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Roundworm Infestation
communications to the editor COlIIlIIUllical ill/ls fill" this s.... ,ion will h.. l'u1>lislll'd as "/HU:.. and priorilil'" /ll'nllil. Thl' t:/IIII/lu'nis should not ..xccrd .3.50 uiords in lenglh . •cith a IIl11ximUIII ofjive rrferl'nc..s; onl' jigun' or tabl .. CIIII h.. prinl ..d . Exr..ptions IIl11y OI TIII' under par/iru/ar drrUllt.IIIIU"'''. Contribution» nuu; includ.. comment» 11/1 article» /nthlL./lI'd in this periodical. or th ..y uUlY be reports of uniqu.. educational dill racier. S/ll'lific p,'nllissio ll 10 puhlL.h should Ill'd ied ill 1/ coverint; letter or appended as a postscript .
Right Atrial Myxoma 11, the Editor: We read with interest the case report of right atrial myxoma hy Keren et OIL' which appeared in the May 1989 issue of Chest, and two subseq ue nt letters to the editor! " Unfortunately, Keren et al, in the ir review of all cases of right atrial myxoma in th e literature. ignored our published echocardiographic experience with right atri al myxomas' and another case report from India.' We carne acro ss two pati ents with isolated large right atrial myxomas. One, a 17-ypar-old hoy, presented with tricu sp id regurgitation, cyanosis, and duhhing. Ill' was thought to have cyanot ic congenital heart disease prior to echocardiogruphy The second patient with right atrial myxoma was a 3.'l-ypar-old man who presented with features of tricuspid regurgitation and right heart failur e . Clinical possibilities of Ehstein anomal y and right-sided endomyocardlal fihrosis were con sidered in this case. Eleetrocardiograms showed generalized low-voltage QRS compl exes and evidence of right atrial enlargement in both patients. M-rnod e echocardiographic examinat ion was inconclusive in our cases of right atrial myxoma . Two-dimensional echocardiography showed a large, pedunculated right atrial mass prolapsing into th e right ventricle through the tricu spid valve in diastole . Cyanosis in the first pat ient was due to right-to-left shunting acro ss a patent foram en (wale , which disappeared after surgery. Cyanosi s and clubbing is a ve ry unusual finding in a patie-nt with right atrial myxoma ; in addition to our case, five other cases have be en reviewed by Talley et al ." We did not hear tumor plop in either of our patients. The histopathologic findings after surgical removal confirmed the diagnosis. Both pati ents are asymptomatic and doing well three years postoperatively.
Numb iar CA, Nair SA, Nunda Kumar V Right heart myxoma presenting as chronic right heart failure : a case report. Indi an Heart J 19118; 40: 129-31 Ii Talley RC, Baldwin RJ, Symbas PN , Nutter DO. Right atrial myxoma : unusual presentation with cyanos is and clubbing. Am J Med 1970; 48:256-60 !)
Roundworm Infestation 7i/ the Editor:
We read with interest the article hy Nicholson et OIL' which appeared in th e October 1989 issue of Chesl. As the author mentions, the A.,caris lumhricoides has a tendency to enter small openings and can obstruct an endotracheal tube.' Many surgeons working in countries where Ascaris infestation is common have seen the worms corning out of the nose or mouth of intubated patients during the surgery, as the y were irritated by the anesthetic gilses," Perhaps this was another factor contributing to the obstruction of the endotracheal tube by a roundwonn in the reported patient.
Ani! Grover; M.D ., and Purshottam L Wahi, M.D., EC .C .P., Department of Cardiology, Ih,tgl'lldual" lnstitute of Medical Edu cation and Research , Chandigarh, India REFERENCES
Keren A, Chenzbruna A, Schuger L , Milgarter E , Tzivoni D. The e tiolo/..'y of tumor plop in a patient with huge right atrial rnvxoma . Chest 1989; 95:1147-49 2 Cheng TO. Right atrial myxoma (letter). Chest 1990; 97:1280 3 Keren A, Chenzhnma A. Right atrial myxoma (lett er). Chest 1990; 97:12RO 4 Grover A, Vanna JS, Khattri liN , Sawhney JPS , Anand IS, Sapru Rp, et a\. Two dimensional echocardiograph y in atri al tumors: a PGI experience. Indian Heart J 1987; 39:421-25
FIG URE I. Autops y specimen showing the wide-open esophagus with several roundworms, Two of them are entering the lar ynx and obstructing the airwa y.
