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Abstract Introduction There are few reported cases of neutrophilic pleural effusions associated with valproic acid therapy. Most of them are of eosinophilic exudates with or without blood eosinophilia. Case presentation This case study describes a 70-year-old man with recurrent episodes of eosinophilic transudative pleural effusions associated with sodium valproate treatment. The recurrence of effusion after re-administration of the drug is strongly suggestive of an association between them. To the best of our knowledge, this is the first reported case with a pleural effusion with these characteristics caused by sodium valproate. Conclusion This is the first report in the literature, with a full understanding of the etiology but with an unknown drug mechanism. This case report is of interest to different medical specialists (such as pulmonologists, neurologists, cardiologists) and pharmacologists.

Abstract Background Sarcoidosis is rarely associated with a distinct disease. One disease infrequently associated with sarcoidosis is psoriasis. Case presentation This case study describes a 38-year-old male, who presented with chest pain, high-grade fever, arthralgias and a skin rash accompanied by bilateral hilar lymphadenopathy on his chest radiograph. Extensive investigations including fiber-optic bronchoscopy with bronchoalveolar lavage and labial and skin biopsies, demonstrated that two distinct clinical entities co-existed in the same patient: pulmonary sarcoidosis and psoriasis vulgaris. Combination therapy for both diseases was applied and the patient was greatly improved. Conclusion This is the first well-documented case of sarcoidosis and psoriasis in the same patient, reported on the basis of safe and widely-used techniques that were not available until fairly recently. These disorders might share common pathogenic mechanisms that could explain their co-existence in the patient.

Smoking is a major cause of morbidity and mortality all over the world. An effective anti-smoking campaign should be based on knowledge of the attitudes and characteristics of the target population. The aimof the present study was to investigate the smoking habits and attitudes of young male adults in Greece and especially the relationship between the age at which smoking begins and the severity of smoking. Aquestionnaire consisting of 38 questions related to smoking habits, was distributed to 1,054 male recruits of the Greek Army. The median age of responders was 21 1 2.5 (range 17-30 years). It was found thatof the 1,054 some 496 (47.1&percnt;) were current smokers and 112 (10.6&percnt;) were ex-smokers. The mean cigarette consumption was 19.41 10.3 per day and the mean age at which smoking began was 17.1 1 2.2. Four hundred and thirty-four (77.5&percnt;) of the responders wanted to stop smoking. There was no significant difference found betweenthe smoking habits of the parents and those of the responders. A significant negative relation was found between the age at which smokingbegan and the severity of smoking (r = -0.234, p < 0.001). The results of this study suggest that a large number of young Greek males aresmokers and a high percentage of them want to quit smoking. An anti-smoking campaign should start early in childhood, since the earlier smoking begins the heavier it is in adulthood. [ABSTRACT FROM AUTHOR]

Cryptogenic organizing pneumonia (COP), previously called bronchiolitis obliterans organizing pneumonia (BOOP) is a clinicopathological disorder of unknown aetiology but increasingly reported. It usually presents with symptoms of dyspnea, cough, fever, weight loss accompanied by the presence of alveolar opacities on chest radiograph. Haemoptysis, described as blood streaking has only rarely been reported as primary presentation of COP. Herein, we report a case of COP in which submassive haemoptysis was the main clinical manifestation. The clinical, radiological, pathological, and therapeutic aspects of the disease are briefly discussed. Cryptogenic organizing pneumonia should be taken into consideration in the differential diagnosis of severe haemoptysis.

Bronchoscopic drainage of a pyogenic lung abscess is an established therapeutic approach in selected patients in whom conventional antibiotic therapy fails. This intervention has also been undertaken in patients with abscess owing to underlying lung cancer and prior combined radiochemotherapy. However, this procedure has rarely been performed in cavitary lesions of advanced tumor origin before initiating any chemotherapy/radiotherapy scheme. Herein, we describe a case of a 68-year-old woman with lung adenocarcinoma stage IIIB, who underwent bronchoscopic drainage of necrotizing tumor lesion, thus improving her initial poor clinical condition and rendering other treatment modalities, such as radiotherapy, more effective and beneficial. Bronchoscopic drainage of a symptomatic cancerous lung abscess should be considered as an alternative and palliative treatment approach in patients with advanced inoperable non-small cell lung cancer.

