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Thrombotic thrombocytopenic purpura (TTP) is a rare syndrome of unknown cause with an estimated incidence of one case per million. The disease is characterized by a pentad of symptoms: thrombocytopenia, microangiopathic hemolytic anemia, neurologic changes, renal dysfunction, and fever. It causes thrombosis in the microvasculature of several organs, producing diverse manifestations. Acute pancreatitis (AP) is a well-described consequence of TTP. We report a patient who developed TTP after presenting with AP, suggesting pancreatitis to be the cause, rather than a consequence, of TTP.

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A 70-year-old woman with the isolated anomaly of azygos continuation of the inferior vena cava is presented. The interest in this anomaly lies in its presentation as a mediastinal mass on the chest roentgenogram. This article reviews the embryogenesis and the diagnostic testing of this venous anomaly.

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Spontaneous pneumomediastinum (SPM) is defined as pneumomediastinum in the absence of an underlying lung disease. It is the second most common cause of chest pain in young, healthy individuals (< 30 years) necessitating hospital visits. It is surpassed in frequency in this setting only by spontaneous pneumothorax. These two conditions may coexist in 18% of patients. The incidence of spontaneous pneumomediastinum varies in different communities and generally is relatively uncommon. Inhalational drug use (cocaine and cannabis) have been associated with a significant number of cases, although cases with no apparent etiologic or incriminating factors are well recognized. Also its recurrence, though uncommon, is worthy of note. It is a benign clinical condition with diverse clinical presentations. Physicians' knowledge of the presentation, treatment, and prognosis of SPM will guard against the need for expensive radiologic and laboratory tests. The differential diagnosis of chest pain, shortness of breath, and dysphagia include cardiac, pulmonary, and esophageal diseases. The tendency to pursue these entities may lead to laboratory investigations such as electrocardiograms, arterial blood gases, ventilation/perfusion scans, and contrast radiographic studies of the esophagus.

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With the influx of immigrants from developing countries, deployment of American troops on foreign soil, and wide-ranging travel patterns of some United States citizens, one should expect an increase in the frequency of parasitic pulmonary diseases. We report a case of tropical pulmonary eosinophilia in a recent immigrant to Upstate New York from India. Tropical pulmonary eosinophilia is unfamiliar to most physicians practicing in North America, but should be included in the differential diagnosis of asthmatic bronchitis with hypereosinophilia when there is a history of recent travel to or residence in endemic areas. Furthermore, knowledge of this entity should also help in the differential diagnosis of other hypereosinophilic syndromes.

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We reviewed our experience with 115 patients with pleural effusion in whom bronchogenic carcinoma was suspected who underwent fiberoptic bronchoscopy (FOB) to identify those for whom the procedure was useful. In 6 of 12 patients with hemoptysis, 8 of 12 with a mass or infiltrate, and 8 of 18 with atelectasis with negative fluid cytology and 3 of 7 with cytology positive, FOB was useful in diagnosis. Sixty-six patients had an isolated cytology-negative effusion. Seven of 18 with massive effusion had FOB detecting cancer. Fiberoptic bronchoscopy usually was nondiagnostic in lesser-sized effusions (47 of 48). Using outcome for those with nondiagnostic FOB, we established operating characteristics for the procedure. We conclude that FOB is useful in diagnosing bronchogenic carcinoma in such patients when there is hemoptysis, accompanying lung mass or infiltrate, atelectasis, the effusion is massive, or in cytology-positive effusions without obvious primary tumor. Due to the low prevalence of bronchogenic carcinoma in patients with effusions of lesser size, we suggest that in this group FOB not be routinely performed.

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Eosinophilic pulmonary infiltration is an uncommon presentation from cocaine abuse. We present a patient with migratory pulmonary infiltrates and eosinophilia consistent with Löffler's syndrome. Our review uncovered two other similar patients. The importance of early recognition is stressed in our report. Either abstinence from cocaine usage and/or steroids result in resolution of this illness.

