RESUMEN
OBJECTIVES: The superior performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis and staging of malignancy has been demonstrated, with some investigators suggesting the same for sarcoidosis. The role of EBUS-TBNA in the diagnosis of histoplasmosis is not clear, however. In this study we estimate the diagnostic yield of conventional TBNA (cTBNA) and EBUS-TBNA for the diagnosis of histoplasmosis in patients with mediastinal lymphadenopathy. METHODS: Retrospective chart review was conducted on 452 consecutive patients who underwent cTBNA or EBUS-TBNA for mediastinal lymphadenopathy from January 1, 2005 to December 31, 2014 at Methodist Le Bonheur Healthcare-affiliated hospitals in Memphis, Tennessee. Data collection included demographic information, reason for the procedure, size of the lymph nodes, procedures performed, and the final diagnosis. RESULTS: Among 452 cases reviewed, 146 underwent cTBNA and 306 underwent EBUS-TBNA. Final diagnoses include malignancy (41.5%), sarcoidosis (11.2%), and histoplasmosis (8.1%). Among 146 patients who underwent cTBNA, a final diagnosis was obtained by this modality in 58 patients (39.7%). The diagnostic rate for cTBNA for malignancy was 68% (40/59), 30% (4/13) for sarcoidosis, and 43% (6/14) for histoplasmosis. In 306 patients who underwent EBUS-TBNA, 188 had a final diagnosis (61.4%) obtained by this modality. For EBUS-TBNA, the diagnostic rates were 79.5% (101/127) for malignancy, 74% (28/38) for sarcoidosis, and 78% (18/23) for histoplasmosis. CONCLUSIONS: EBUS-TBNA had a higher yield than cTBNA for the diagnosis of histoplasmosis. Clinicians practicing in areas with a high prevalence of histoplasmosis and sarcoidosis should use EBUS-TBNA, whenever available, for this reason.
Asunto(s)
Histoplasmosis/diagnóstico , Linfadenopatía/etiología , Enfermedades del Mediastino/etiología , Biopsia con Aguja/métodos , Biopsia con Aguja/estadística & datos numéricos , Bronquios/microbiología , Bronquios/patología , Femenino , Histoplasmosis/complicaciones , Histoplasmosis/patología , Humanos , Linfadenopatía/diagnóstico , Masculino , Enfermedades del Mediastino/diagnóstico , Persona de Mediana Edad , Estudios Retrospectivos , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Small cell lung carcinoma (SCLC) usually presents as lung or mediastinal lesions. It is very rare for SCLC to present primarily as an isolated pleural effusion with no lung or mediastinal lesions. CASE REPORT: We report the case of a 77-year-old white male with a 60-pack year history of smoking, chronic obstructive pulmonary disease (stage IV), and asbestos exposure who presented with shortness of breath and left lateral chest pain for 7 days. On physical examination, he was very short of breath, with a prolonged expiratory phase on chest auscultation. Laboratory results were normal except for leukocytosis and chest radiograph revealing left-sided pleural effusion. Computerized tomography (CT) scanning of the chest with IV contrast showed left-sided pleural effusion without any lung or mediastinal lesions. Thoracentesis was performed and fluid was sent for analysis. Repeat CT chest/abdomen/pelvis, done immediately following thoracocentesis, did not show any masses or lymphadenopathy. Fluid analysis, including cytology and immunostain pattern, was consistent with small cell carcinoma. CONCLUSIONS: Small cell lung cancer presenting as an isolated pleural effusion is extremely rare. It requires close attention to cytology and immunohistochemistry of pleural fluid samples. It also has implications for management and should be managed as limited-stage SCLC.
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Derrame Pleural Maligno/diagnóstico , Neoplasias Pleurales/diagnóstico , Carcinoma Pulmonar de Células Pequeñas/diagnóstico , Anciano , Diagnóstico Diferencial , Humanos , Masculino , Derrame Pleural Maligno/etiología , Neoplasias Pleurales/complicaciones , Carcinoma Pulmonar de Células Pequeñas/complicaciones , Toracocentesis , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Strongyloides stercoralis (SS) is a parasite seen in certain parts of the USA and in people from other endemic areas. In these patients steroids might precipitate or exacerbate asthma. Apart from worsening of asthma, serious complications like hyperinfection syndrome and even death can occur in these patients if treated with steroids. Treatment is either ivermectin or albendazole based on severity of the disease. Clinicians have to be very careful when prescribing steroids in patients presenting with an exacerbation of asthma from areas endemic for Strongyloides stercoralis. CASE REPORT: A young woman with history of asthma presented with complaints of nausea, vomiting, abdominal pain, wheezing, and dry cough. Physical examination revealed diffuse expiratory wheezing and mild diffuse abdominal pain without rebound or guarding. Laboratory results showed leukocytosis with eosinophilia. Stool studies showed Strongyloides stercoralis. Imaging revealed ground-glass opacities in the right upper and lower lobe along with an infiltrate in the lingular lobe on the left side. Bronchoscopy showed Strongyloides stercoralis. The patient was diagnosed with hyperinfection syndrome due to Strongyloides stercoralis most probably exacerbated by prednisone given for her asthma. Steroids were then discontinued and the patient was started on ivermectin. The patient improved with treatment. Repeat stool examination was negative for Strongyloides stercoralis. CONCLUSIONS: Clinicians have to be very careful when prescribing steroids in patients presenting with an exacerbation of asthma who are from areas endemic for Strongyloides stercoralis and should test for it (preferably with serology test) before starting treatment.