Actinomycosis is a rare and slowly progressive infectious disease that can affect a variety of organ systems including the lung. It is caused by filamentous Gram-positive anaerobic bacteria of the genus Actinomyces. Despite its rarity, pulmonary actinomycosis can involve lung parenchyma, bronchial structures, and chest wall. The disease can mimic lung malignancy given its nonspecific clinical and radiological presentation, thus posing a diagnostic dilemma to the attending physician. In this paper, we describe two patients with pulmonary actinomycosis mimicking bronchogenic carcinoma; the former presented with peripheral infiltrate and associated hilar/mediastinal lymphadenopathy and the latter presented with a foreign body-induced endobronchial mass. Clinical, imaging, diagnostic, and therapeutical aspects of the disease are discussed, demonstrating the paramount importance of the histological examination of lung tissue specimens in the confirmation of the infection given either its low culture yield or the limited use of new molecular diagnostic tools in routine clinical practice.

Background: The recent literature shows an increased incidence of obstructive sleep apnea (OSA) in patients with idiopathic pulmonary fibrosis (IPF). On the other hand, there are no published studies related to continuous positive airway pressure (CPAP) treatment in this patient group. Our aim was to assess the effect of CPAP on sleep and overall life quality parameters in IPF patients with OSA and to recognize and overcome possible difficulties in CPAP initiation and acceptance by these patients., Methods: Twelve patients (ten males and two females, age 67.1 ± 7.2 years) with newly diagnosed IPF and moderate to severe OSA, confirmed by overnight attended polysomnography, were included. Therapy with CPAP was initiated after a formal in-lab CPAP titration study. The patients completed the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Functional Outcomes in Sleep Questionnaire (FOSQ), the Fatigue Severity Scale (FSS), the SF-36 quality of life questionnaire, and the Beck Depression Inventory (BDI) at CPAP initiation and after 1, 3, and 6 months of effective CPAP therapy., Results: A statistically significant improvement was observed in the FOSQ at 1, 3, and 6 months after CPAP initiation (baseline 12.9 ± 2.9 vs. 14.7 ± 2.6 vs. 15.8 ± 2.1 vs. 16.9 ± 1.9, respectively, p = 0.02). Improvement, although not statistically significant, was noted in ESS score (9.2 ± 5.6 vs. 7.6 ± 4.9 vs. 7.5 ± 5.3 vs. 7.7 ± 5.2, p = 0.84), PSQI (10.7 ± 4.4 vs. 10.1 ± 4.3 vs. 9.4 ± 4.7 vs. 8.6 ± 5.2, p = 0.66), FSS (39.5 ± 10.2 vs. 34.8 ± 8.5 vs. 33.6 ± 10.7 vs. 33.4 ± 10.9, p = 0.44), SF-36 (63.2 ± 13.9 vs. 68.9 ± 13.5 vs. 72.1 ± 12.9 vs. 74.4 ± 11.3, p = 0.27), and BDI (12.9 ± 5.5 vs. 10.7 ± 4.3 vs. 9.4 ± 4.8 vs. 9.6 ± 4.5, p = 0.40). Two patients had difficulty complying with CPAP for a variety of reasons (nocturnal cough, claustrophobia, insomnia) and stopped CPAP use after the first month, despite intense follow-up by the CPAP clinic staff. Heated humidification was added for all patients in order to improve the common complaint of disabling nocturnal cough., Conclusion: Effective CPAP treatment in IPF patients with OSA results in a significant improvement in daily living activities based on the FOSQ, namely an OSA-specific follow-up instrument. Improvement was also noted in other questionnaires assessing quality of life, though not to a statistically significant degree, probably because of the multifactorial influences of IPF on physical and mental health. The probability of poor CPAP compliance was high and could only be eliminated with intense follow-up by the CPAP clinic staff.

