis. More studies on this issue is needed.

Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in various lung diseases

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of lung disease, and its use is increasing worldwide. It has been used as a means of diagnosing lung cancer in its initial stages, and there are data supporting its use for the diagnosis of benign lung disease. The aim of this study was to share our experience with EBUS-TBNA and discuss its diagnostic value. Methods: We retrospectively analyzed the results related to 159 patients who underwent EBUS-TBNA at our pulmonary medicine clinic between 2010 and 2013. We recorded the location and size of lymph nodes seen during EBUS. Lymph nodes that appeared to be affected on EBUS were sampled at least twice. We recorded the diagnostic results of EBUS-TBNA and (for cases in which EBUS-TBNA yielded an inconclusive diagnosis) the final diagnoses after further investigation and follow-up. Results: We evaluated 159 patients, of whom 89 (56%) were male and 70 (44%) were female. The mean age was 54.6 ± 14.2 years among the male patients and 51.9 ± 11.3 years among the female patients. Of the 159 patients evaluated, 115 (84%) were correctly diagnosed by EBUS. The diagnostic accuracy of EBUS-TBNA was 83% for benign granulomatous diseases and 77% for malignant diseases. Conclusions: The diagnostic value of EBUS-TBNA is also high for benign pathologies, such as sarcoidosis and tuberculosis. In patients with mediastinal disorders, the use of EBUS-TBNA should be encouraged, primarily because it markedly reduces the need for mediastinoscopy.

Our Experience on Silicone Y-Stent for Severe COPD Complicated with Expiratory Central Airway Collapse

Background: Expiratory central airway collapse (ECAC) is abnormal central airway narrowing during expiration. ECAC involves 2 different pathophysiological entities as tracheobronchomalacia and excessive dynamic airway collapse (EDAC). Although the exact cause is unknown, chronic obstructive pulmonary disease (COPD) is frequently accompanied by ECAC. Although there are various publications on the relationship between COPD and ECAC, there are very few data for stent placement in patients with tracheobronchomalacia accompanied severe COPD. We share our results for stenting in ECAC among patients with severe COPD. Methods: The data in this case series were collected retrospectively. The ECAC diagnosis was made during flexible bronchoscopy with severe COPD. Silicone Y-stents were placed via rigid bronchoscopy under general anesthesia. Results: A total of 9 patients’ (7 men) data were evaluated with an average age of 67±10.73 years. One patient experienced stent migration on the second day of stenting prompting stent removal. Another patient died 1 month after stenting. Consequently, we evaluated the follow-up data of remaining 7 patients. The changes in forced expiratory volume 1 was not significant for these 7 cases (P=0.51). The modified Medical Research Council (mMRC) score improvement was statistically significant (P=0.03). Functional status improvement was observed in 4 of 7 patients. Of the 7 patients, mean additional follow-up bronchoscopic interventions requirement was 2.2 times. Conclusions: Our study showed significant decrease in mMRC score with stenting for ECAC in severe COPD. For 2 patients, we experienced severe complications during short-term follow-up period after stenting. Additional follow-up bronchoscopic interventions were required.

Prevalence and outcomes of comorbid illnesses in elderly patients with respiratory diseases.

The aim of the present study was to determine the prevalence of comorbidities in very elderly patients hospitalized as a result of acute respiratory diseases and to analyze sex‐specific differences, and to examine the effects of these comorbidities on their treatment outcomes.

Neutrophil/lymphocyte ratio in granulomatous disease

We read with great interest the article entitled ‘The clinical significance of hematologic parameters in patients with sarcoidosis’ by Dirican and colleagues. In that well-organized study, Dirican et al. examined the usability of the neutrophil/lymphocyte ratio (NLR) and other hematologic parameters in sarcoidosis. In the study, NLR is higher in patients with sarcoidosis compared with healthy volunteers and found that NLR showed a positive correlation with erythrocyte sedimentation rate (1). NLR as a new inflammatory marker is very popular subject and was studied in many clinical situations. The NLR has been studied in malignancies, dementia and cardiovascular disease. In pulmonary medicine, the NLR has been studied mostly in lung cancer and high level of NLR was associated with poor prognosis in patients with lung cancer (2). Also NLR has been studied in chronic obstructive pulmonary disease (COPD) and has been shown to be higher in patients with exacerbations compared with stable COPD and healthy controls (3). NLR is a marker that can be calculated easily from complete blood count. This inflammatory marker is repeatable and easily accessible. Therefore, use of NLR may increase in the future. Sarcoidosis is a multisystemic granulomatous disease and frequently presents with lung involvement. Tuberculosis is a common infectious disease in the world, and like sarcoidosis, it is a granulomatous disease that mostly affects lungs. Because both diseases involve lung and lymph node, the differential diagnosis of sarcoidosis and tuberculosis may create a challenge. A recent study demonstrated that NLR was significantly higher in the tuberculosis patients compared with the patients with sarcoidosis. Also, the same study showed that NLR is higher in patients with sarcoidosis and tuberculosis compared with healthy volunteers (4). In another study, it was reported that NLR is a good marker in the differentiation of pulmonary tuberculosis from bacterial pneumonia (5). NLR is a new inflammatory marker that can be useful in pulmonary medicine. But it is a bit early to make solid conclusions. A lot of studies showed that NLR is high in many cases and is a nonspecific parameter.

