Biomedical subjects
Publications and source records attributed to M A Ossorio.
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.
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.
Treatment of asthma in the pregnant female poses a dilemma for the physician who must select medications that will effectively suppress maternal bronchospasm but that will not jeopardize the fetus. To compound the practitioner's problem, the inability to perform human studies with asthma drugs has led the pharmaceutical companies to formally list precautions against the use of antiasthmatic drugs during pregnancy in the Physician's Desk Reference (PDR), a book which is available to the lay public and is often introduced in medicolegal suits as the primary reference for standard of care. This article provides the clinician with the current recommended treatments that are considered acceptable during pregnancy based on the published evidence involving animal studies and the cumulative human experience that is reported in the English language medical literature.
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.
The majority of patients with the acquired immunodeficiency syndrome will develop clinical and radiographic pulmonary involvement during the course of their disease. Although opportunistic pathogens account for the majority of these intrathoracic abnormalities, pulmonary neoplasms are being encountered more often than would be expected for the age group under consideration. Clinicians need to be vigilant for the possibility of the early appearance of bronchogenic carcinoma in this subset of patients.
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.
The incidence of nontraumatic chylothorax is sufficiently low that most primary care physicians are unclear about the criteria for this diagnosis and the proper treatment options. A ten-year review of patients with pleural effusion treated by the university medical service identified 12 individuals with chylothorax. These patients and a current review of the English language medical literature provide us an opportunity to review the clinical presentation of chylothorax. The differential diagnosis and treatment options are reviewed.
The recent medical literature documents the occurrence of progressive muscle weakness 30 to 40 years after apparent recovery from poliomyelitis. We present a patient whose respiratory failure was attributed to the late effects of poliomyelitis on the respiratory muscles via spinal cord impairment. We examine the characteristics and proposed causes of the "postpolio syndrome."
The routine use of hyperbaric oxygen as therapy for carbon monoxide intoxication is being critically reexamined nationally. There are no controlled prospective clinical studies that show this modality to clearly be superior to the more traditional use of high concentrations of supplemental oxygen. Proponents of hyperbaric therapy often claim that such studies would now be unethical, would violate the accepted standard of care for this medical emergency, and would place the treating physician in an indefensible medical-legal position. In an attempt to determine the status of hyperbaric oxygen in our community as treatment for significant carbon monoxide exposure, we surveyed physicians practicing at the university regional trauma center to determine their perception of the indications for hyperbaric oxygen therapy for carbon monoxide poisoning. We then audited the medical records of all patients treated during a four-year period with the diagnosis of carbon monoxide poisoning or smoke inhalation to determine the actual utilization of this therapeutic modality. The results of our study indicate that hyperbaric referral is not the standard treatment for significant carbon monoxide intoxication in this academic setting.
Attention is called to prior gastric stapling as a risk factor for emesis and aspiration in those patients who are treated with single or repeated oral activated charcoal for tricyclic antidepressant overdose. When administered activated charcoal as part of the standard protocol for drug poisoning, these individuals have the potential for developing severe and repeated emesis with subsequent aspiration of this compound into the respiratory tract with development of the Acute Lung Injury syndrome.
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