Yeon Joo Jeong

Amyloidosis and lymphoproliferative disease in Sjogren syndrome : thin-section computed tomography findings and histopathologic comparisons

Objective: To describe the thin-section computed tomography (CT) findings of Sjögren syndrome accompanying pulmonary amyloidosis and lymphoproliferative disease and to compare these with histopathologic findings. Subjects and Methods: The thin-section CT findings of 5 women (age range: 42-59 years, mean age = 50 years) with primary Sjögren syndrome accompanying pulmonary amyloidosis and lymphoproliferative disease were reviewed retrospectively by 2 chest radiologists, and decisions on findings were reached by consensus. The pathologic specimens of parenchymal lesions (nodules, dense consolidation, and cystic lesion at CT) obtained using video-assisted thoracoscopic surgery were studied to compare with the thin-section CT findings. Results: Nodules, observed in all 5 patients, were variable in size and ranged from 3 to 24 mm (mean = 9.9 mm) in diameter, with lobulated or irregular margins. Nodular calcifications were present in 3 patients. Cysts, which also were observed in all patients, ranged from 4 to 45 mm (mean = 18.6 mm) in diameter, with a thin (1-2 mm) or no visible wall. Multiple cysts were observed, especially in the distal portion of narrowed bronchioles. Nodules and cysts showed a random distribution. Mild bronchial wall thickening with bronchial dilatation was seen in all patients, ground-glass opacities were seen in 3, and consolidation was seen in 1. Nodules, consolidation, and bronchial wall thickening at CT were caused histopathologically by the interstitial and peribronchiolar deposition of mixed amyloid and lymphoproliferative cells. Cysts lined with respiratory epithelium contained amyloid deposition and lymphoproliferative cells in their walls. Conclusion: Sjögren syndrome accompanying pulmonary amyloidosis and lymphoproliferative disease manifests as multiple, large, thin-walled cysts; multiple nodules; parenchymal opacity; and bronchiectasis. These findings are caused by the interstitial or peribronchial infiltration of mixed amyloid and lymphoproliferative cells.

PET/CT imaging correlates with treatment outcome in patients with multidrug-resistant tuberculosis

PET/CT imaging in humans with TB correlates with drug response and final treatment outcomes. Visualizing Drug Responses in TB A pair of papers by Chen et al. and Coleman et al. investigate how changes in quantitative positron emission tomography/computed tomography (PET/CT) scans in both nonhuman primates and humans can be used as early surrogate markers of treatment efficacy in tuberculosis. The Coleman et al. study shows that treatment of Mtb-infected macaques with linezolid and the second-generation oxazolidinone AZD5847 resulted in a reduced bacterial load at necropsy and reduced FDG PET avidity and CT-quantified lung pathology. Similar PET/CT changes were seen in human patients infected with extensively drug-resistant Mtb and treated with linezolid. The companion study by Chen et al. corroborated this effect in a prospective analysis of patients with multidrug-resistant tuberculosis and demonstrated that early PET/CT changes predicted final treatment outcomes. Definitive clinical trials of new chemotherapies for treating tuberculosis (TB) require following subjects until at least 6 months after treatment discontinuation to assess for durable cure, making these trials expensive and lengthy. Surrogate endpoints relating to treatment failure and relapse are currently limited to sputum microbiology, which has limited sensitivity and specificity. We prospectively assessed radiographic changes using 2-deoxy-2-[18F]-fluoro-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT) at 2 and 6 months (CT only) in a cohort of subjects with multidrug-resistant TB, who were treated with second-line TB therapy for 2 years and then followed for an additional 6 months. CT scans were read semiquantitatively by radiologists and were computationally evaluated using custom software to provide volumetric assessment of TB-associated abnormalities. CT scans at 6 months (but not 2 months) assessed by radiologist readers were predictive of outcomes, and changes in computed abnormal volumes were predictive of drug response at both time points. Quantitative changes in FDG uptake 2 months after starting treatment were associated with long-term outcomes. In this cohort, some radiologic markers were more sensitive than conventional sputum microbiology in distinguishing successful from unsuccessful treatment. These results support the potential of imaging scans as possible surrogate endpoints in clinical trials of new TB drug regimens. Larger cohorts confirming these results are needed.

