- