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Accidental Ingestion of a Tracheal Stent
x-ray film appearance is that of alveolar hemorrhage, with alveolar infiltrates appearing like "snowflakes" and occurring in 45 to 60% of patients. Radiologic manifestations are most common in lower lobes and the peripheral lung fields. Bilateral interstitial infiltrates with small pleural effusions are less common. 6•7 The resolution of infiltrates on the chest xray film occurs faster than in other forms of bacterial pneumonia. Complete resolution evidenced on x-ray film usually occurs between the 6th and lOth days of illness. REFEHENCES
1 O'Neil KM , Rickman LS, La7..arus AA. Pulmonary manifestations of leptospirosis. H.ev Infect D is 1991; 13:705-09 2 Heath CW Jr, Alexander AD , Galton MM . Leptospirosis in the United States: an analysis of 483 cases in man, 1949-61. Engl J Med 1965; 273:857-64 3 Edwards G, Domm BM . Human leptospirosis. Medicine (Baltimore) 1960; 39:117-56 4 DeBrito T, Bohm GM, Yasuda PH. Vascular damage in acute experimental leptospirosis of the guinea-pig. JPathol 1979; 128: 177-82 5 Burke BJ, Searle JF, Mattingly D. Leptospirosis presenting with profuse hemoptysis. BMJ 1976; 2:982 6 Im JM, Yeon KM , Han MC, et al. Leptospirosis of the lung: radiographic findings in 58 patients. Am J H.oentgenol 1989;152: 955-59 7 De Brito T, Morais CF, Yasuda PH, et al. Cardiovascular involvement in human and experimental leptospirosis: pathologic findings and immunohistochemical detection of leptospiral antigen. Ann Trop Med Parasitol 1987; 81:207-14
Accidental Ingestion of a Tracheal Stent* Lalaine E. Mattison, MD; Michael D. Frye, MD, FCCP; and Nancy A Gallop, MD, FCCP
A 53-year-old man with tracheobronchomalacia had two ste nts place d in his airways to maintain patency. He ingeste d one of the trache al stents that was inadvertently dislodged during a brie f coughing episode. The swallowed stent was re covere d without complications.
Key words: silicone stent; stent; tracheobronchomalacia
stents provide aprimary or adjunctive role in I ntraluminal the therapy of airway obstruction due to neoplastic
encroachment, extrinsic airway compression, fibrotic stenosis, and tracheal or bronchial malacia. In adults, most cases of tracheobronchomalacia involve COPD and previous intubation, although dynamic airway collapse also has been *From the Pulmonary and Critical Care Division, Medical University of South Carolina, Charleston . Reprint requests: Dr. Mattison, CSB 812 (Pulmonary Division), Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29412
FlGUHE l. Abdominal radiograph showing the tracheal stent in the lumen of the ascending colon (arrow).
noted in lung transplant, posttrauma, and relapsing polychondritis patients. A potentially serious complication of silicone stents is displacement. We describe acase in which stent displacement resulted in an unusual complication. CASE R EPO RT
l upper lobe lobectomy 33 years A 53-year-old man had a eft earlie r for a benign tumor. Several years afterward, he developed hemoptysis and underwent rigid bronchoscopy which was compliarrest requiring a tracheostomy for several r cated by espiratory months. Since th at time, he had slowly progressive dyspnea and recurrent pneumonia. At presentation, his spirometry test results revealed severe obstmction, and the flow-volume loop showed a tmncated ell.piratory limb consistent with a variable intrathoracic obstmction . Fiberoptic bronchoscopy showed airway collapse of the trachea and left mainstem bronchus on expiration . lie underwent stent placemen t at naother institution: a 50x18-mm silicone stent in the trachea and a35x 14-mm stent in the left main stem bronchus. One week later, he returned to ou r institution complaining of fever, chills, productive cough, and dyspnea. Arterial blood gas value determination revealed the following: pH, 7.50; PaC02, 24 mm Hg, Pa0 2, 121 mm llg. At the time of admission, a chest radiograph showed the stents to be in good position in the trachea and the el ft mainstem bronchus. On the evening of admission, the patient had a paroxysm of coughing and became cyanotic. DUling the eoughing spell, the tracheal stent was dislodged, and the patient swallowed it. Esophageal gastroduodenoscopy was performed the next morning, but the stent could not be ol cated. The patient was maintained on a peanut butter and high fiber diet. Serial abdominal films were taken (Fig 1), and the stent was passed 72 h after ingestion. The patient's left main stem silicone stent remained in place. The patient was discharged and has declined furth er intervention at this time. CHEST /108/3/ SEPTEMBER, 1995
