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Introduction: Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) is a syndrome that combines dermatological, articular and osseous inflammatory manifestations. Bilateral laryngeal immobility relative to cricoarytenoid joint origin is very uncommon. This article presents a case of bilateral cricoarytenoid joint ankylosis in a SAPHO syndrome context., Case Report: A 53-year-old patient presenting with a two year history of intermittent bouts of dyspnea. A SAPHO syndrome was discussed on repeated thoracic CT-scan. The link between dyspnea and SAPHO syndrome had not been made immediately given the absence of any known anteriority. However, having ruled out other etiologies and after having had to perform a tracheotomy due a worsening of the respiratory condition, this diagnosis was considered. Treatment by corticosteroids and infliximab permitted a clinical improvement of the patient., Conclusion: This clinical case report should increase awareness of possible cricoarytenoid joint involvement in SAPHO., (Copyright © 2017 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Background: Pulmonary disease is a well recognised and important extra-articular manifestation of rheumatoid arthritis (RA). The objective of this study was to determine the prevalence of airway and parenchymal abnormalities in newly diagnosed patients with RA and to correlate these with clinical measures of RA severity and laboratory tests., Methods: 60 patients with a new (symptom duration <12 months) diagnosis of RA (43 females, 42 European, mean age 54, 33 ever smoker, (17 current) underwent lung function testing and high resolution computed tomography (HRCT) scored by two independent radiologists., Results: Eighteen (30%) patients reported respiratory symptoms: dyspnoea (11), cough (11), and wheeze (8). Twelve (20%) patients had physiologic evidence of airflow obstruction and 24 (40%) had reduced gas transfer. The prevalence of HRCT abnormalities (in any lobe) was as follows: decreased attenuation 67%, bronchiectasis 35%, bronchial wall thickening 50%, ground glass opacification 18%, reticular changes 12%. All abnormalities were more common in the lower lobes. With the exception of reduced DLCO, there were no significant differences in the prevalence of HRCT patterns or lung function parameters between smokers and non smokers. Anti-CCP antibodies and rheumatoid factor (RF) correlated strongly with DLCO and variably with other physiologic measures but poorly with radiologic abnormalities., Conclusion: Patients with newly diagnosed RA have a moderate prevalence of airway and parenchymal abnormalities on HRCT and lower than predicted lung function parameters which cannot entirely be explained by smoking. These data suggest that pulmonary involvement is present early in the disease course in RA., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: In the past, the clinical diagnosis of venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE) had been very challenging, because clinical presentation is non-specific and inaccurate., Objective: To review and assess clinical signs, symptoms and risk factors of DVT and PE and identify most common differential diagnoses., Results: Important components for the clinical diagnosis of VTE include risk factors such as immobilization, presence of cancer, confinement to bed, previous major surgery, prior VTE and - specific for DVT - whole limb enlargement, one-sided calf enlargement and dilatation of superficial veins. Additional items specific for PE include tachycardia, dyspnea chest pain and hemoptysis. Many of these clinical characteristics are included into clinical prediction rules, such as the Wells pre-test probability score for DVT or PE or the Geneva score for PE. These scores are used to determine the pre-test probability for VTE and they constitute the basis for a diagnostic algorithm. Various clinical prediction rules for DVT or PE show comparable accuracy., Conclusion: Even though the clinical presentation of DVT and PE varies substantially in individual patients and settings and may be misleading, diagnostic prediction rules based on clinical presentation and risk factors are very useful to assess pre-test probability, which is a very important concept for the diagnosis of DVT and PE., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Patients with centrally located lung tumors have been reported to have a higher risk of toxicity when treated with stereotactic body radiotherapy (SBRT) compared with patients with peripheral tumors. The optimal SBRT fractionation schedule for treatment of central tumors is unknown. The primary purpose of this study was to assess toxicity in patients with central lesions treated with SBRT at our institution, the majority of whom were treated with four fractions., Methods: Forty-seven patients with 51 central lesions, either primary lung cancer or lung metastases, were treated with SBRT at the Department of Therapeutic Radiology, Yale University School of Medicine/Yale Cancer Center from 2007 to 2011. The patients were treated with three to five fractions with the majority of patients receiving 50 Gy in four fractions of 12.5 Gy. Forty of the lesions were located within 2 cm of the proximal tracheobronchial tree whereas 11 were located within 2 cm of other mediastinal structures. Toxicity data were collected and analyzed according to pretreatment and tumor characteristics and dosimetric parameters. Lobar control data were compiled., Results: With a median follow-up of 11.3 months (range, 4.8-40.8), four patients experienced grade 3 dyspnea and one patient developed hemoptysis that contributed to respiratory failure and subsequent death. Grade 2 toxicity included fatigue (n = 3), dyspnea (n = 3), chest-wall pain (n = 1), and cough (n = 1). Patients with grade 3+ toxicity had larger maximum tumor diameters compared with those patients without grade 3+ toxicity (median diameter 4.3 cm versus 2.9 cm, p = 0.02). There were no detectable significant differences between the two groups with respect to baseline pulmonary function tests, distance to tracheobronchial tree, maximum point dose to the tracheobronchial tree, maximum dose to 5 cc of the tracheobronchial tree, mean lung dose, and volume of lung receiving 5 Gy, 10 Gy, and 20 Gy. There were two patients who experienced local recurrences. The median biological equivalent dose (linear quadratic formula, α/β = 10) for patients with local recurrence was 76 Gy compared with 112.5 Gy for patients without local recurrence (2-tailed t test, p = 0.04). The 2-year actuarial lobar local control for the entire cohort was 94%. The 2-year lobar local-control rate for patients receiving a biological equivalent dose of 100 Gy or more was 100% and for those receiving less than 100 Gy was 80% (log rank, p = 0.02)., Conclusion: SBRT for central lung tumors seems to be safe, although treatment of larger tumors does carry an increased risk of high-grade toxicity. Efforts to decrease the toxicity risk by decreasing the biologically equivalent dose resulted in increased local failure.

