Wen-Lin Su

Association of reduced tumor necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-1β but increased interleukin (IL)-10 expression with improved chest radiography in patients with pulmonary tuberculosis

ABSTRACT Mycobacterium tuberculosis infection is a major world health issue. The early identification of patients at risk for a poor response to anti-M. tuberculosis therapy would help elucidate the key players in the anti-M. tuberculosis response. The objective of the present study was to correlate the modulation of cytokine expression (interleukin-1 [IL-1], IL-6, IL-8, IL-10, IL-12, gamma interferon [IFN-γ], interferon-inducible protein [IP-10], and monocyte chemotactic protein 1 [MCP-1]) with the clinical response to 2 months of intensive therapy. From January to December 2007, 40 M. tuberculosis-infected patients and 40 healthy patients were recruited. After exclusion for diabetes, 32 patients and 36 controls were analyzed. The clinical responses of the M. tuberculosis-infected patients on the basis of the findings of chest radiography were compared to their plasma cytokine levels measured before and after 2 months of intensive anti-M. tuberculosis therapy and 6 months of therapy with human cytokine antibody arrays. Chest radiographs of 20 of 32 M. tuberculosis-infected patients showed improvement after 2 months of intensive therapy (early responders), while the M. tuberculosis infections in 12 of 32 of the patients resolved after a further 4 months (late responders). The levels of expression of TNF-α, MCP-1, IFN-γ, and IL-1β were decreased; and the level of IL-10 increased in early responders. After adjustment for age, gender, and the result of sputum culture for M. tuberculosis, significant differences in the levels of MCP-1 and IP-10 expression were observed between the early and the late responders after 2 months of intensive anti-M. tuberculosis therapy. Due to the interpatient variability in IP-10 levels, intrapatient monitoring of IP-10 levels may provide more insight into the M. tuberculosis responder status than comparison between patients. Plasma MCP-1 levels were normalized in patients who had resolved their M. tuberculosis infections. Further studies to evaluate the association of the modulation in MCP-1 levels with early and late responses are warranted.

Acute Respiratory Distress Syndrome After Zinc Chloride Inhalation: Survival After Extracorporeal Life Support and Corticosteroid Treatment

No standard protocol exists for the treatment of acute respiratory distress syndrome induced by inhalation of smoke from a smoke bomb. In this case, a 23-year-old man was exposed to smoke from a smoke grenade for approximately 10 to 15 minutes without protective breathing apparatus. Acute respiratory distress syndrome developed subsequently, complicated by bilateral pneumothorax and pneumomediastinum 48 hours after inhalation. Despite mechanical ventilation and bilateral tube thoracostomy, the patient was severely hypoxemic 4 days after hospitalization. His condition improved upon treatment with high-dose corticosteroids, an additional 500-mg dose of methylprednisolone, and the initiation of extracorporeal life support. Arterial oxygenation decreased gradually after abrupt tapering of the corticosteroid dose and discontinuation of the life support. On day 16 of hospitalization, the patient experienced progressive deterioration of arterial oxygenation despite the intensive treatment. The initial treatment regimen (ie, corticosteroids and extracorporeal life support) was resumed, and the patients arterial oxygenation improved. The patient survived.

Effects of Implementing Adaptive Support Ventilation in a Medical Intensive Care Unit

BACKGROUND: Adaptive support ventilation (ASV) facilitates ventilator liberation in postoperative patients in surgical intensive care units (ICU). Whether ASV has similar benefits in patients with acute respiratory failure is unclear. METHODS: We conducted a pilot study in a medical ICU that manages approximately 600 mechanically ventilated patients a year. The ICU has one respiratory therapist who manages ventilators twice during the day shift (8:00 am to 5:00 pm). No on-site respiratory therapist was present at night. We prospectively enrolled 79 patients mechanically ventilated for ≥ 24 hours on pressure support of ≥ 15 cm H2O, with or without synchronized intermittent mandatory ventilation, FIO2 ≤ 50%, and PEEP ≤ 8 cm H2O. We switched the ventilation mode to ASV starting at a “%MinVol” setting of 80–100%. We defined spontaneous breathing trial (SBT) readiness as a frequency/tidal-volume ratio of < 105 (breaths/min)/L on pressure support of ≤ 8 cm H2O and PEEP of ≤ 5 cm H2O for at least 2 h, and all spontaneous breaths. The T-piece SBT was considered successful if the frequency/tidal-volume ratio remained below 105 (breaths/min)/L for 30 min, and we extubated after successful SBT. The control group consisted of 70 patients managed with conventional ventilation modes and a ventilator protocol during a 6-month period immediately before the ASV study period. RESULTS: Extubation was attempted in 73% of the patients in the ASV group, and 80% of the patients in the non-ASV group. The re-intubation rates in the ASV and non-ASV groups were 5% and 7%, respectively. In the ASV group, 20% of the patients achieved extubation readiness within 1 day, compared to 4% in the non-ASV group (P = <.001). The median time from the enrollment to extubation readiness was 1 day for the ASV group and 3 days for the non-ASV group (P = .055). Patients switched to ASV were more likely to be liberated from mechanical ventilation at 3 weeks (P = .04). Multiple logistic regression analysis showed that, of the independent factors in the model, only ASV was associated with shorter time to extubation readiness (P = .048 via likelihood ratio test). CONCLUSIONS: Extubation readiness may not be recognized in a timely manner in at least 15% of patients recovering from respiratory failure. ASV helps to identify these patients and may improve their weaning outcomes.