875
Drscussro!\ Patients with tracheobronchomalacia usually present 'Nith cough, stridor, or dyspnea. The long-standing airway obstruction may result in air trapping, hypercarbia, defective mucus expectoration, recurrent infections, and bronchiectasis. Management is a challenging problem, since the obstruction is not amenable to laser or radiation therapy. Resection of the malacic portion or external rib stenting, if feasible, involves the risk of thoracotomy. 1 The use of an endoprosthesis provides a nonsurgical alternative.2·3 The ideal stent should (1) be easy to install, ( 2) beeasily retrievable by bronchoscopy, (3) be difficult to dislodge during maneuvers that increase airway pressures, (4) allow unimpeded mucus clearance, and (5) incite little or no mucosal irritation. When silicone T-tube stents were modified to a straight tube, the design allowed easier endoscopic insertion, less incidence of secretion plugging, and the added benefit of being more esthetically acceptable to patients since astoma was no longer needed. However, with removal of the horizontal limb from the T-tube design, stent displacement has increasingly been r eported. In 1990, Dumon 4 described a silicone stent with regularly spaced external studs to minimize stent dislodgment. Further external fixation of silicone stents has been described by Colt et al. 5 Risks factors for stent migration include using a stent too loose for the airway or stenting a short (:::::2.5 em) segment \vith smooth mucosa. 4 •6 Cough is the most common symptom of stent migration. At the first sign of stent migration, rapid bro.nchoscopic removal should be done to avoid any further unfavorable outcome. A 1993 study noted a 10% incidence of Dumon stent migration among patients with advanced lung cancer 6 While stent dislodgment may be the most common cause for replacement, other repmt ed complications include lumen o cclusion by granulation tissue or inspissated mucus, reflex otalgia, vocal cord injury, and the potential for igniting the silicone material in laser therapy. Migration of silicone stents remains a problem. When ~slodged from the airway, asilicone stent can potentially be mgested or cause asphyxiation if it remains trapped in the hypopharynx. As this case shows an ingested stent can be conservatively managed if endoscopic attempts at removal are unsuccessful.
R EFERENCES
1 Johnston MR, Loeber N, Hillver P, et al. Extemal stent for repair of secondary tracheomal;cia. Ann Thorac Surg 1980; 30: 291-96 2 Cooper JD, Pearson FG, Patterson GA, eta!. Use of silicone stents i~ the management of airway problems. Ann Thorac Surg 1989; 41 :371-78 .'3 \'l air EA, Parsons DS, Lally KP, et al. Compmison of expandable endotracheal stents in the treatment of surgically induced piglet tracheomalacia. Lal)'llgoscope 1991; 101:1002-08 4 Dumon JF. A dedicated tracheobronchial stent. Chest 1990; 97: 328-32 .5 Colt HC, Harrell J, Neuman TR, e t a!. External fixation of subglottic tracheal stents. Chest 1994; 105:1653-57 6 Bolliger CT, Probst R, Tschopp K, et al. Silicone stents in the management of inoperable tracheobronchial stenoses: indications and limitations. Chest 1993; 104:1653-59
876
Herpes Simplex Viral Pneumonia in the Postthoracotomy Patient* Brian Camazine, MD; Joseph G. Antkowiak, MD, FCCP; Maria Enriqueta R. Nava, MD; Brian]. Lipman, MD; and Hiroshi Takita, MD Ov~r a 6-month period, 6 of 54 postthoracotomy patients developed pneumonia and respiratory failure. Pneumonia was secondary to herpes simplex virus type I in 3 of the 6 patients. Diagnostic efforts including bronchoscopy with bronchial washing, viral cultures, and cytologic examination pennitted early diagnosis and successful treatment with acyclovir. A high index of suspicion for herpes simplex pneumonia must be maintained in critically ill patients with undiagnosed pneumonia.