Background: Exercise induced asthma may symptomatically be difficult to differentiate from exercise related obstruction in the upper airways, sometimes leading to diagnostic confusion and inappropriate treatment. Larynx accounts for a significant fraction of total airway resistance, but its role as a limiting factor for airflow during exercise has been hampered by lack of diagnostic tools. We aimed to study laryngeal function in exercising humans by transnasal laryngoscopy., Methods: Continuous video recording of the larynx was performed in parallel with continuous film recording of the upper part of the body and recording of breath sounds in subjects running to respiratory distress or exhaustion on a treadmill., Results: A successful examination was obtained in 20 asymptomatic volunteers and 151 (91%) of 166 young patients with a history of inspiratory distress or stridor during exercise. At rest, six patients had abnormal laryngeal findings. During exercise, a moderate or severe adduction of laryngeal structures was observed in parallel with increasing inspiratory distress in 113 (75%) patients. In 109 of these, adduction started within supraglottic structures, followed by adduction of the vocal cords in 88. In four patients, laryngeal adduction started in the vocal cords, involving supraglottic structures secondarily in three., Conclusion: Larynx can safely be studied throughout a maximum intensity exercise treadmill test. A characteristic laryngeal response pattern to exercise was visualised in a large proportion of patients with suspected upper airway obstruction. Laryngoscopy during ongoing symptoms is recommended for proper assessment of these patients.

Postpneumonectomy syndrome is a rare complication secondary to postsurgical anatomic changes in the pneumonectomy space. Patients present with marked dyspnea on exertion secondary to airflow limitation from proximal airway compression and overdistention of the remaining lung because of mediastinal shift. Postpneumonectomy syndrome is treated by surgical repositioning of the mediastinum. Knowledge of the clinical and radiological features will enable prompt diagnosis and appropriate treatment.

Study Objective: The present study evaluated the relationship between health status (HS) and peripheral muscle histochemical characteristics in chronic obstructive pulmonary disease (COPD), and identified selected independent respiratory and extrapulmonary variables that predicted the HS of these patients., Design: Cross-sectional study., Setting: Outpatient respiratory clinic of a university hospital., Patients and Methods: We studied 29 patients (63+/-10 yrs) with a forced expiratory volume in 1s (FEV1) of 39+/-12%. All patients underwent vastus lateralis muscle biopsies for histochemical analysis. They also had spirometry, arterial blood gas analysis, body mass index (BMI), dyspnea determined with the MMRC scale and responded to the St. George's Respiratory Questionnaire (SGRQ) for HS assessment., Results: SGRQ total score correlated with fiber type distribution. A stepwise multiple regression identified three independent predictors of SGRQ total score: type I fiber proportion, BMI, and FEV1; r = 0.78 and r2 = 0.61., Conclusions: These results indicate that impaired HS in COPD is related to the peripheral muscle changes characterized by less type I fibers proportion. The findings argue in favor of an important contribution of the systemic consequences on the HS in COPD independently from the airflow limitation severity, and help to explain the observation of the poor correlation between the degree of airflow limitation and SGRQ total score.

