Wallace T. Miller

Role of fiberoptic bronchoscopy in the diagnosis of invasive pulmonary aspergillosis in patients with acute leukemia

The utility and safety of fiberoptic bronchoscopy in the diagnosis of invasive pulmonary aspergillosis in patients with acute leukemia have not been examined. The results of 21 bronchoscopic procedures in 19 patients with invasive pulmonary aspergillosis and acute leukemia were reviewed. Analysis was confined to the 16 patients who had histopathologically documented infection on biopsy or at autopsy. Fiberoptic bronchoscopy established or suggested the diagnosis of invasive pulmonary aspergillosis in eight of 16 (50 percent) patients. Transbronchial or bronchial biopsy added only one diagnosis to those obtained by bronchial washing and brushing. Although fiberoptic bronchoscopy was a safe and well-tolerated procedure in our patients with invasive pulmonary aspergillosis and acute leukemia, its success rate was only 50 percent overall, and it appeared to be even less successful when performed early in the course of the disease. Fiberoptic bronchoscopy is a useful first procedure for the evaluation of patients with acute leukemia and possible invasive pulmonary aspergillosis, but a negative result does not exclude aspergillosis. Further diagnostic procedures, including repeated bronchoscopy, or institution of empiric antifungal therapy may be warranted if the clinical suspicion of invasive pulmonary aspergillosis is high.

Recurrence-free survival time for surgically treated soft tissue sarcoma patients. Multivariate analysis of five prognostic factors.

A staging system, based upon the experience of 1215 patients, was published by the American Joint Committee Task Force on Soft Tissue Sarcoma in 1977. A subset of these patients, 594, was selected to study recurrence‐free survival time. The authors found 331 patients with a recurrence within 5 years (100 local only, 123 metastatic only, and 108 local + metastatic); median months to recurrence was 9.7. Within 5 years, recurrence was clearly associated with mortality: among the 331 patients who experienced a recurrence, 245 died, whereas only 31 died among the 263 who had no recurrence. To further evaluate the utility of the published staging system, a multivariate analysis of five factors was carried out for 297 of the 594 patients (patients with unknown information for any one of these factors were excluded). Factors in addition to grade that exerted a significant influence on recurrence were: direct extension, symptoms, and location of tumor when survival was measured to the first of any recurrence, and tumor size, measuring survival to the first metastatic recurrence. It is therefore recommended that these factors be taken into account in staging this disease. Estimates of probable recurrence‐free survival time based upon the multivariate model (Weibull) are also presented.

Diagnosis of Pneumonia With an Electronic Nose: Correlation of Vapor Signature With Chest Computed Tomography Scan Findings

Objectives/Hypothesis: The electronic nose is a sensor of volatile molecules that is useful in the analysis of expired gases. The device is well suited to testing the breath of patients receiving mechanical ventilation and is a potential diagnostic adjunct that can aid in the detection of patients with ventilator‐associated pneumonia.

Evaluation of Radiographic Lucency or Opaqueness of Gallstones as a Means of Identifying Cholesterol or Pigment Stones: Correlation of lucency or opaqueness with calcium and mineral

A major criterion for the selection of patients with gallstones for treatment with chenodeoxycholic acid is the radiographic demonstration of lucent gallstones. In this study, we sought to evaluate the degree of selectivity of that criterion for distinguishing patients with cholesterol stones from those with pigment stones and to define the determinants of stone lucency or opaqueness. Of 92 lucent stones, 14% were pigment stones; and of 18 of opaque stones, 33% were cholesterol. Thus, the criterion of stone lucency allows inclusion of a significant number of subjects (14%) with lucent pigment stones, which may account for about one-half of the reported 33% incidence of treatment failures with chenodeoxycholic acid. Conversely, of patients with opaque stones, the one-third with cholesterol stones would be excluded from chenodeoxycholic acid treatment. Calcium is the major metal of both types of stones. However, opaque stones contain 6 times more calcium than lucent stones, which accounts for the difference in radiographic appearance.

Acute Reversible Lupus Vasculitis of the Gastrointestinal Tract

Acute gastrointestinal vasculitis is a recognized but frequently misdiagnosed complication of systemic lupus erythematosus. Of 141 patients with SLE, 20 had ischemic disease reversible in all cases with steroid therapy. Nine patients had radiographic findings consistent with vasculitis such as pseudo–obstruction of the gastric outlet, duodenal stasis, effacement of mucosal folds, spasticity and thumbprinting. Lupus gastrointestinal vasculitis is a rnore common entity than generally recognized. Careful evaluation of the abdominal plain film or gastrointestinal series helps to establish the diagnosis of vasculitis.