BW=hronchial washing; HSV=herpes simplex virus; POD=postoperative day
Key words: herpes simplex; pneumonia; postthoracotomy erpes simplex virus (HSV) is a ubiquitous pathogen in humans and infects a wide varietyof tissues including the upper respiratory tract, esophagus, genitalia, and visceral organs. 1•2 Before the last decade, however, HSV infection of the lower respiratory tract was thought to occur rarely and was generally diagnosed in immunosuppressed patients at the time of autopsy. 3-5 More recently, Tuxen et al6 have shown HSV type 1 in the lower respiratory tract of 30% of patients with ARDS . This was the first large series of patients in whom HSV involvement of the lower respiratory tract was recognized during life. In this study, the presence of the virus was associated with significantly increased morbidity and mortality. This report describes three patients who developed HSV type 1 pneumonia after thoracotomy. Each patient had a significant risk factor for immunosuppression including a recent history of chemotherapy, malnutrition, concurrent viral infection, or severe postoperative complications, or all of the aforementioned. All three patients were diagnosed during the acute stage of the viral pneumonia and were successfully treated with acyclovir. H
METHODS
For the 6-month period of January through June 1992, 54 patients underwent 60 thoracotomies. Procedures included wedge resection (16), lobectomy (11 ), pneumonectomy (10), lobectomy ·with en bloc chest wall resection (5), exploration and biopsy (5), ·*From the Department ofThoracic Surgery and Oncology, Division ofSurg1cal Oncology (Drs. Camazine, Antkowiak, and Takita), and the Departments of Pathology (Dr. Nava) and Medicine (Dr. Lipman), New York State Department o f Health Roswell Park Cancer Institute, Buffalo, NY. ' Reprint requests: Dr. Takita, Department of Thoracic Surge1'lj and Oncology, Roswell Park Cancer Institute, I!lm and Carlton Streets, Buffalo, New York 14263 Selected Reports
1 O'Neil KM , Rickman LS, La7..arus AA. Pulmonary manifestations of leptospirosis. H.ev Infect D is 1991; 13:705-09 2 Heath CW Jr, Alexander AD , Galton MM . Leptospirosis in the United States: an analysis of 483 cases in man, 1949-61. Engl J Med 1965; 273:857-64 3 Edwards G, Domm BM . Human leptospirosis. Medicine (Baltimore) 1960; 39:117-56 4 DeBrito T, Bohm GM, Yasuda PH. Vascular damage in acute experimental leptospirosis of the guinea-pig. JPathol 1979; 128: 177-82 5 Burke BJ, Searle JF, Mattingly D. Leptospirosis presenting with profuse hemoptysis. BMJ 1976; 2:982 6 Im JM, Yeon KM , Han MC, et al. Leptospirosis of the lung: radiographic findings in 58 patients. Am J H.oentgenol 1989;152: 955-59 7 De Brito T, Morais CF, Yasuda PH, et al. Cardiovascular involvement in human and experimental leptospirosis: pathologic findings and immunohistochemical detection of leptospiral antigen. Ann Trop Med Parasitol 1987; 81:207-14
Accidental Ingestion of a Tracheal Stent* Lalaine E. Mattison, MD; Michael D. Frye, MD, FCCP; and Nancy A Gallop, MD, FCCP
A 53-year-old man with tracheobronchomalacia had two ste nts place d in his airways to maintain patency. He ingeste d one of the trache al stents that was inadvertently dislodged during a brie f coughing episode. The swallowed stent was re covere d without complications.