Background: The aim of the present study was to demonstrate the capability of B-type natriuretic peptide (BNP) and amino terminal proBNP (NT-proBNP) as prognostic markers in patients with dyspnoea as a chief complaint., Methods: BNP and NT-proBNP plasma concentrations were obtained from 251 short of breath patients presenting to the emergency department of a tertiary care hospital. Patients with acute coronary syndromes or trauma were excluded. The endpoint was defined as all-cause mortality, and the study participants were followed up for 365 days from the time they attended the emergency department., Results: Of the 251 patients, 62 died and 189 stayed alive during follow-up. In the present study, optimal cut off levels for the prediction of survival were 454 ng/L for BNP, and 2060 ng/L for NT-proBNP. Mortality was higher in patients with baseline BNP and NT-proBNP concentrations above these cut off levels (log rank p<0.001; hazard ratios, 0.325 and 0.357, respectively). In multivariate Cox proportional-hazards regression analyses, elevated BNP/NT-proBNP, low systolic blood pressure, and renal dysfunction were predictors of mortality even when the baseline diagnosis of acute destabilized heart failure was factored into the model., Conclusions: Both BNP and NT-proBNP measures obtained from short of breath patients presenting to an emergency department may be predictive of one-year all-cause mortality independently of the baseline diagnosis of acute destabilized heart failure.

This study aims to investigate the possibility of additional value of leukotriene receptor antagonist (LTA) on dyspnea score, arterial blood gases (ABG), pulmonary function tests (PFTs), and quality of life (St. George QoL) in chronic obstructive pulmonary disease (COPD) patients. In this randomized, prospective, single-blind, and controlled study, 117 non-reversible COPD patients defined by global initiative for chronic obstructive lung disease (GOLD) criteria were randomized to receive ipratropium bromide, formoterol and montelukast (n:58, montelukast group) or ipratropium bromide and formoterol (n:59, control group) after a 2-week run-in period. There was no significant demographic difference between the two groups (P>0.05). Baseline ABG, PFT, visual analoque scores (VAS), and QoL scores were obtained and at first month and second month, PFT, VAS, and QoL scores were repeated and ABG was obtained at second month and the values were compared with baseline values. As the result of the comparison, there was significant increase in vital capacity, FVC, FEV1, VAS, and PaO2 parameters (P<0.05), and a significant decrease in the QoL scores (P<0.05) in the montelukast group. These parameters did not show any difference in the control group (P>0.05). Sputum samples that could be obtained in 24 of the COPD patients were evaluated and in the montelukast group, there was a decrease in neutrophilic activity after treatment (n:13) (P:0.059). These results suggest that LTA that is used additionally in routine treatment protocol can produce additive improvement on PFT, dyspnea score and especially QoL in patients with stable COPD and for these reasons, LTA may be taken into account when there is need for an additional anti-inflammatory treatment in COPD patients.

Background: Increased pulmonary capillary pressure (PAWP) and decreased serum colloid osmotic pressure (COP) are important factors in pulmonary edema (PE) formation. The aim of this study was to evaluate the clinical usefulness of noninvasive determination of COP, PAWP and COP-PAWP gradient in patients with acute dyspnea., Methods: Thirty four patients presenting with PE, 19 with preserved left ventricular systolic function (Ia) and 15 with depressed systolic function (Ib), and 26 patients presenting with acute pulmonary diseases (II) were enrolled. COP was estimated using Landis and Pappenheimer formula (COP = 2.1 x P + 0.16 x P2 + 0.009 x P3, P: serum total protein concentration). PAWP was measured by transthoracic Doppler echocardiography using E/Vp and 1000/(2 x IPT + Vp) Doppler indexes., Results: The mean value of the gradient was 0.5 +/- 5, 1.7 +/- 3.4 and 10.4 +/- 4.7 mmHg in Ia, Ib and II respectively (P < 0.001 Ia and Ib vs II). PAWP was higher in Ia and Ib than in II (P < 0.001). However, hypoalbuminemia with COP < or = 18 mmHg was observed in 63% of patients in Ia as compared to those in Ib (7%) and II (8%)., Conclusions: Severe hypoalbuminemia frequently contributes to PE formation in the presence of normal left ventricular systolic function. A COP-PAWP gradient value lower than 6 mmHg is highly predictive of the diagnosis of acute heart failure in these patients presenting with acute dyspnea.

In this work, alveolar lesions induced after systemic administration of cocaine (30 mg/kg per day, i.p.) to rats were evaluated both by light microscope analysis for morphological assessment as well as by measurement of the alveolar area as a quantitative index of the alveolar damage. Rats were examined after different times of exposure: 7, 15, 30, 45, 60 and 75 days. The histopathological evaluation of cocaine-treated rats revealed a remarkable thickening in some interalveolar septa, with interstitial hemorrhages, progressive thrombosis and transformation of reticular and elastic fibers into diffuse fibrosis. A significant decrease of the alveolar area was also observed. These findings are indicative of severe changes in capillaries, alveoli and bronchiole after cocaine exposure, which in turn may progressively disrupt the general function of the lungs. Differential mechanisms of systemic toxicity after cocaine exposure are discussed.