Role of Open Lung Biopsy in Patients with Diffuse Lung Infiltrates and Acute Respiratory Failure

BACKGROUND AND PURPOSE Open lung biopsy (OLB) is the standard procedure for the diagnosis of specific parenchymal lung diseases. The purpose of this study was to investigate the influence of OLB on subsequent treatment strategy and outcome in patients with diffuse lung infiltrates and acute respiratory failure. METHODS This retrospective review included 32 patients (aged 50.6 +/- 21.7 years) with acute respiratory failure and diffuse pulmonary infiltrates who underwent OLB from 1990-2002. Data analyzed included diagnoses, treatment alterations, 30-day survival, oxygenation status, and histologic results. RESULTS Specific diagnoses were made in 53.1% of patients (17/32), 23 (71.9%) of whom had acute respiratory distress syndrome (ARDS). Diagnostic yields did not differ with immunity status or ARDS. OLB led to specific decisions of treatment in 46.9% of patients (15/32), and only 7 of these 32 patients (21.8%) survived. Overall mortality was 56.2% (18/32) and was not influenced by pre-OLB oxygenation or histologic results. Although perioperative complications affected 40.6% of patients (13/32), none of the deaths were surgery-related. Complication rates were significantly higher in patients with ARDS (p = 0.04). CONCLUSIONS OLB is associated with a low perioperative mortality rate and acceptable morbidity rate in patients with diffuse lung infiltrates and acute respiratory failure, including those patients with ARDS. In this study, a specific diagnosis was obtained by OLB in more than half of patients with diffuse pulmonary infiltrates and ARDS. In addition, OLB resulted in either use of a new therapeutic strategy or elimination of unnecessary treatment in nearly one-half of patients (46.9%).

Multiple Pulmonary Nodules in Ectopic Adrenocorticotropic Hormone Syndrome: Cause or Result?

Objective: To report a case of invasive pulmonary aspergillosis mimicking lung cancer with lung to lung metastases in ectopic adrenocorticotropic hormone syndrome (EAS). Clinical Presentation and Intervention: A 60-year-old man suffering from hypokalemic alkalosis, hypertension and limbs paralysis was referred to our hospital. EAS caused by malignancy of lung was highly suspected due to multiple pulmonary nodules presenting on chest film and positron emission tomography (PET) images. Video-assisted thoracic surgical biopsy tissue was used to confirm invasive aspergillosis instead of malignancy. Finally, the patient died of opportunistic infection. Conclusion: This case showed that although EAS is usually associated with solid tumors, multiple pulmonary nodules secondary to opportunistic infections such as invasive aspergillosis must be kept in mind.

Small Cell Lung Cancer Presenting as Ectopic ACTH Syndrome with Hypothyrodism and Hypogonadism

Background: Small-cell lung cancer accounts for 15–20% of all lung cancers, and it is the cell type most commonly associated with paraneoplastic syndrome. Small-cell lung cancer presenting as ectopic adrenocorticotropic hormone (ACTH) syndrome associated with hypothyrodism and hypogonadotropic hypogonadism is clinically very rare. Case Report: A 43-year-old man who presented with bilateral lower-extremity edema and hypokalemia had a mass lesion in his left hilum base visible on chest radiograph. Biopsy identified the mass as smallcell lung cancer with focal ACTH staining. The endocrine tests disclosed hypercortisolism, hypogonadism and hypothyroidism. Results: Partial remission as evidenced by regression of the tumor mass and return to normal serum cortisol and ACTH levels occurred after the first course of combination chemotherapy using cisplatin and etoposide. An unexpected left-sided spontaneous pneumothorax developed after the first course of chemotherapy and was treated with thoracostomy and a chest tube. The patient developed persistent air leakage and chronic empyema. The patient received surgery of the Eloesser flap and reconstruction with the latissimus dorsalis flap. The treatment of the complicated problems was successful. Conclusion: Combination chemotherapy may prove effective in the treatment of small-cell lung cancer with ectopic ACTH syndrome, hypothyroidism and hypogonadism.