Efficacy and Safety of Metronidazole for Pulmonary Multidrug-Resistant Tuberculosis

ABSTRACT Pulmonary lesions from active tuberculosis patients are thought to contain persistent, nonreplicating bacilli that arise from hypoxic stress. Metronidazole, approved for anaerobic infections, has antituberculosis activity against anoxic bacilli in vitro and in some animal models and may target persistent, nonreplicating bacilli. In this double-blind, placebo-controlled trial, pulmonary multidrug-resistant tuberculosis subjects were randomly assigned to receive metronidazole (500 mg thrice daily) or placebo for 8 weeks in addition to an individualized background regimen. Outcomes were measured radiologically (change on high-resolution computed tomography [HRCT]), microbiologically (time to sputum smear and culture conversion), and clinically (status 6 months after stopping therapy). Enrollment was stopped early due to excessive peripheral neuropathies in the metronidazole arm. Among 35 randomized subjects, 31 (15 metronidazole, 16 placebo) were included in the modified intent-to-treat analysis. There were no significant differences by arm in improvement of HRCT lesions from baseline to 2 or 6 months. More subjects in the metronidazole arm converted their sputum smear (P = 0.04) and liquid culture (P = 0.04) to negative at 1 month, but these differences were lost by 2 months. Overall, 81% showed clinical success 6 months after stopping therapy, with no differences by arm. However, 8/16 (50%) of subjects in the metronidazole group and 2/17 (12%) of those in the placebo group developed peripheral neuropathy. Subjects who received metronidazole were 4.3-fold (95% confidence interval [CI], 1.1 to 17.1) more likely to develop peripheral neuropathies than subjects who received placebo. Metronidazole may have increased early sputum smear and culture conversion but was too neurotoxic to use over the longer term. Newer nitroimidazoles with both aerobic and anaerobic activity, now in clinical trials, may increase the sterilizing potency of future treatment regimens.

Neoplastic and nonneoplastic conditions of serosal membrane origin: CT findings.

Computed tomography (CT) is an important imaging modality for diagnosis and follow-up of neoplastic or nonneoplastic conditions of the serosal membrane. The characteristic CT findings of malignant pleural mesothelioma include unilateral pleural effusion, thickening of the mediastinal pleura, and circumferential and nodular pleural thickening of greater than 1 cm. Malignant peritoneal mesothelioma manifests as a large mass or diffuse peritoneal thickening without a definable mass and is difficult to differentiate from peritoneal carcinomatosis or tuberculosis. The imaging features of primary serous papillary carcinoma of the peritoneum resemble those of peritoneal carcinomatosis; however, the ovary is usually of normal size. The possibility of desmoplastic small round cell tumor should be considered in children or young adults with multiple peritoneal masses and no identifiable primary malignancy. The CT findings of secondary tumors include a variable amount of fluid in the serosal cavity, thickening of the serosal lining (irregular and nodular), and serosal implants. Nonneoplastic conditions manifest as focal or diffuse thickening of the serosal membrane, a variable amount of fluid in the serosal cavity, and a soft-tissue mass at CT. Although the CT findings of some of the conditions overlap, knowledge of the typical findings is helpful in narrowing the differential diagnosis.

Clinical Implication of PET/MR Imaging in Preoperative Esophageal Cancer Staging: Comparison with PET/CT, Endoscopic Ultrasonography, and CT

This was a study to compare the diagnostic efficacies of endoscopic ultrasonography (EUS), CT, PET/MR imaging, and PET/CT for the preoperative local and regional staging of esophageal cancer, with postoperative pathologic stage used as the reference standard. Methods: During 1 y, 19 patients with resectable esophageal cancer were enrolled and underwent preoperative EUS, CT, PET/CT, and PET/MR imaging. A chest radiologist and nuclear medicine physician retrospectively reviewed the images and assigned tumor and lymph node stages according to the seventh version of the TNM system and the American Joint Committee on Cancer staging system. Four patients who were treated nonsurgically were excluded from data analysis. The efficacies of EUS, CT, PET/CT, and PET/MR imaging were compared. Results: Primary tumors were correctly staged in 13 (86.7%), 10 (66.7%), and 5 (33.3%) patients at EUS, PET/MR imaging, and CT, respectively (P value ranging from 0.021 to 0.375). The accuracy of determining T1 lesions was 86.7%, 80.0%, and 46.7% for EUS, PET/MR imaging, and CT, respectively. For distinguishing T3 lesions, the accuracy was 93.3% for EUS and 86.7% for both PET/MR imaging and CT. For lymph node staging, the accuracy was 83.3%, 75.0%, 66.7%, and 50.0% for PET/MR imaging, EUS, PET/CT, and CT, respectively. In addition, area-under-the-curve values were 0.800, 0.700, 0.629, and 0.543 for PET/MR imaging, EUS, PET/CT, and CT, respectively. Conclusion: PET/MR imaging demonstrated acceptable accuracy for T staging compared with EUS and, although not statistically significant, even higher accuracy than EUS and PET/CT for prediction of N staging. With adjustments in protocols, PET/MR imaging may provide an important role in preoperative esophageal cancer staging in the future.