CHEST I 100 I 1 I JULY, 1991
2B7
On occasion-particularly in cases of massive infestation-the roundworms can obstruct the normal airways. In our hospital. we saw a two-year-old h..y admitted to the emergency ro.. m with diarrhea, fever, and dehydration produced hy infestation with A lumbricoid.'''' Four hours after admissiou he attempted to vomit and had acute respiratory distress. cyanosis, convulsions, and loss o f cousciousm-ss. Two hours later th. , patient had convulsions again and died . Al autopsy. many worms wen' fouud in the intestine and stomach and severnl mort' in the esophagus: two of them entered the larynx and wen' obstructing the airway OIl thr- ~I ottic level (Fig I). Then' was no other explanation for the death of the patient. At least two similar cas. 's haw Iweu reported in till' medical literature in Mexi«o.·1.1 In h.. th cases there wen' several worms in the trachea and bronchi , Therefore, health workers in areas when' Ascaris infestation is endemic should hear ill miud the p.. ssihility of airway obstruction hy Ihe roundworms, particularly in children. whos .. air passages are very narrow.
David Prrcz-Loria . .\1 .1) .. F.C.C.P., and Roger Sanchez-Elias, M .D . ,
Hospital Gnll'ral O'Horan SSA, Merida , Mexico RqJrinl request«: Dr Pcrcz-loria , Calle 1.3 .\'0. 199-J G . (;i'll'n 's, stcrida, lUClllllu 9iOiO, stcxir» HEFEBE:'oJ( :ES
Nicholson JI~ Kr.. i~.'r K, lIartman B, Isom \\: Laragh JII . Cardiac arrest postop,'ralin'ly in a patu-nt infecu-d with Ascarls, till' ....undworm . Clu-st I!mH: %:H22-23 2 Pawlowski AS. Ascariasis: host-patho~,'n hiolo~y. H.,\· luli 'cl Dis lHH2: 4;1l0fi-1l14 3 Cil-Barhosa \1. Santia~o -Emk,·nlt· A, Quifio'll's-Ortiz \: Ascariasis erratica. Bol ..led 1I0sp Infant \lex 1H1l2: 3H:127-:30 4 Hustamente-Surabi» J, Murtuscolli-Ouintanu A, Curcia-Estradu D . Ascariasis complicada: infornu- .I.. 12 casos .I" autopsia . Cac \It'd Mex I!J7H: 115:5W-26
F' CURE I. Bronch ople u rul fistul u ill I" ft br onch ial stu mp.
\Vith 1111' patient under local ar... sthesia . a f1exihlt, bronchoscope (Olympus Ill", IT20D; Olympus Optical. li,kyo) was used . The site of the bronchopleural fistula was locate-d with the f1pxiblt, bronchoscope. A multichannel cath..ter (Spray Set : lmmuno, Vi..una) was ins e rlt'd into the bronchoscope. Two milliliter» of homogeneous fibrin sealant components (Tisseel [thrombin, 500 units/ml: aprntinin , .1 ,500 units/rnll : lmmuno. Vienna) was injet'l,'d simultaneously through the cannula into tlu- fistula . Additionallv; antihiotie therapy was administered systemicullv iiII' ten days. The ti~htnt·ss of lh., closure was tpsll'd hy endoscopy and bronchography at the end of fcmr weeks (Fi~ 2). Tht' patient has remained well. \Ve believe that fiheroptil' Imll,t'hosmpy and fibrin sealant administration should he the first line of management in patients with a postresection fistula . II is important 10 apply thrombin , SOO units!
Endoscopic Treatment of Bronchus Stump Fistula with Fibrin Sealant following Pneumonectomy 'II, IIII' Editor: \\t' read with inn-n-st thr- n 'c, 'utly publisbr-d arlid..s ah out endoscopic dia~nosis and trealmenl of hronchopl.. ural fistula .' I Bronchus stump fistulas an' major complications of pulmonary resections. TIll' dia~nosis of small postresection hronchopl.. ural fislula can h., accomplishe-d with fiheroptic hronl'l,os."py and selective hrtlnl'llll~raphy. This report describes the munagement and treatme-nt of bronchus stump fistula with fihrin ~Iu.' applied through tlu - f1,'xihle hro nchoscop« iiII' closure under direct vision . A .')()-y,'ar-old mall uud,',,,,,'ul a I..ft p,u'ulIHlnt'clomy fc,r squamOils cell carciuoma. Sixlt','n months aftt'r sllr~ery, f,'n'r. a .'III~h prcKlucli\'" of purul.'ut spllillm , alld an air-fluid lev..J iu till' pleural span' ,1,'Yelop",1. A small fislula alone ..nd of Ih,' slllmp was suspeel.'{1 011 hrollchos,,,py: s"I.'elin' hronl'llO~raphy"lIIfil'llll'd Ih.. pn 'Sl'nc,' of a hrlHu'hopl"lIralfislula iu 1111' I.,ft hronchial StUlllp (Fi~ I) . TIll' pali ..nt iuitially was Irealt'd couSl'rvalively with 1>ClStnral draina~e allli approprialt· autihiotic II... rapy: A hrollchoplenralfish,la persisl..d iiII' Ihree w", 'ks . \'t' decid"d 10 plu~ th .. hrnnchoplenral fislllia from wilhill.