We report a rare case of a 59 year-old female, who was admitted to the hospital because of a recurrent right-sided pleural effusion. The initial work-up was non-diagnostic. The diagnosis was finally confirmed following medical thoracoscopy, where an osteophyte of a rib was found to protrude sharply into the thoracic cavity. Chronic inflammatory changes of the pleura suggested mechanical irritation due to long lasting friction between this bony structure and the underlying lung. This is the first report where an osteophyte seems to be implicated in pleural pathology. A brief review of the available data from the literature is presented to further support our results.

Microscopic polyangiitis (MPA) is a systemic small vessel vasculitis that is included in the pulmonary-renal syndromes. Although glomerulonephritis represents the major clinical feature of MPA indicative of renal involvement, diffuse alveolar haemorrhage is the classic manifestation of pulmonary involvement. However, pulmonary fibrosis is a less frequently reported pulmonary manifestation. Herein we describe a patient who was diagnosed with MPA presenting with radiographic evidence of pulmonary interstitial fibrosis as an early clinical manifestation accompanied by constitutional symptoms such as fever and weight loss. We also include a short literature review focusing on the association between pulmonary fibrosis and MPA.

There are few reported cases of clear cell tumor of the lung, a very rare benign mesenchymal neoplasm. We describe a 41-year-old asymptomatic man who presented with a coin lesion in a routine chest roentgenogram that was absent in a roentgenogram performed a year earlier. After a thorough workup, including radionuclide scintigraphy, the diagnosis of cell tumor of the lung was established. Somatostatin receptor positivity was demonstrated, and this clear cell tumor of the lung had a rapid growth rate. Because of these features, the benign nature of such a tumor remains questionable., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Congenital bronchial atresia is a rare anomaly, which usually presents in adulthood as an incidental finding on routine examinations., Case Presentation: In this report we present a patient with a cavitary lesion at his right upper lobe, found by chance on chest radiography. Computed tomography of the chest revealed the characteristic findings of a mucocele with distal oligemia and hyperlucency of the affected lung parenchyma. Further examination including bronchoscopy virtually excluded other possible disorders and the diagnosis of congenital bronchial atresia was established., Conclusion: The radiological presentation of congenital bronchial atresia may occasionally mimic serious lung diseases. The procedure of choice for the diagnosis is the computed tomography of the chest. Bronchoscopy is not diagnostic but is valuable in doubtful cases to exclude different disorders.

Familial Mediterranean fever (FMF) is an autosomal recessive disease affecting predominantly populations surrounding the Mediterranean basin. It is the most prevalent hereditary periodic fever syndrome characterized mainly by recurrent and short attacks of fever and serositis (pleuritis, arthritis, peritonitis). Unilateral polymorphonuclear exudative pleuritis associated with fever has been reported as the solitary manifestation of the first FMF attack, in < 10% of patients. This case study describes a 30-year-old Greek man with recurrent episodes of lymphocytic exudative pleuritis associated with fever. After a thorough workup (clinical criteria and molecular genetic testing identifying homozygosity polymorphisms of the FMF gene), the diagnosis of FMF was established. Treatment with colchicine, 2 mg/d, eliminated FMF attacks. To our knowledge, this is the first well-documented case report of a patient with FMF presenting with a lymphocytic exudative pleural effusion.