Nodular Bronchiectatic Mycobacterium avium Complex Pulmonary Disease. Natural Course on Serial Computed Tomographic Scans

RATIONALE Existing literature is inconclusive regarding how the nodular bronchiectatic form of Mycobacterium avium complex (MAC) disease will progress without treatment and when treatment initiation should be considered. OBJECTIVES To assess the natural course of MAC pulmonary disease by serial thin-section computed tomography (CT). METHODS Of 339 patients with nodular bronchiectatic form of MAC disease, we selected 265 untreated patients who had serial CTs (mean observation period, 32 ± 21 mo). Two independent chest radiologists reviewed retrospectively all CT scans for the presence and extent of lung abnormalities (maximal total score, 30). MEASUREMENTS AND MAIN RESULTS Of 265 patients, 126 patients (48%) had disease that had progressed and that needed treatment owing to radiologic deterioration or worsening symptoms, and the remaining 139 patients (52%) did not. On multivariate analysis, the presence of cavity (adjusted hazard ratio, 2.06; P = 0.004) and consolidation (adjusted hazard ratio, 1.55; P = 0.019) at initial CT remained as independent factors associated with disease progression and treatment requirement. The presence of cavitary lesions demonstrated the highest positive predictive value (61%) and significant correlation (P = 0.005) with smear positivity. Differences in the extent of each pattern and total CT score in the serial studies were significantly larger (P < 0.05) in patients requiring treatment. The total CT score increased by 2.41 in the treatment-requiring group compared with 0.25 in the group that did not receive treatment. CONCLUSIONS Without treatment, about half of patients demonstrate progressive disease on serial CT over a mean follow-up period of 32 months and, thus, required treatment. Patients showing cavities or consolidation on initial CT are more likely to have progressive disease and thus to require treatment eventually.

Sonography of Patients with Hemiplegic Shoulder Pain After Stroke: Correlation with Motor Recovery Stage

OBJECTIVE This study was performed to clarify the cause of shoulder pain using sonography and to evaluate the relationship between the sonographic findings and the motor recovery stages in stroke patients with hemiplegic shoulder pain. SUBJECTS AND METHODS Between March 2005 and January 2007, 71 consecutive stroke patients with hemiplegic shoulder pain underwent shoulder sonography. For comparison, bilateral shoulder joints were evaluated in 20 of the 71 patients. The interpretations of the sonographic findings were based on the findings of previously published studies. Whether a correlation existed between the sonographic findings and the motor recovery stages was determined. RESULTS Subacromial-subdeltoid (SA-SD) bursal effusion (n = 36) was the most common abnormality seen on sonography. Tendinosis of the supraspinatus tendon (n = 7), partial-thickness tear of the supraspinatus tendon (n = 6), and full-thickness tear of the supraspinatus tendon (n = 2) were also noted. Biceps tendon sheath effusion (n = 39) and normal findings without any biceps tendon sheath effusion (n = 13) were detected. Clinicians managed each patients shoulder pain on the basis of the sonographic findings. No statistically significant correlation was found between the grade of sonographic findings and Brunnstrom stage (p = 0.183). A shoulder with hemiplegia had a higher number of abnormal sonographic findings than a noninvolved shoulder (p = 0.007). CONCLUSION The cause of shoulder pain was variable and there was no correlation between the stages of motor recovery and the grades of sonographic findings in patients with hemiplegic shoulder pain.

High-Resolution CT Findings in Fibrotic Idiopathic Interstitial Pneumonias With Little Honeycombing: Serial Changes and Prognostic Implications