Key words: silicone stent; stent; tracheobronchomalacia
stents provide aprimary or adjunctive role in I ntraluminal the therapy of airway obstruction due to neoplastic
encroachment, extrinsic airway compression, fibrotic stenosis, and tracheal or bronchial malacia. In adults, most cases of tracheobronchomalacia involve COPD and previous intubation, although dynamic airway collapse also has been *From the Pulmonary and Critical Care Division, Medical University of South Carolina, Charleston . Reprint requests: Dr. Mattison, CSB 812 (Pulmonary Division), Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29412
FlGUHE l. Abdominal radiograph showing the tracheal stent in the lumen of the ascending colon (arrow).
noted in lung transplant, posttrauma, and relapsing polychondritis patients. A potentially serious complication of silicone stents is displacement. We describe acase in which stent displacement resulted in an unusual complication. CASE R EPO RT
l upper lobe lobectomy 33 years A 53-year-old man had a eft earlie r for a benign tumor. Several years afterward, he developed hemoptysis and underwent rigid bronchoscopy which was compliarrest requiring a tracheostomy for several r cated by espiratory months. Since th at time, he had slowly progressive dyspnea and recurrent pneumonia. At presentation, his spirometry test results revealed severe obstmction, and the flow-volume loop showed a tmncated ell.piratory limb consistent with a variable intrathoracic obstmction . Fiberoptic bronchoscopy showed airway collapse of the trachea and left mainstem bronchus on expiration . lie underwent stent placemen t at naother institution: a 50x18-mm silicone stent in the trachea and a35x 14-mm stent in the left main stem bronchus. One week later, he returned to ou r institution complaining of fever, chills, productive cough, and dyspnea. Arterial blood gas value determination revealed the following: pH, 7.50; PaC02, 24 mm Hg, Pa0 2, 121 mm llg. At the time of admission, a chest radiograph showed the stents to be in good position in the trachea and the el ft mainstem bronchus. On the evening of admission, the patient had a paroxysm of coughing and became cyanotic. DUling the eoughing spell, the tracheal stent was dislodged, and the patient swallowed it. Esophageal gastroduodenoscopy was performed the next morning, but the stent could not be ol cated. The patient was maintained on a peanut butter and high fiber diet. Serial abdominal films were taken (Fig 1), and the stent was passed 72 h after ingestion. The patient's left main stem silicone stent remained in place. The patient was discharged and has declined furth er intervention at this time. CHEST /108/3/ SEPTEMBER, 1995
875
Drscussro!\ Patients with tracheobronchomalacia usually present 'Nith cough, stridor, or dyspnea. The long-standing airway obstruction may result in air trapping, hypercarbia, defective mucus expectoration, recurrent infections, and bronchiectasis. Management is a challenging problem, since the obstruction is not amenable to laser or radiation therapy. Resection of the malacic portion or external rib stenting, if feasible, involves the risk of thoracotomy. 1 The use of an endoprosthesis provides a nonsurgical alternative.2·3 The ideal stent should (1) be easy to install, ( 2) beeasily retrievable by bronchoscopy, (3) be difficult to dislodge during maneuvers that increase airway pressures, (4) allow unimpeded mucus clearance, and (5) incite little or no mucosal irritation. When silicone T-tube stents were modified to a straight tube, the design allowed easier endoscopic insertion, less incidence of secretion plugging, and the added benefit of being more esthetically acceptable to patients since astoma was no longer needed. However, with removal of the horizontal limb from the T-tube design, stent displacement has increasingly been r eported. In 1990, Dumon 4 described a silicone stent with regularly spaced external studs to minimize stent dislodgment. Further external fixation of silicone stents has been described by Colt et al. 5 Risks factors for stent migration include using a stent too loose for the airway or stenting a short (:::::2.5 em) segment \vith smooth mucosa. 4 •6 Cough is the most common symptom of stent migration. At the first sign of stent migration, rapid bro.nchoscopic removal should be done to avoid any further unfavorable outcome. A 1993 study noted a 10% incidence of Dumon stent migration among patients with advanced lung cancer 6 While stent dislodgment may be the most common cause for replacement, other repmt ed complications include lumen o cclusion by granulation tissue or inspissated mucus, reflex otalgia, vocal cord injury, and the potential for igniting the silicone material in laser therapy. Migration of silicone stents remains a problem. When ~slodged from the airway, asilicone stent can potentially be mgested or cause asphyxiation if it remains trapped in the hypopharynx. As this case shows an ingested stent can be conservatively managed if endoscopic attempts at removal are unsuccessful.