288
FIl:( 'RE 2. Follow-up hrtlnt'ho~rarn re\'eals dosed fistula . Communications 10lhe Editor
Right Atrial Myxoma 11, the Editor: We read with interest the case report of right atrial myxoma hy Keren et OIL' which appeared in the May 1989 issue of Chest, and two subseq ue nt letters to the editor! " Unfortunately, Keren et al, in the ir review of all cases of right atrial myxoma in th e literature. ignored our published echocardiographic experience with right atri al myxomas' and another case report from India.' We carne acro ss two pati ents with isolated large right atrial myxomas. One, a 17-ypar-old hoy, presented with tricu sp id regurgitation, cyanosis, and duhhing. Ill' was thought to have cyanot ic congenital heart disease prior to echocardiogruphy The second patient with right atrial myxoma was a 3.'l-ypar-old man who presented with features of tricuspid regurgitation and right heart failur e . Clinical possibilities of Ehstein anomal y and right-sided endomyocardlal fihrosis were con sidered in this case. Eleetrocardiograms showed generalized low-voltage QRS compl exes and evidence of right atrial enlargement in both patients. M-rnod e echocardiographic examinat ion was inconclusive in our cases of right atrial myxoma . Two-dimensional echocardiography showed a large, pedunculated right atrial mass prolapsing into th e right ventricle through the tricu spid valve in diastole . Cyanosis in the first pat ient was due to right-to-left shunting acro ss a patent foram en (wale , which disappeared after surgery. Cyanosi s and clubbing is a ve ry unusual finding in a patie-nt with right atrial myxoma ; in addition to our case, five other cases have be en reviewed by Talley et al ." We did not hear tumor plop in either of our patients. The histopathologic findings after surgical removal confirmed the diagnosis. Both pati ents are asymptomatic and doing well three years postoperatively.
Numb iar CA, Nair SA, Nunda Kumar V Right heart myxoma presenting as chronic right heart failure : a case report. Indi an Heart J 19118; 40: 129-31 Ii Talley RC, Baldwin RJ, Symbas PN , Nutter DO. Right atrial myxoma : unusual presentation with cyanos is and clubbing. Am J Med 1970; 48:256-60 !)
Roundworm Infestation 7i/ the Editor:
We read with interest the article hy Nicholson et OIL' which appeared in th e October 1989 issue of Chesl. As the author mentions, the A.,caris lumhricoides has a tendency to enter small openings and can obstruct an endotracheal tube.' Many surgeons working in countries where Ascaris infestation is common have seen the worms corning out of the nose or mouth of intubated patients during the surgery, as the y were irritated by the anesthetic gilses," Perhaps this was another factor contributing to the obstruction of the endotracheal tube by a roundwonn in the reported patient.
Ani! Grover; M.D ., and Purshottam L Wahi, M.D., EC .C .P., Department of Cardiology, Ih,tgl'lldual" lnstitute of Medical Edu cation and Research , Chandigarh, India REFERENCES
Keren A, Chenzbruna A, Schuger L , Milgarter E , Tzivoni D. The e tiolo/..'y of tumor plop in a patient with huge right atrial rnvxoma . Chest 1989; 95:1147-49 2 Cheng TO. Right atrial myxoma (letter). Chest 1990; 97:1280 3 Keren A, Chenzhnma A. Right atrial myxoma (lett er). Chest 1990; 97:12RO 4 Grover A, Vanna JS, Khattri liN , Sawhney JPS , Anand IS, Sapru Rp, et a\. Two dimensional echocardiograph y in atri al tumors: a PGI experience. Indian Heart J 1987; 39:421-25
FIG URE I. Autops y specimen showing the wide-open esophagus with several roundworms, Two of them are entering the lar ynx and obstructing the airwa y.
CHEST I 100 I 1 I JULY, 1991
2B7
On occasion-particularly in cases of massive infestation-the roundworms can obstruct the normal airways. In our hospital. we saw a two-year-old h..y admitted to the emergency ro.. m with diarrhea, fever, and dehydration produced hy infestation with A lumbricoid.'''' Four hours after admissiou he attempted to vomit and had acute respiratory distress. cyanosis, convulsions, and loss o f cousciousm-ss. Two hours later th. , patient had convulsions again and died . Al autopsy. many worms wen' fouud in the intestine and stomach and severnl mort' in the esophagus: two of them entered the larynx and wen' obstructing the airway OIl thr- ~I ottic level (Fig I). Then' was no other explanation for the death of the patient. At least two similar cas. 's haw Iweu reported in till' medical literature in Mexi«o.·1.1 In h.. th cases there wen' several worms in the trachea and bronchi , Therefore, health workers in areas when' Ascaris infestation is endemic should hear ill miud the p.. ssihility of airway obstruction hy Ihe roundworms, particularly in children. whos .. air passages are very narrow.