Mefloquine has been widely used for prophylaxis and treatment of patients with chloroquine-resistant malaria; the drug is usually well tolerated. Rarely, adverse effects may be severe, including gastrointestinal disturbances, neuropsychiatric reactions, cardiovascular manifestations, skin lesions, musculoskeletal symptoms, and bone marrow toxicity. We describe a 67-year-old woman with fever, dyspnea on exertion, peripheral blood eosinophilia, and diffuse pulmonary infiltrates on chest radiography. She had taken mefloquine for malaria prophylaxis for an 8-week trip to South Africa. A thorough work-up led to the diagnosis of eosinophilic pneumonia caused by the mefloquine. Her condition improved after the drug was discontinued. To our knowledge, this is the first report of mefloquine-induced eosinophilic pneumonia. Clinicians should be aware of this rare, potential adverse effect of mefloquine.

We report a case of an 18-yr-old male with high-grade persistent fever, productive cough, malaise, diarrhea and associated abnormal findings on chest radiography. The patient suffered from ulcerative colitis receiving mesalazine and azathioprine. After a further and scrutinized work-up the diagnosis of drug-induced pulmonary toxicity was made. His condition was improved after discontinuing both drugs and the administration of corticosteroids. This is a rarely reported case of eosinophilic pneumonia. Although it has not been reported previously, the possibility of mesalazine and azathioprine synergism cannot be excluded. The clinical, aetiological, diagnostic and therapeutic aspects of the disease are discussed demonstrating the paramount importance of bronchoalveolar lavage in the diagnosis of this disorder. One should be aware of this entity in patients with inflammatory bowel disease.

Background: Sarcoidosis is rarely associated with a distinct disease. One disease infrequently associated with sarcoidosis is psoriasis., Case Presentation: This case study describes a 38-year-old male, who presented with chest pain, high-grade fever, arthralgias and a skin rash accompanied by bilateral hilar lymphadenopathy on his chest radiograph. Extensive investigations including fiber-optic bronchoscopy with bronchoalveolar lavage and labial and skin biopsies, demonstrated that two distinct clinical entities co-existed in the same patient: pulmonary sarcoidosis and psoriasis vulgaris. Combination therapy for both diseases was applied and the patient was greatly improved., Conclusion: This is the first well-documented case of sarcoidosis and psoriasis in the same patient, reported on the basis of safe and widely-used techniques that were not available until fairly recently. These disorders might share common pathogenic mechanisms that could explain their co-existence in the patient.

In patients receiving anti-tumor necrosis factor (TNF) therapy, a probable exacerbation of latent tuberculosis (TB) is a major adverse event. The impairment of granuloma differentiation is considered a characteristic feature of TB in these patients. In this report we present three patients with rheumatic disease who developed TB under infliximab treatment. All of them had typical granulomas on the biopsy specimens, indicating that the expected impairment of granuloma formation is not always the case. The notion of granuloma-free TB in patients receiving anti-TNF therapy could shift a clinician's path away from performing a biopsy, thus delaying the establishment of a correct diagnosis.

Study Objective: 8-Isoprostane is considered an index of oxidative stress. Measurement of 8-isoprostane in the expired breath condensate, a totally noninvasive method, has not been used to explore the level of inflammation in pulmonary sarcoidosis. Therefore, the aim of our study was to measure the levels of 8-isoprostane in the expired breath condensate of patients with sarcoidosis, and to investigate the relation of 8-isoprostane level to disease activity., Patients: We investigated 30 patients with pulmonary sarcoidosis (active disease, n = 14; nonactive disease, n = 16) and 12 healthy subjects as control group., Methods: 8-Isoprostane was measured in the expired breath condensate of all subjects, and its levels were compared between the control and sarcoidosis groups as well as between the subgroups of patients with active and nonactive disease. In the group with sarcoidosis, 8-isoprostane levels were further correlated with markers that may reflect disease activity, such as serum angiotensin-converting enzyme (sACE) level, serum calcium level, and pulmonary function test results., Results: The concentration of 8-isoprostane was increased in patients with sarcoidosis compared to control subjects (mean, 64.23 pg/mL; 95% confidence interval [CI], 37.00 to 91.46 pg/mL; vs mean, 20.75 pg/mL; 95% CI, 16.06 to 25.44 pg/mL; p = 0.04). The difference was primarily due to the patients with active disease, who had significantly higher levels of 8-isoprostane (mean, 111.4 pg/mL; 95% CI, 62.56 to 160.30 pg/mL; p < 0.001) compared to patients with nonactive disease (mean, 22.94 pg/mL; 95% CI, 15.89 to 29.99 pg/mL) or healthy subjects. 8-Isoprostane levels in patients with nonactive disease did not differ from those in healthy subjects (p > 0.05). In the patients with sarcoidosis, 8-isoprostane levels were positively correlated with sACE level (p < 0.0001, r = 0.69), but was not correlated with serum calcium level or pulmonary function test values., Conclusions: Our data suggest that 8-isoprostane levels are increased in the expired breath condensate of patients with sarcoidosis and might serve as an index of disease activity.