Are neutrophil/lymphocyte ratio and platelet/lymphocyte ratio reliable parameters as prognostic indicators in malignant mesothelioma?

Background Malignant mesothelioma (MM) is an aggressive asbestos-related pleural tumor. The incidence is increasing with intensive use of asbestos in developing countries. We need an easily accessible, inexpensive, and reliable method for determining the low survival time prognosis of this tumor. The aim of our study was to investigate the viability of neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) as prognostic indicators in MM. Patients and methods Thirty-six patients with MM, whose histopathologic diagnosis and follow-up were performed by our clinic and whose complete archive data were accessible, were included in this retrospective study. The patients’ histopathologic disease types and stages, complete blood count parameters at diagnosis, and survival were recorded. Results Eighteen of the patients with MM were male and the remaining 18 of them were female; the average follow-up period was 24.83±3.61 months. The PLR levels of the patients were statistically significant (P<0.05). The NLR and PLR area under the receiver operating characteristic curve values were 0.559 and 0.749, respectively (P=0.631 and P=0.044, respectively). Conclusion PLR was a significant prognostic indicator of MM at diagnosis on complete blood count parameters; however, NLR was not a significant prognostic indicator. A large number of prospective studies are needed to prove the reliability of the parameters.

An outbreak of multidrug-resistant tuberculosis among a family.

Tuberculosis is a major public health problem and it may be complicated by multidrug-resistant tuberculosis (MDR-TB). Wide transmission among immunocompetent contacts of the index case is possible. If you detect tuberculosis in two contacts of the index case, it is called an outbreak. The aim of our paper is to evaluate the characteristics of a MDR-TB outbreak affecting 7 people in a family treated during 2012-2014 in Istanbul Yedikule Training and Research Hospital for Chest Disease and Thoracic Surgery, Turkey. The cultures, spoligotyping, and DNA fingerprinting revealed the same Mycobacterium tuberculosis species as T1 genotype and ST53 subtype. All patients were negative for human immunodeficiency virus and free of other underlying diseases.

Comorbidities in elderly patients with pulmonary disease.