OBJECTIVE This retrospective study evaluates serial changes of lung abnormalities on high-resolution CT (HRCT) and clarifies prognostic determinants among CT findings in fibrotic idiopathic interstitial pneumonias (IIPs) with little honeycombing. MATERIALS AND METHODS We enrolled 154 patients with a histologic diagnosis of a fibrotic IIP (< 5% honeycombing on CT) who were followed clinically for at least 2 years. One hundred one patients had usual interstitial pneumonia (UIP) and 53 had fibrotic nonspecific interstitial pneumonia (NSIP). On baseline CT, the extent and distribution of lung abnormalities were visually assessed, and serial CT scans were evaluated with a follow-up period of at least 6 months (n = 132). RESULTS Significant differences were noted in the extent of reticulation and ground-glass opacification (GGO) between the UIP and fibrotic NSIP groups (p < 0.001). On serial scans, honeycombing (5% in UIP and 3% in fibrotic NSIP; p = 0.08) and reticulation (3% in UIP and 8% in fibrotic NSIP; p = 0.03) progressed in extent and GGO (-2% in UIP and -10% in fibrotic NSIP; p = 0.009) decreased in extent. Overall extent of lesions increased in UIP (6%) and decreased in NSIP (-4%) (p = 0.04). On univariate and multivariate Cox proportional hazards analysis, the overall extent of parenchymal abnormalities was a prognostic factor predictive of poor survival duration. CONCLUSION Even in cases of fibrotic IIP with little honeycombing, serial CT reveals an increase in the extent of honeycombing and reticulation and a decrease in extent of GGO. Overall extent of lung fibrosis on the baseline CT examination appears predictive of survival in fibrotic IIP with little honeycombing.

Treatment of mediastinitis using video-assisted thoracoscopic surgery

BACKGROUND Mediastinitis remains a life-threatening disease that is difficult to manage and has a poor prognosis. This is especially true of descending necrotizing mediastinitis, which before the 1990s era had a mortality of approximately 40% despite the use of antibiotics, surgical techniques, and intensive care monitoring. Several authors have recommended that aggressive surgical approaches for mediastinitis are more effective than simple surgical approaches; however the best surgical option for mediastinitis remains controversial. MATERIALS AND METHODS In a retrospective analysis between January 2000 and June 2006, 17 patients who underwent surgical debridement and drainage using video-assisted thoracoscopic surgery are included in this report. Data extracted from medical records included sex, age, origin of infection, surgical intervention, progress, and outcome including cause of death. There were eight men and nine women. The mean age was 52 years old (range, 20-72). RESULTS The origins of infection included esophageal perforation in nine patients and odontogenic or peritonsillar abscesses in the remaining eight patients. Among them, two patients required conversion to thoracotomy during operation in cases of mediastinitis due to esophageal perforation, so excluding the two patients, we calculated next five data for 15 patients. The mean duration from onset of symptoms to surgery was 12.4+/-13.1 days (range, 0-43) and the mean duration from the initial operation to discharge was 43.6+/-24.4 days (range, 8-113). There was serial operation in one case. There were three cases of postoperative mortality. CONCLUSION Mediastinal drainage using video-assisted thoracoscopic surgery with or without cervical drainage can be a feasible and effective surgical option. This less invasive technique seems to have an outcome similar to more aggressive open surgical approaches for patients with mediastinitis previously reported in the literature, although it has not been directly compared.

Computed tomographic features of pulmonary septic emboli: comparison of causative microorganisms.

Objective: To describe and compare the computed tomographic (CT) findings of pulmonary septic emboli in causative microorganisms. Methods: The CT findings of 16 patients (8 men and 8 women; age range, 17 to 80 years; mean, 53.1 years) with documented pulmonary septic emboli were retrospectively reviewed by 2 radiologists; their decisions on the findings were reached by consensus. Statistical analysis was performed using the t test and the &khgr;2 test. Results: A total of 197 peripheral nodules were seen in 6 gram-positive (n = 88) and 10 gram-negative (n = 109) septic pulmonary emboli patients, respectively. The sizes of the nodules (15.94 mm; range, 3-46 mm) in gram-positive septic emboli were larger than those (12.29 mm; range, 4-44 mm) in gram-negative septic emboli (P = 0.006). Cavitation (n = 30 [34%] vs n = 23 [21%]; P = 0.041) and air bronchogram (n = 12 [14%] vs n = 4 [4%]; P = 0.008) within the nodules were more commonly seen in gram-positive septic emboli. A ground-glass attenuation halo around a nodule (n = 69 [63%] vs n = 32 [36%]; P = 0.000) and feeding vessel signs (n = 56 [51%] vs n = 25 [28%]; P = 0.001) were more commonly seen in gram-negative septic emboli. Wedge-shaped peripheral lesions abutting the pleura were seen in 4 gram-positive (67%) and in 1 gram-negative (10%) septic emboli patients, respectively (P = 0.047). Conclusions: The detailed CT characteristics of peripheral nodules in pulmonary septic emboli may be able to differentiate the causative microorganisms and to provide additional information regarding treatment plans in patients with sepsis.