Biomedical subjects
Publications and source records attributed to C L Fields.
Vocal cord dysfunction is a little recognized cause of dyspnea and wheezing. Its lack of recognition has often led to the institution of inappropriate therapeutic methods, including intubation and tracheostomy. Awareness of this possible cause of respiratory distress should allow early institution of appropriate psychotherapy, rather than unnecessary medical intervention.
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The high-probability ventilation-perfusion lung scan is accepted as supportive of pulmonary embolism and often negates further diagnostic evaluation; however, there are processes that mimic the clinical presentation and radiographic findings of pulmonary emboli, including a unilateral segmental or greater perfusion defect. We present the findings in a patient whose presentation and ventilation-perfusion scans over a three-month course were suggestive of pulmonary embolism, yet pulmonary angiography revealed a thrombosed pulmonary artery aneurysm. The interpretation of a unilateral segmental perfusion defect as high probability does not secure the diagnosis of pulmonary embolism and should not preclude further evaluation for alternative etiologies.
The safety and ease of fiberoptic bronchoscopy recommends its use in the intensive care unit. In critically ill patients, the procedure may be a valuable diagnostic or therapeutic tool. In most instances, the diagnostic indications are well defined. The therapeutic indications for bronchoscopy, however, are more controversial. They center around using the bronchoscope for removal of secretions, mucus plugs and reversing atelectasis in mechanically ventilated patients. This report examines the small but definite risk of therapeutic bronchoscopy in mechanically ventilated patients.
Although not as common as Histoplasmosis, the disease caused by Blastomyces dermatitidis is also endemic in the Commonwealth of Kentucky. Greater clinical awareness of this systemic mycosis and the newer effective forms of treatment may lessen the significant morbidity and mortality of this potentially serious infection. To illustrate the varied manifestations of this illness, we contrast the presentation of an urban female with blastomycosis and atypical chest radiographic changes to the more classic features of blastomycosis described in the literature.
Premature and rapidly progressing emphysema of the lung is unique in the absence of cigarette smoking or an inherited homozygous alpha-1-antitrypsin deficiency. We describe a young man with radiographic evidence of early onset bullous emphysema without the usual risk factors and provide a review of the alternative explanations proposed for this form of lung damage.
In 1871, DaCosta published his observation of somatic symptoms preceded by significant hyperventilation. More than a century later, the hyperventilation syndrome remains a poorly defined but common clinical condition. Although familiar to most practitioners of medicine when it presents as an acute phenomenon, the diagnosis may go unrecognized in its chronic form. The ability of a chronic hyperventilatory state to mimic a life-threatening cardiopulmonary disease is not always appreciated.
Distinguishing new onset asthma from an insidious upper airway obstruction can prove difficult and is more frequently being addressed in the medical literature. We examine our experience in a teaching hospital and analyze the problems relating to establishing the correct diagnosis.
The Department of Labor has set guidelines for the use of resting arterial blood gas analysis in determination of total and permanent disability for coal workers' pneumoconiosis. To determine the prevalence with which bituminous coal miners fall below the arterial tensions of both oxygen and carbon dioxide published in the Federal Register, we studied 1012 miners who had both reproducible spirometry and arterial blood gas analysis as part of their disability evaluation. Eighty-seven percent of impaired miners could be identified by the spirometric criteria. Thirteen percent of impaired bituminous coal miners had acceptable pulmonary function but were eligible for black lung benefits by the blood gas guidelines. This population would have been missed if blood gas analysis were excluded from the evaluation process. On the other hand, approximately 25% of the blood gas analyses that were performed could be eliminated if a policy was adopted to do this test only on miners with spirometry that exceed the federal guidelines.
A survey of 150 practicing pulmonary physicians was conducted to determine chemotherapy preferences for the treatment of the patient suffering respiratory insufficiency secondary to active nonmiliary tuberculosis. An equal sample was selected from both the private sector and academic medicine in order to determine if antituberculous agent selection differed between these two groups. The majority of the 109 physicians who responded to the questionnaire (64.2%) indicated that they would use isoniazid, rifampin, and a third agent. There was no statistical difference in the choice of ethambutol, pyrazinamide, or streptomycin as the third drug. There was no difference between university and community based physicians in the use of three drug combinations or in the selection of the specific third agent. This study suggests that, although the majority of pulmonologists responding would treat the patient with respiratory insufficiency from tuberculosis with an aggressive three drug approach, there is no consensus as to which agent should be the third drug.