Background: Congenital bronchial atresia is a rare anomaly, which usually occurs in adulthood as an incidental finding on routine chest radiograph., Methods: The purpose of the study was to retrospectively evaluate the cases that were diagnosed in our hospital, from January 1995 to March 2003, to estimate the prevalence of this disorder and to determine the diagnostic studies of choice, according to the existing literature. Since the main portion of the male population of our country is referred to our hospital for screening soon after their enrollment in the army, epidemiological data can be easily estimated for many congenital anomalies occuring in adulthood, such as bronchial atresia., Results: We found seven patients with Congenital Bronchial Atresia and the prevalence of this disorder was estimated at 1.2 cases per 100,000 in males. The chosen diagnostic procedure is computed tomography of the chest with high-resolution scans. Bronchoscopy would only exclude serious alternative diagnosis and prevent unnecessary surgical interventions., Conclusions: Congenital bronchial atresia is a rare anomaly, with a mild clinical course. The diagnosis is made radiologically, the HRCT of the chest being the procedure of choice. Bronchoscopy should be performed to exclude any endobronchial lesion due to a different disease entity and to prevent unnecessary surgical intervention in an otherwise asymptomatic individual.

Inhaled prostaglandin (PG)E2 has been found to cause bronchodilation in asthmatics, although it does not have bronchodilative effects in normal subjects. The aim of this study was to investigate the levels of PGE2 in the expired breath condensate of patients with asthma, the possible contribution of smoking habit to its levels and the possible relationship between PGE2 and the degree of bronchial hyperresponsiveness, as assessed by the provocation dose of histamine causing a 20% fall in forced expiratory volume in one second (FEV1) (PD20). A total of 30 mild asthmatics (15 smokers, all steroid-naive, FEV1 88+/-6 (%+/-SD)) and 20 healthy control subjects (10 smokers) were studied. Histamine challenge testing was performed in all subjects and the PD20 was determined. The results showed that asthmatic smokers had significantly higher values of PGE2 compared to asthmatic nonsmokers and control subjects (40+/-21 versus 14.5+/-4.5 versus 11.7+/-3 pg x mL(-1), respectively). Further analysis showed that PGE2 levels were significantly higher in asthmatic smokers compared to smoker and nonsmoker controls (40+/-21 versus 11.6+/-2 versus 11.7+/-4 pg x mL(-1), respectively). No significant difference was observed between asthmatic nonsmokers and both control smokers and control nonsmokers. No significant correlation was found between PGE2 levels and PD20 in all groups of asthmatics, irrespective of smoking habit. In conclusion, the elevation of prostaglandin E2 in the expired breath condensate of patients with asthma is mainly attributed to smoking habit and prostaglandin E2 levels do not predict the degree of bronchial hyperresponsiveness.