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Massive pericardial effusion in sarcoidosis is rare. We summarize the features of a recent patient along with a review of 9 previously reported cases. All but 1 patient with massive pericardial effusion were female and all had massive cardiomegaly on their chest roentgenogram with 7 of the 10 also showing features suggestive of sarcoidosis (bilateral hilar adenopathy with or without interstitial infiltrates). Nine of the 10 patients required a drainage procedure (pericardiectomy or pericardiocentesis). Pericardial histology revealed noncaseating granulomas in 6 of 7 patients. Two of the patients expired within the first week of hospitalization with evidence of myocardial involvement. The remainder of the patients have had clinical stability most responding to steroids, yet recurrences were seen in 3 patients and 1 patient required cyclophosphamide for control.

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Recommended criteria for surgical drainage of parapneumonic effusions include evidence of frank purulence, a glucose level less than 40 mg/dl, a pH of less than 7.00, or an LDH greater than 1,000 IU/L. To test the utility of these criteria, we reviewed the three-year experience of three Rochester, NY, hospitals. We identified 133 patients undergoing thoracentesis for putative parapneumonic effusions. Of 91 patients with neutrophilic exudates, 43 met one or more criteria for tube thoracostomy: 48 did not. Twenty-one of the 43, including 9 with frank empyema, underwent immediate drainage. Of the 22 who did not, 11 eventually required tube thoracostomy and/or decortication. Of the 48 not meeting any of the criteria, 7 also came to surgery. Using whether the patients eventually underwent surgery as a measure of outcome, we calculated for those patients not undergoing immediate drainage the sensitivity, specificity, positive predictive values, and negative predictive values for each of the criteria. The four criteria have relatively high specificity ranging from 82 to 96 percent, but have low sensitivity varying from only 18 percent for a positive Gram stain to 53 percent for a fluid LDH greater than 1,000 IU/L. We conclude that these criteria have limited usefulness in predicting the need for eventual chest tube drainage/decortication. Patients not meeting the criteria require close follow-up as well.

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Irwin and co-workers have designed an anatomic approach to the diagnosis and treatment of cough. In their hands, diagnosis was consistently determined and treatment successful almost without exception, if sustained. We reviewed the results of a similar approach in 139 consecutive and unselected patients referred to pulmonary specialists in two community hospitals. Thirty-nine patients demonstrated hyperreactive airways (HA) by carbachol inhalation and/or eucapnic hyperventilation of cold air. Twenty-seven of 78 without HA had postnasal drip, and 13 of 78 had a persistent cough following acute upper airway inflammation. Other less common diagnoses included chronic bronchitis, gastro-esophageal reflux, occupational bronchitis, interstitial lung disease, and psychologic causes. We were able to find the cause of cough 88 percent of the time. Treatment adjusted for noncompliance was not always a success. While all patients with HA improved, 8 percent of patients without HA or specific diagnosis did not have an improvement in their cough upon retrospective inquiry. Based on this analysis, we find that the diagnosis and treatment of cough may not be as successful as originally reported using Irwin's approach.

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Eucapneic hyperventilation of cold air (EHCA) provokes bronchospasm in asthmatics. Although inhaled cromolyn powder and sympathomimetic solutions have attenuated the bronchospasm induced by EHCA, comparison of both drugs in solution has not been performed. We performed a prospective double-blind study comparing cromolyn solution, metaproterenol solution, and placebo (normal saline) given prior to EHCA. Eight asthmatics defined by a 20% reduction in forced expiratory volume in 1s (FEV1) after EHCA consented to the study. Patients were tested on 3 separate occasions at a similar time of day. Each session began with a determination of FEV1 followed by a randomized double-blind treatment. A repeat FEV1 (pre-EHCA) was performed 20 min after drug inhalation. Twelve minutes of EHCA was performed consisting of 4 min of tidal breathing, 4 min of eucapneic hyperventilation (60-70% of the predicted MVV) and a final 4 min of tidal breathing. FEV1 was performed immediately, 5 min, and 10 min after EHCA. The lowest value was defined as the post-EHCA FEV1. The pre-EHCA FEV1 was significantly larger after metaproterenol pretreatment compared to the pre-EHCA FEV1 following cromolyn (p = 0.01) and saline (p = 0.04). Metaproterenol pretreatment had a significant protective effect in comparison to placebo pretreatment (p less than 0.01). No other paired comparisons (cromolyn vs. placebo, cromolyn vs. metaproterenol) achieved statistical significance at a 0.05 level. In conclusion, metaproterenol is superior to cromolyn in protecting against cold-air-induced bronchospasm.