David Prrcz-Loria . .\1 .1) .. F.C.C.P., and Roger Sanchez-Elias, M .D . ,
Hospital Gnll'ral O'Horan SSA, Merida , Mexico RqJrinl request«: Dr Pcrcz-loria , Calle 1.3 .\'0. 199-J G . (;i'll'n 's, stcrida, lUClllllu 9iOiO, stcxir» HEFEBE:'oJ( :ES
Nicholson JI~ Kr.. i~.'r K, lIartman B, Isom \\: Laragh JII . Cardiac arrest postop,'ralin'ly in a patu-nt infecu-d with Ascarls, till' ....undworm . Clu-st I!mH: %:H22-23 2 Pawlowski AS. Ascariasis: host-patho~,'n hiolo~y. H.,\· luli 'cl Dis lHH2: 4;1l0fi-1l14 3 Cil-Barhosa \1. Santia~o -Emk,·nlt· A, Quifio'll's-Ortiz \: Ascariasis erratica. Bol ..led 1I0sp Infant \lex 1H1l2: 3H:127-:30 4 Hustamente-Surabi» J, Murtuscolli-Ouintanu A, Curcia-Estradu D . Ascariasis complicada: infornu- .I.. 12 casos .I" autopsia . Cac \It'd Mex I!J7H: 115:5W-26
F' CURE I. Bronch ople u rul fistul u ill I" ft br onch ial stu mp.
\Vith 1111' patient under local ar... sthesia . a f1exihlt, bronchoscope (Olympus Ill", IT20D; Olympus Optical. li,kyo) was used . The site of the bronchopleural fistula was locate-d with the f1pxiblt, bronchoscope. A multichannel cath..ter (Spray Set : lmmuno, Vi..una) was ins e rlt'd into the bronchoscope. Two milliliter» of homogeneous fibrin sealant components (Tisseel [thrombin, 500 units/ml: aprntinin , .1 ,500 units/rnll : lmmuno. Vienna) was injet'l,'d simultaneously through the cannula into tlu- fistula . Additionallv; antihiotie therapy was administered systemicullv iiII' ten days. The ti~htnt·ss of lh., closure was tpsll'd hy endoscopy and bronchography at the end of fcmr weeks (Fi~ 2). Tht' patient has remained well. \Ve believe that fiheroptil' Imll,t'hosmpy and fibrin sealant administration should he the first line of management in patients with a postresection fistula . II is important 10 apply thrombin , SOO units!
Endoscopic Treatment of Bronchus Stump Fistula with Fibrin Sealant following Pneumonectomy 'II, IIII' Editor: \\t' read with inn-n-st thr- n 'c, 'utly publisbr-d arlid..s ah out endoscopic dia~nosis and trealmenl of hronchopl.. ural fistula .' I Bronchus stump fistulas an' major complications of pulmonary resections. TIll' dia~nosis of small postresection hronchopl.. ural fislula can h., accomplishe-d with fiheroptic hronl'l,os."py and selective hrtlnl'llll~raphy. This report describes the munagement and treatme-nt of bronchus stump fistula with fihrin ~Iu.' applied through tlu - f1,'xihle hro nchoscop« iiII' closure under direct vision . A .')()-y,'ar-old mall uud,',,,,,'ul a I..ft p,u'ulIHlnt'clomy fc,r squamOils cell carciuoma. Sixlt','n months aftt'r sllr~ery, f,'n'r. a .'III~h prcKlucli\'" of purul.'ut spllillm , alld an air-fluid lev..J iu till' pleural span' ,1,'Yelop",1. A small fislula alone ..nd of Ih,' slllmp was suspeel.'{1 011 hrollchos,,,py: s"I.'elin' hronl'llO~raphy"lIIfil'llll'd Ih.. pn 'Sl'nc,' of a hrlHu'hopl"lIralfislula iu 1111' I.,ft hronchial StUlllp (Fi~ I) . TIll' pali ..nt iuitially was Irealt'd couSl'rvalively with 1>ClStnral draina~e allli approprialt· autihiotic II... rapy: A hrollchoplenralfish,la persisl..d iiII' Ihree w", 'ks . \'t' decid"d 10 plu~ th .. hrnnchoplenral fislllia from wilhill.
288
FIl:( 'RE 2. Follow-up hrtlnt'ho~rarn re\'eals dosed fistula . Communications 10lhe Editor