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Asma/terapia , Glucocorticoides , Ivermectina/uso terapéutico , Strongyloides stercoralis/aislamiento & purificación , Estrongiloidiasis/terapia , Adulto , Animales , Antiparasitarios/uso terapéutico , Asma/complicaciones , Broncoscopía , Contraindicaciones , Diagnóstico Diferencial , Femenino , Humanos , Estrongiloidiasis/complicaciones , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with a huge burden of suffering and healthcare expenditures. Patients hospitalized due to COPD have increased risk of death. Starting in 2015, reimbursements by the Centers for Medicaid Medicare Services will be significantly reduced to hospitals with excess 30 day readmissions for COPD. Oral corticosteroid (OCS) therapy is established in improving outcomes in COPD patients treated in the emergency department and hospital. The objective of this article is to review the evidence evaluating home OCS treatment of COPD exacerbations as part of a comprehensive self-management action plan. METHODS: We reviewed the English literature via PubMed, Embase, and Scopus using the search terms: chronic obstructive pulmonary disease exacerbations AND: oral corticosteroids, prednisone, prednisolone, methylprednisolone, treatment, self-management, disease management, written action plans. When pertinent articles were found, we reviewed the relevant articles cited. FINDINGS: Two randomized trials enrolling 933 patients provide evidence of reduced rates of hospitalization by using comprehensive COPD action plans, including OCS therapy. Three trials with 790 patients enrolled did not reveal reduced rates of hospitalization. Among all five trials together, there were no differences in deaths (76 in the intervention groups [home action plans]; 81 in the usual care groups). Additional studies not assessing hospitalizations have found home use of OCSs increases time to the next exacerbation and decreases recovery time. CONCLUSION: Further randomized trials are needed to establish that home use of OCS therapy, as part of a comprehensive action plan, reduces the rate of hospitalizations. Such action plans should include structured patient education, early initiation of OCSs, oral antibiotics, and frequent telephone reinforcement and support from case management.
Asunto(s)
Manejo de la Enfermedad , Glucocorticoides/administración & dosificación , Hospitalización , Planificación de Atención al Paciente , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Autocuidado , Administración Oral , Humanos , Enfermedad Pulmonar Obstructiva Crónica/complicacionesRESUMEN
INTRODUCTION: The objective is to describe the incidence and nature of significant abdominal pathologies in patients with diabetes ketoacidosis (DKA) and abdominal pain. METHODS: Retrospective chart review (N = 86) of patients with DKA from January 1, 2005, to January 31, 2010, was performed. Data included demographics, co-morbidities, compliance, chief complaints and physical findings, blood count, metabolic profile, lactic acid, glycosylated hemoglobin (HbAlC), amylase, lipase, anion gap, arterial gases, imaging and final diagnosis. Continuous variables were described as mean ± standard deviation and compared with the Student's t test. Categorical variables were expressed as percentages (%) and compared with the Mantel-Haenszel χ test. Univariate analysis was conducted among patients with and without significant abdominal pain and also with and without significant abdominal pathology. Two lipase strata were created at 400 U. Multivariate model to identify limits (confidence interval) of the estimated risk imposed by the predictor found significant in univariate analysis. A P value of ≤ 0.05 was considered significant. Stat View 5.0 (SAS Institute, Cary, NC) was used for the statistical analysis. RESULTS: In patients with abdominal pain, 17% had significant abdominal pathology mainly acute pancreatitis (AP). Serum amylase and lipase level were found to be an indicator of significant underlying pathology (both P values ≤0.001). The logistic model created showed that patients with lipase level ≥400 U have a 7% increased risk of having AP with confidence interval of 0.01 to 0.6. CONCLUSION: Patients with DKA and abdominal pain with lipase >400 U have an increased risk of significant underlying abdominal pathology (AP).