Objective: To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS., Subjects and Methods: Six new cases of confirmed or probable pulmonary aspergillosis were discovered during a search of hospital records. These are reviewed with 30 previously reported cases with special attention to radiographic appearance of disease and how radiographic appearance influences clinical outcome., Results: Symptoms of pulmonary aspergillosis in AIDS were nonspecific, most often including fever, cough, and dyspnea, and less commonly, chest pain or hemoptysis. Major risk factors for the development of pulmonary aspergillosis in patients with AIDS were steroid administration and neutropenia. Neutropenia was often a complication of therapies for AIDS, in particular, ganciclovir and zidovudine. Radiographic appearance of disease could be divided into three general categories. One third of the patients (13/36) presented with cavitary upper lobe disease resembling noninvasive or chronic necrotizing aspergillosis. Fatal hemoptysis occurred in 42 percent of patients with this form of disease. Twenty-two percent (8/36) of the cases presented as a nondescript focal alveolar opacity similar to invasive aspergillosis. In several patients, the focal infiltrate remained stable for several months, a feature that is unusual for aspergillosis in non-AIDS patients. The air crescent sign was present in none of the 36 reported cases. Patients with only focal disease had the best prognosis of patients with pulmonary aspergillosis. Bilateral alveolar or interstitial disease similar to invasive aspergillosis was present in 23 percent (9/36) of the patients. Bilateral disease appears to be a marker for disseminated infection and was associated with a high mortality due to aspergillosis. Two new forms of bronchial aspergillosis (5/36 cases) have been described previously. These patients presented with either obstructing fungal casts or bronchial pseudomembranes demonstrated bronchoscopically. In some patients with the bronchial forms of aspergillosis, transient alveolar opacities were seen on chest radiographs. These opacities may represent regions of atelectasis due to airway obstruction. One patient who had bilateral pneumothoraces without parenchymal opacities did not correspond to any of the three previously mentioned categories. Mortality due to aspergillosis was greater than 50 percent among AIDS patients. Death was subsequent to fatal hemoptysis or widespread pulmonary or systemic infection., Conclusion: Unlike other risk groups that tend to contract only one form of pulmonary aspergillosis, AIDS patients can develop the whole spectrum of aspergillosis-related pulmonary disorders, including chronic cavitary, invasive, and bronchial forms of aspergillosis. Clinical symptoms are nonspecific and major risk factors include neutropenia, which is often a side effect of various therapies for AIDS, and steroid administration. Patients with the chronic cavitary form of disease have an unusually high mortality due to fatal hemoptysis. Patients with bilateral pulmonary infiltrates and aspergillosis have a high mortality due to disseminated infection.

In the present study the consequences of administration of low-dose (0.5 mg) OKT3 for respiratory side-effects and pulmonary sequestration of labelled granulocytes are compared with the known effects of 5 mg OKT3. Ten renal transplant patients were studied, of whom five were treated with 0.5 mg OKT3 and five with 5 mg OKT3. None of the patients in the 0.5 mg group and two of the patients in the 5 mg group experienced dyspnoea. Sequestration of labelled granulocytes in the lungs was significantly lower in the patients receiving 0.5 mg OKT3 compared with the patients receiving 5 mg OKT3. The simultaneously occurring peripheral blood granulocytopenia was significantly more severe in the 5 mg group than in the 0.5 mg group. We suppose that this sequestration of circulating granulocytes in the lungs is at least partly mediated by complement activation products. In vitro it is demonstrated that fixation of complement activation products on peripheral blood lymphocytes depends on the concentration of OKT3 present in the culture medium. We conclude that respiratory side-effects shortly following infusion of OKT3 are related to complement-induced pulmonary leucostasis, the degree of which is dependent on the administered dose of OKT3.

To evaluate the efficacy of a mild anxiolytic, alprazolam, in relieving dyspnea, we conducted a randomized, placebo-controlled double-blind study on patients with chronic obstructive lung disease. Twenty-four patients had alprazolam (0.5 mg bid) or placebo administered for one week, followed by placebo for one week, then either placebo or alprazolam for the third week. Assessment tests were performed at the outset, end of the first and second weeks, and finally end of the third week. The parameters measured were: pulmonary function, exercise testing on a bicycle ergometer, and the distance covered in a 12 minute walk. Subjective sensations of dyspnea at rest and during guarded exercise, as well as subjective feelings of calmness or anxiety were also recorded. There was no difference in mechanical lung function, but the PO2 tended to decrease and PCO2 to increase after alprazolam administration. The maximum exercise level attained and the distance covered in the 12 minute walk was unchanged. The subjective perception of dyspnea was the same before and after alprazolam, at rest and during exercise. We conclude that alprazolam is not effective in relieving exercise dyspnea in patients with obstructive lung disease.