Air Crescent Sign: A Rare Presentation of Varicose Bronchiectasis with Hemoptysis

The most common cause of the air crescent sign is aspergilloma resulting from saprophytic aspergillosis. The fungal ball consisting of condensed hyphae can vary in both size and number. Although saprophytic aspergillosis can be asymptomatic, patients may occasionally experience severe, life-threatening hemoptysis. Other causes of the air crescent sign include pulmonary hydatid cysts; lung colonization by other fungi; Rasmussen aneurysms in a tuberculous cavity; lung abscesses; bacterial necrotizing pneumonia caused by Staphylococcus aureus, Klebsiella pneumoniae, or Pseudomonas aeruginosa; and cavitating neoplasm of the lung. Bronchiectasis has not yet been reported as a cause of the air crescent sign. In this paper, we present a case of varicose bronchiectasis complicated with massive hemoptysis; a chest computed tomography (CT) scan of the patient showed the air crescent sign. Clinicians should therefore be aware that while there are several well-known causes of the appearance of the air crescent sign in a chest CT scan, varicose bronchiectasis complicated with severe hemoptysis should be considered as a diagnosis if rapid changes in the image occur during the follow-up period.

Extracorporeal Membrane Oxygenation for Management of Carbon Monoxide Intoxication

Emergency use of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary failure is well documented. However, the use of ECMO for carbon monoxide (CO) poisoning is rare. We report a case of a patient with severe CO poisoning that initially manifested as stunned myocardium-induced acute pulmonary edema. The patient was severely hypoxemic and refractory to mechanical ventilation at 7 hours after hospitalization. We applied veno-arterial ECMO for rescue life support for 3 days. The patient had a dramatic full recovery without immediate neurologic sequelae for the 3-day period. Under ECMO support, PaO2 increased from 34.8 to 299.9 mmHg, and ventilator FiO2 decreased to 0.4 within 3 days. The patients consciousness also improved, with the Glasgow Coma Scale (GCS) score increasing from 8 to 15. Although the standard treatment for CO poisoning remains controversial, an aggressive rescue strategy is warranted for concurrent cardiovascular collapse and acute respiratory failure after severe CO poisoning in order to reduce the mortality of a reversible etiology.

Intravenous Immunoglobulin Therapy in a Patient with Tuberculosis-associated Hemophagocytic Syndrome: A Case Report

Hemophagocytic syndrome is an uncommon but severe fatal condition associated with a variety of infectious agents, as well as genetic, neoplastic, and autoimmune diseases. We report a 63-year-old man presenting with severe shock, acute respiratory distress syndrome, and multi-organ failure. Hemophagocytic syndrome was suspected due to the high level of serum ferritin and cytopenia, and was confirmed by bone marrow aspiration. His hemodynamic status, cytopenia, and oxygenation improved dramatically after administration of intravenous immunoglobulin for 2 consecutive days. Tuberculosis was confirmed by positive polymerase chain reaction for tuberculosis in the sputum and blood, and later by sputum mycobacterium culture. He recovered uneventfully and was successfully weaned from the ventilator. This case highlights disseminated tuberculosis as a potential cause of HPS; immediate intravenous immunoglobulin administration may rescue the patient from the catastrophic state.

Resuscitation Using Extracorporeal Membrane Oxygenation for Fat Embolism Syndrome-A Case Report and Literature Review

Fat embolism syndrome (FES) is a rare fatal complication. The treatment of FES is mainly supportive. Extracorporeal membrane oxygenation (ECMO) is currently being used in ICUs worldwide for respiratory failure, but rarely for ARDS associated with FES. We report the case of a 15-year-old male with close fractures of the left clavicle, right humerus and femur, and who developed ARDS associated with FES 3 days after the fracture. The patient remained profoundly hypoxic despite ventilatory support and veno-venous ECMO. After 1 week of resuscitation using ECMO, his oxygenation improved and the patient was discharged from the hospital in good condition.