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The need for fiberoptic bronchoscopy in the patient with hemoptysis and a normal or nonlocalizing chest roentgenogram remains a subject of debate. Currently, diagnostic fiberoptic bronchoscopy is recommended as the investigative procedure of choice. To develop predictors that identify the patient in whom fiberoptic bronchoscopy is most likely to be diagnostic, we reviewed our community's experience with this population over a five-year period. We identified 196 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram who underwent fiberoptic bronchoscopy. Three quarters were active or previous smokers. We examined the relationship of advancing age, sex, smoking, nonspecific roentgenographic findings and the amount, duration, and previous bouts of hemoptysis to the incidence of a diagnostic fiberoptic bronchoscopy. Twelve patients (6 percent) had bronchogenic carcinoma and 33 (17 percent) another specific cause for the hemoptysis identified by fiberoptic bronchoscopy. By univariate and discriminant analyses, we found that the three factors of age of 50 years or more, male sex, and smoking of 40 pack-years or more best predicted a diagnosis of malignancy. Bleeding in excess of 30 ml daily was associated with an increase in overall diagnostic yield. The presence of two of the three factors associated with malignancy or bleeding in excess of 30 ml daily (or both) identified 100 percent of the patients with bronchogenic carcinoma and 82 percent of all of the diagnostic fiberoptic bronchoscopic procedures. use of these criteria in selecting the patient for fiberoptic bronchoscopy could have reduced our use of the bronchoscope by 28 percent, with the remaining patients safely observed.

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We studied the effect of smoking cessation on airway reactivity. We recruited cigarette smokers who were attempting to stop smoking. Entry criteria required each subject to be smoking at least 10 cigarettes each day and report a chronic cough. Exclusion criteria included significant airflow obstruction or the presence of any medical condition contraindicating challenge testing. Carbachol challenge was performed to assess airway reactivity according to a standardized method. Baseline measurements of forced expiratory volume in 1 s (FEV1), specific airway conductance (SGaw) and the provocative dose of carbachol causing a 35% reduction in SGaw (PD35), and a 20% reduction in FEV1 (PD20) were established on entry while each subject was still smoking. Thereafter, repeat measurements were performed after 2 and 6 months of smoking cessation. Adherence to smoking cessation was checked by self-report and verified by measurement of alveolar carbon monoxide levels at each session. Of the 34 subjects who gave consent, 13 relapsed prior to the 2nd month and an additional 8 relapsed before the 6th month. Thirteen of the 34 remained abstinent throughout the 6-month study. All 13 subjects had complete resolution of their cough. The difference in reactivity on entry to that at the 2nd and 6th month was not significant. We conclude that (1) the symptom of chronic cough resolved completely after 2 months of smoking cessation, and (2) airway reactivity remained unchanged at 2 and 6 months of smoking cessation.

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Hemoptysis is a significant pulmonary symptom. Because there are numerous causes, a systematic approach is necessary for the diagnosis and management of these patients. A thorough clinical evaluation and chest roentgenogram are pivotal in formulating a differential diagnosis. Diagnostic testing is tailored to the individual patient. This article provides an overview to help deal with patients with hemoptysis.

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We studied the effect of increased thyroid function on airway reactivity. Carbachol challenge was performed to assess airway reactivity according to a standardized method. Measurements of forced expiratory volume-1 second (FEV1), specific airway conductance (SGaw), the provocative dose of carbachol for a 20 percent decrease in FEV1 (PD-20) and that for a 35 percent decrease in SGaw (PD-35) were established upon entry when each subject was hyperthyroid, and subsequently, after the subjects had returned to the euthyroid state. It was concluded that hyperthyroidism reduced the severity of carbachol-induced changes in airway reactivity as measured by SGaw.