The Yellow Nail syndrome is an unusual lymphangitic disorder classically characterized by the presence of nail discoloration, lymphedema and pleural effusion. Since the recognition of the significance of these associated physical findings, four cases have been diagnosed at our institution in the last six years. This suggests that the syndrome may not be as rare as previously reported in medical literature. More often it may remain unrecognized in the absence of the classic triad of physical findings. To heighten awareness of this disorder, we describe our most recent patient diagnosed with YNS and provide a review of the current medical literature.
A 23-year-old woman who presented in the 17th week of her third intrauterine pregnancy was diagnosed as having active Wegener's granulomatosis. Therapy, consisting of corticosteroids, cyclophosphamide and hemodialysis, was instituted and maintained until delivery. Although Wegener's granulomatosis complicated by pregnancy has been reported previously, this is the first reported patient to be treated successfully with the above agents during the second and third trimesters without apparent harm to her or her infant.
We report the occurrence of spontaneous pneumothorax as the initial pulmonary event in a patient subsequently found to have a primary adenocarcinoma of the ipsilateral lung. A review of the literature regarding this rare presenting feature of bronchogenic neoplasm is provided.
We have described three patients with clinical evidence of myocardial sarcoidosis to illustrate the utility of thallium-201 scintigraphy in demonstrating the myocardial lesions. Both the symptomatic and asymptomatic individuals studied showed the characteristic "reverse redistribution" phenomenon. No abnormalities were seen during the exercise phase of the thallium study, but myocardial defects were detected in each patient when repeat studies were obtained at rest six hours later. Steroid therapy resolved the defects in each case. We propose thallium-201 scintigraphy of the heart as a safe and useful tool for documenting myocardial involvement in sarcoidosis and following the effects of therapy.
Pulmonary infection due to the filariform larvae of Strongloides stercoralis may occur in immunocompromised patients residing in endemic areas of the United States. Such infection usually presents as dyspnea with a cough that sometimes results in bloody sputum. Although the chest roentgenogram often reveals a patchy bilateral alveolar infiltrate, acute respiratory distress is unusual. We report a patient who experienced severe exacerbation of his underlying obstructive lung disease that was associated with chest infiltrates and recovery of S stercoralis from his sputum. Although initial improvement was accomplished with Thiobendazole treatment, a re-exacerbation occurred when antiparasitic therapy was completed. The persistence of his infection is correlated to factors that are commonly employed in the treatment of COPD but may be overlooked as predisposing causes of hyperinfection with S stercoralis.
Sporothrix schenckii produces an insidious debilitating illness in humans. The lungs are seldom involved and pleural involvement is distinctly unusual, with only four patients described in the literature. We have described a patient with both parenchymal lung disease and pleural effusion. The characteristics of the pleural fluid were unlike those previously reported, and suggest that the coexistence of a parenchymal Sporothrix infiltrate may alter the nature of the pleural fluid to mimic an empyema rather than a self-limited hypersensitivity reaction.
We studied 82 consecutive patients admitted to the ICU with predominant tricyclic antidepressant overdose (mean plasma tricyclic level, 1,025 ng/ml) to determine the nature and incidence of respiratory complications. The majority of patients (80.4 percent) had a decreased arterial to alveolar oxygen tension ratio (PaO2/PAO2) on initial emergency room arterial blood gas analysis (mean, 0.56). Mechanical ventilation was required in 76.8 percent of the patients for a mean duration of 46.2 h. Chest radiograph abnormalities developed during the first 48 h in 32/82 patients (39 percent). The group with radiographic abnormalities had higher mean drug levels than the group without (p less than 0.05). Of 82 patients, nine (11 percent) developed radiographic evidence of bilateral alveolar infiltrates suggestive of acute lung injury. This group had significantly higher mean drug levels than the groups with other types of radiographic abnormalities (p less than 0.001). Charcoal was recovered from the airway of 18/72 patients who received activated charcoal slurry by nasogastric tube in the emergency room after endotracheal intubation. The group who aspirated did not show statistically significant difference in the incidence of chest radiograph abnormalities, gas exchange, or survival compared with the group that did not aspirate.
Current information about deep vein thrombosis and pulmonary embolism indicates that both conditions are greatly underdiagnosed. Since some of the newer methods for accurate diagnosis constitute a potential hazard to the fetus, underdiagnosis is most assuredly true for pregnant patients as well. The diagnostic approach to the pregnant female suspected of having pulmonary thromboembolism is discussed and the current treatment recommendations are reviewed.