Objective: To evaluate the levels of hydrogen peroxide (H(2)O(2)) and 8-isoprostane in the expired breath condensate (EBC) of patients with COPD, and to assess the relationship between the above markers of oxidative stress and parameters expressing inflammatory process and disease severity., Setting: Inpatient respiratory unit and outpatient clinic in tertiary care hospital., Design: Cross-sectional study., Patients: Thirty stable COPD patients (all smokers) with disease severity ranging from mild to severe. Ten subjects who were smokers with stage 0 disease (ie, at risk for COPD; mean [+/- SD] FEV(1), 88 +/- 5% predicted) were studied as a control group., Methods: H(2)O(2) and 8-isoprostane levels were measured in EBC, and the values were correlated with variables expressing COPD severity (ie, FEV(1) percent predicted, dyspnea severity score (ie, Medical Research Council scale) and airway inflammation (ie, differential cell counts from induced sputum)., Results: The mean concentration of H(2)O(2) was significantly elevated in COPD patients compared to control subjects (mean, 0.66 micromol/L [95% confidence interval (CI), 0.54 to 0.68 micro mol/L) vs 0.31 micro mol/L [95% CI, 0.26 to 0.35 micromol/L], respectively; p < 0.0001). The difference was primarily due to the elevation of H(2)O(2) in patients with severe and moderate COPD, whose expired breath H(2)O(2) levels were significantly higher than those of patients with mild disease (mean, 0.96 micromol/L [95% CI, 0.79 to 1.13 micromol/L], 0.68 micromol/L [95% CI, 0.55 to 0.81 micromol/L], and 0.33 micromol/L [95% CI, 0.24 to 0.43 micromol/L], respectively, p < 0.0001). The mean concentration of 8-isoprostane was significantly elevated in patients with COPD compared to that of the control group (47 pg/mL [95% CI, 41 to 53 pg/mL] vs 29 pg/mL [95% CI, 25 to 33 pg/mL], respectively; p < 0.0001) but did not differ significantly among the different stages of the disease (p = 0.43). Repeatability and stability data within measurements showed that H(2)O(2) has a better repeatability and stability than 8-isoprostane. Furthermore, we observed significant correlations of H(2)O(2) with FEV(1), neutrophil count, and dyspnea score. Those correlations existed only in patients with moderate and severe disease. No correlations were found between levels of 8-isoprostane and the above parameters., Conclusions: We conclude that levels of H(2)O(2) and 8-isoprostane are elevated in the EBC of patients with COPD, but that H(2)O(2) seems to be a more repeatable and a more sensitive index of the inflammatory process and the severity of the disease.

Study Objectives: To determine the intracellular and extracellular Mg concentrations in patients with acute asthma and their correlation with parameters expressing the disease severity., Patients: Thirty patients with acute asthma (FEV(1), 56% predicted [SD, 14.5]), 20 patients with stable asthma (FEV(1), 97% predicted [SD, 10]), and 20 healthy subjects (FEV(1), 97% predicted [SD, 8])., Methods: Mg concentrations in erythrocytes and plasma were measured four times: at hospital admission, after 2 days, after 5 days, and at hospital discharge. Percentage of predicted FEV(1) and peak expiratory flow rate variability were recorded simultaneously. Similar measurements were carried in all study groups., Results: Mg concentrations of healthy subjects and patients with stable asthma remained unchanged in both plasma and erythrocytes. Initial Mg content in erythrocytes was significantly lower in patients with acute asthma (1.77 fmmol per cell; 95% confidence interval [CI], 1.71 to 1.83) compared to normal subjects (1.94 fmmol per cell; 95% CI, 1.82 to 2.00) and patients with stable asthma (1.92 fmmol per cell; 95% CI, 1.87 to 1.96) [p < 0.0001], and it increased significantly after the resolution of the exacerbation (from 1.77 fmmol per cell [95% CI, 1.71 to 1.83] at hospital admission to 1.90 fmmol per cell [95% CI, 1.83 to 1.98] at hospital discharge; p < 0.0001). No correlation was observed between parameters of disease severity and the initial values of Mg concentrations in erythrocytes and plasma., Conclusions: Acute asthma is associated with lower erythrocyte Mg content while plasma levels remain unchanged. This decrease in intracellular Mg content occurs regardless of the severity of the exacerbation and returns to normal values after control has been achieved.