R EFERENCES
1 Johnston MR, Loeber N, Hillver P, et al. Extemal stent for repair of secondary tracheomal;cia. Ann Thorac Surg 1980; 30: 291-96 2 Cooper JD, Pearson FG, Patterson GA, eta!. Use of silicone stents i~ the management of airway problems. Ann Thorac Surg 1989; 41 :371-78 .'3 \'l air EA, Parsons DS, Lally KP, et al. Compmison of expandable endotracheal stents in the treatment of surgically induced piglet tracheomalacia. Lal)'llgoscope 1991; 101:1002-08 4 Dumon JF. A dedicated tracheobronchial stent. Chest 1990; 97: 328-32 .5 Colt HC, Harrell J, Neuman TR, e t a!. External fixation of subglottic tracheal stents. Chest 1994; 105:1653-57 6 Bolliger CT, Probst R, Tschopp K, et al. Silicone stents in the management of inoperable tracheobronchial stenoses: indications and limitations. Chest 1993; 104:1653-59
876
Herpes Simplex Viral Pneumonia in the Postthoracotomy Patient* Brian Camazine, MD; Joseph G. Antkowiak, MD, FCCP; Maria Enriqueta R. Nava, MD; Brian]. Lipman, MD; and Hiroshi Takita, MD Ov~r a 6-month period, 6 of 54 postthoracotomy patients developed pneumonia and respiratory failure. Pneumonia was secondary to herpes simplex virus type I in 3 of the 6 patients. Diagnostic efforts including bronchoscopy with bronchial washing, viral cultures, and cytologic examination pennitted early diagnosis and successful treatment with acyclovir. A high index of suspicion for herpes simplex pneumonia must be maintained in critically ill patients with undiagnosed pneumonia.
BW=hronchial washing; HSV=herpes simplex virus; POD=postoperative day
Key words: herpes simplex; pneumonia; postthoracotomy erpes simplex virus (HSV) is a ubiquitous pathogen in humans and infects a wide varietyof tissues including the upper respiratory tract, esophagus, genitalia, and visceral organs. 1•2 Before the last decade, however, HSV infection of the lower respiratory tract was thought to occur rarely and was generally diagnosed in immunosuppressed patients at the time of autopsy. 3-5 More recently, Tuxen et al6 have shown HSV type 1 in the lower respiratory tract of 30% of patients with ARDS . This was the first large series of patients in whom HSV involvement of the lower respiratory tract was recognized during life. In this study, the presence of the virus was associated with significantly increased morbidity and mortality. This report describes three patients who developed HSV type 1 pneumonia after thoracotomy. Each patient had a significant risk factor for immunosuppression including a recent history of chemotherapy, malnutrition, concurrent viral infection, or severe postoperative complications, or all of the aforementioned. All three patients were diagnosed during the acute stage of the viral pneumonia and were successfully treated with acyclovir. H
METHODS
For the 6-month period of January through June 1992, 54 patients underwent 60 thoracotomies. Procedures included wedge resection (16), lobectomy (11 ), pneumonectomy (10), lobectomy ·with en bloc chest wall resection (5), exploration and biopsy (5), ·*From the Department ofThoracic Surgery and Oncology, Division ofSurg1cal Oncology (Drs. Camazine, Antkowiak, and Takita), and the Departments of Pathology (Dr. Nava) and Medicine (Dr. Lipman), New York State Department o f Health Roswell Park Cancer Institute, Buffalo, NY. ' Reprint requests: Dr. Takita, Department of Thoracic Surge1'lj and Oncology, Roswell Park Cancer Institute, I!lm and Carlton Streets, Buffalo, New York 14263 Selected Reports