Identification of Patients with Cholesterol or Pigment Gallstones by Discriminant Analysis of Radiographic Features

In a search for a way to distinguish cholesterol gallstones from pigment gallstones by oral cholecystography, we evaluated 56 patients with surgically confirmed cholelithiasis. Only buoyancy was highly predictive of gallstone composition: all 14 patients with floating stones had cholesterol stones (P less than 0.01), but only one third of the patients with cholesterol stones had stone buoyancy. Using a function derived by stepwise discriminant analysis, we separated patients with cholesterol stones from those with pigment stones. The predictive accuracy was significantly improved: sensitivity was 95 per cent (37 of 39 patients with cholesterol stones), specificity was 82 per cent (14 of 17 patients with pigment stones), and efficiency was 91 per cent (51 of 56 total patients). The resultant function, applied prospectively to 17 additional cases, classified all of them correctly. In patients with cholelithiasis and gallbladders visualized on oral cholecystography, discriminant analysis can improve the prediction of gallstone composition and the subsequent selection of medial or surgical therapy.

Pigmented Villonodular Synovitis of the Temperomandibular Joint

Two cases of pigmented villonodular synovitis of the temperomandibular joint are reported. The diagnosis was not considered originally in either case and this entity has never been previously reported in this location. Smooth destruction of adjacent bone was encountered in both cases. Differential diagnosis including carcinoma of the external auditory canal and middle ear as well as other, less likely possibilities, are discussed.

Prospective, randomized study of diagnosis and outcome in acute upper-gastrointestinal bleeding: Endoscopy versus conventional radiography

Sixty patients with mild to moderate upper-gastrointestinal bleeding were admitted to a prospective, controlled study of diagnosis and management, and were randomized to endoscopy or upper-gastrointestinal (UGI) barium series as the initial study. Definitive localization of the source of bleeding was made initially in 69% of the endoscopy group and 21% of the UGI group (P<0.0005). Of 54 patients undergoing both studies, endoscopy was definitive in 67% and UGI series in 22%. Thus, endoscopy also made more diagnoses when used as the second study (P<.01). The use of endoscopy as the initial procedure led to significantly more rapid diagnosis than with UGI series. However, there were no significant differences between the two groups in clinical outcome. Endoscopy is the initial diagnostic procedure of choice in patients with mild to moderate upper-gastrointestinal bleeding because it enables detection of superficial bleeding lesions and has significantly increased the speed of diagnosis.

Chest CT features of community-acquired respiratory viral infections in adult inpatients with lower respiratory tract infections.

Purpose The appearance of respiratory virus infection on thoracic computed tomography (CT) has been described only to a limited extent in the current literature, and viral pneumonias may be under-recognized by radiologists. Our objective was to describe thoracic CT findings in a broad range of adult inpatients with respiratory virus infections. Materials and Methods A retrospective analysis of chest CTs was performed on symptomatic adult inpatients presenting with positive nucleic acid-based assays for 1 of 4 common community-acquired respiratory viruses. Forty-two patients with viral respiratory tract infections who underwent chest CT imaging were evaluated. The reviewer was blinded to virus type and patient information. CT findings were compared with CT reports produced at the time of the original study and correlated with clinical outcome measures. Results Influenza (n=21), adenovirus (n=9), respiratory syncytial virus (n=8), and parainfluenza (n=4) were represented among the cohort. Three patterns of the disease were seen with viral infection: (1) limited infection with normal imaging (21%), (2) bronchitis/bronchiolitis characterized by bronchial wall thickening and tree-in bud opacities (31%), and (3) pneumonia characterized by multifocal consolidation or ground-glass opacities (36%). Viral infection was suggested in only 4/42 (10%) of the original radiology reports, all of which had evidence of bronchitis/bronchiolitis on chest CT. Viral pneumonia, characterized by multifocal ground-glass opacities or multifocal consolidations, was interpreted as aspiration pneumonia or bacterial pneumonia in 15/16 (94%) of the original CT reports. Conclusions CT scans of the inpatients with community-acquired viral infections most commonly show 1 of 2 patterns: consolidation and ground-glass opacities or bronchial wall thickening and tree-in-bud opacities. It is important that physicians interpreting CTs with multifocal consolidations and/or multifocal ground-glass opacities consider viral pneumonia when these findings are observed and recommend appropriate diagnostic testing when clinically warranted.

Aspergillosis: A disease with many faces

Aspergillus causes a variety of pulmonary diseases. For the most part, they can be divided into three groups: mycetoma, invasive aspergillosis, and allergic forms of aspergillosis. The mycetoma form of aspergillosis has no effective treatment other than surgery, which is reserved for the severely symptomatic patient, usually with massive hemoptysis. Invasive aspergillosis is a dangerous pulmonary infection seen in patients who are generally severely immunocompromised. It is treated with amphotericin B and success in treatment of this form of aspergillosis is limited. Two of the allergic forms of Aspergillus infection, allergic bronchopulmonary aspergillosis and bronchocentric granulomatosis, are treated with steroids. The third allergic type of reaction, hypersensitivity lung, is best treated by removal of the patient from exposure to the antigen. Although these are the characteristic forms of aspergillosis, there is occasional overlap of the different types of aspergillosis.