We read with great interest the article entitled “Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment” by Wardzynska et al. In that well organized study, the Authors examined the comorbidities and polypharmacy in elderly patients with asthma. In the study, 93 elderly patients with mean age of 72.6 ± 5.2 years were compared with 78 non-elderly asthmatic patients for the effect of comorbidities on asthma control. The authors of this study showed that elderly asthmatic patients had a higher incidence of comorbidities and a higher number of prescribed medicines. Also, they demonstrated that the high number of comorbidities in the elderly group did not affect asthma control. Interestingly, this study reported that proton pump inhibitors (PPI) were associated with an increased risk of exacerbations in the elderly group. Asthma control levels according to Global Initiative for Asthma (GINA) were not similar in the elderly and younger groups despite similar scores with the asthma control test (ACT). So, it is hard to say whether asthma control levels of these two groups were similar. Angiotensin converting enzyme (ACE) inhibitors, betablockers, and aspirin are well known drugs which interfere with asthma control and pulmonary symptoms. In the study of Wardzynska et al., these drugs and comorbidities were more common in the elderly group. However, ACT scores were found to be similar between groups. The mean ACT scores were low in both groups. Despite ACT score similarity, the rate of patients under control according to GINA were significantly lower in the elderly (15.1% vs 34.6%, P = 0.003). So, we thought it might not be true to say that asthma control levels of these two groups were similar despite the elderly group’s comorbidities or multidrug use. It might be more appropriate to analyze asthma control levels among two groups with similar non-respiratory drug use to see the effect of comorbidities and/or age on asthma status. Not using PPI, but undiagnosed gastroesphageal reflux disease (GERD) might be associated with asthma exacerbations. The study of Wardzynska et al. was based on a questionnaire to record comorbidities. As a result of the study, the Authors speculated that PPI use was related with asthma exacerbations and difficult asthma. However, gastroeosphageal reflux disease is common in asthmatic patients, especially in difficult to control asthma. However, treatment of GERD does not appear to improve asthma control. GERD is difficult to diagnose in the elderly, because they are more asymptomatic. That might be the cause of the lower rate of GERD in the elderly compared with the prevalence studies. In our opinion, not using PPI, but undiagnosed GERD might be associated with asthma exacerbations in this study. In addition, it is difficult to rule out GERD without invasive tests, such as pH monitoring. Comorbidities are more common in elderly patients with respiratory diseases, and this might be related with in-hospital mortality or transfer to intensive care unit. In the study of Wardzynska et al., they found that elderly patients with asthma had 8.4 ± 3.4 comorbidities. Also, this study showed that the number of comorbidities in the elderly group was significantly higher than younger asthmatic patients. In another study, Bahadir et al. showed that comorbidities in patients with respiratory diseases are very common. Also, Bahadir et al. reported that these comorbidities were associated with in-hospital mortality during hospitalization for respiratory diseases and the need for intensive care unit admission. In elderly patients, comorbidities are common, and management is usually challenging. Therefore, we must be careful in the evaluation of geriatric patients, and always take into consideration comorbid conditions. Well organized studies assessing comorbidities in the elderly, such as the study of Wardzyńska et al., are important to draw the attention of physicians to this issue in daily practice.

Does the 6-minute walk test predict nocturnal oxygen desaturation in patients with moderate to severe COPD?

Patients with chronic obstructive pulmonary disease (COPD) who have nocturnal oxygen desaturation (NOD) can be treated with nocturnal oxygen therapy (NOT) to avoid possible morbidity and mortality. Although there is no definite data recommending NOT alone, our aim is to evaluate the relationship between desaturation during the six-minute walk test (6MWT) and NOD in COPD. Fifty-five stable patients with COPD were enrolled in this study. The 6MWT and nocturnal oximetry were performed. Patients with comorbid diseases and respiratory failure were excluded. In total, 55 patients (49 males and 6 females, mean age: 65.8 ± 8.4 years) were analysed. Twenty-seven of the patients had moderate COPD and the remainder (n = 28) had severe COPD. Three patients (11%) with moderate COPD and 12 patients (42.9%) with severe COPD desaturated during 6MWT (p = 0.003). NOD was observed in five patients with severe COPD (17.9%). There were no patients with NOD in the moderate COPD group. Three (25%) of patients with severe COPD who desaturated during the 6MWT also had NOD. NOD was more common in patients with severe COPD and the patients with higher carbon dioxide levels (p = 0.02 and p = 0.001). Three patients (11%) with moderate COPD desaturated during the 6MWT; however they did not have NOD. Although the sample size in this study was too small to be conclusive, NOD was more common in desaturators during the 6MWT particularly in patients with severe COPD.

Author reply to the editor

Complete blood count and other inflammation markers were all analyzed in our hospital’s routinely used biochemical laboratory by their automatic biochemical analyzers. We did not prefer peripheral blood smears to calculate neutrophil/ lymphocyte ratio, because we were looking for a more practical marker. Although peripheral blood smear is a well-known method of blood cell analysis, it takes time to prepare it for evaluation. We focused on a new inflammation marker like neutrophil/lymphocyte ratio(NLR), because it does not require extra time and any other equipment. It is simply calculated from complete blood count and shows correlation with other well-known inflammation markers like CRP, total leukocyte count, and ESR.Complete blood count and other inflammation markers were all analyzed in our hospital’s routinely used biochemical laboratory by their automatic biochemical analyzers. We did not prefer peripheral blood smears to calculate neutrophil/ lymphocyte ratio, because we were looking for a more practical marker. Although peripheral blood smear is a well-known method of blood cell analysis, it takes time to prepare it for evaluation. We focused on a new inflammation marker like neutrophil/lymphocyte ratio(NLR), because it does not require extra time and any other equipment. It is simply calculated from complete blood count and shows correlation with other well-known inflammation markers like CRP, total leukocyte count, and ESR.