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Chest ultrasonography (CU) has been advocated as an effective tool for diagnosis and localization of pleural fluid. Studies to date supporting the technique have been anecdotal and nonrandomized. To determine if CU was beneficial when thoracentesis was performed by clinicians or house staff, we evaluated prospectively 205 patients presenting with pleural effusion at 2 community teaching hospitals. Decubitus roentgenograms were obtained on all patients, but CU with targeting by skin marker was performed on a randomized basis. Results were evaluated as to (1) whether the quantity of fluid obtained was sufficient for the intent of the procedure, (2) the number of needle insertions required to obtain the fluid, and (3) the incidence of complications such as pneumothorax. One hundred three effusions were evaluated by CU and 102 by roentgenography alone. The effusions in each group were stratified as small (obliteration of less than half of the hemidiaphragm on roentgenogram) or large. Small effusions were further stratified as free flowing or loculated (no layering of fluid on decubitus roentgenograms). By chi-square test, CU was significantly superior to decubitus roentgenograms alone for obtaining adequate fluid samples in small effusions (p less than 0.01). This was true regardless of whether the effusion was loculated (p less than 0.02) or free flowing (p less than 0.05). The technique had no such advantage in large effusions. We did not find that CU significantly reduced the need for multiple attempts nor incidence of complications in any group.

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The authors have studied five cases of biopsy-proven pulmonary toxicity caused by the administration of mitomycin C (M), vincristine, and cisplatin in 64 patients with advanced non-small cell lung cancer. The clinical triad of progressive dyspnea, rales, and pulmonary infiltrates presented in all five cases. In addition, pulmonary function tests showed hypoxemia (four/five), reduced forced vital capacity (three/four), total lung capacity (two/three), and forced expiratory volume (FEV1) (three/four) and very profound reduction in diffusion capacity (three/three). Transbronchial biopsy for tissue examination was necessary to rule out other causes. Characteristics but nonspecific pathologic changes were documented in all five cases. All the patients responded quickly and dramatically to high-dose glucocorticoids with improvement of hypoxia, dyspnea, exercise tolerance, and sense of well being. In three patients the pulmonary infiltrates cleared. However, abrupt stopping or early withdrawal of steroid resulted in aggravation of dyspnea and pulmonary infiltrate in three cases who improved subsequently with escalation of steroid doses. The authors conclude that the treatment of choice for pulmonary toxicity induced by M or M-containing chemotherapy regimens is a high dose of glucocorticoid and discontinuation of M at once when suspicion is raised.

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Bronchoscopic examination to diagnose lung metastases has not been as rewarding as in primary lung cancer. Despite a lower expected yield, we believe the procedure has value in certain patients, ie, those with clinical findings of endobronchial disease. To determine better the value of bronchoscopy in this population, we retrospectively reviewed records of patients at five community teaching hospitals over a 66-month period. These patients all underwent fiberoptic bronchoscopy. They had a history of prior nonpulmonary malignancy and an abnormal chest roentgenogram suspicious for recurrent malignant disease, or they presented with abnormal chest roentgenographic findings and further evaluation showed the lung disease to be metastatic. Bronchoscopy for metastatic lung disease was most likely diagnostic in patients with primary colorectal cancer (79 percent) and breast cancer (57 percent), and least likely in patients with genitourinary tract cancer (33 percent). Hemoptysis, signs of local airway obstruction, or a roentgenogram showing either atelectasis or diffuse lung disease especially favored a positive biopsy. Bronchoscopy is a valuable diagnostic procedure in selected patients with metastatic lung disease.

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Tuberculous and nontuberculous cavitary lung disease is often initially misdiagnosed, delaying therapy. To identify findings which might help avoid such delays, we performed a retrospective review of all patients admitted to two community hospitals over a 6-year period for infectious cavitary disease of the upper lobe or apical segment of the lower lobe. 10 patients with tuberculosis and 16 with nontuberculous infections were identified. Delays in initiating therapy were common to both. Most signs and symptoms were nonspecific. The mean duration of symptoms was greater in tuberculosis (72 days) compared to nontuberculous infections (18 days). Putrid sputum was found only in nontuberculous infections (11/16). Roentgenographic features of fibronodular infiltration and atelectasis occurred only in tuberculosis. Air fluid levels were seen only in nontuberculous disease (10/16). Leukocytosis with immature neutrophils was found only in patients with nontuberculous cavities. We conclude that the previously described clinical, laboratory, and roentgenographic features may be useful in correctly diagnosing infectious cavitary lung disease.

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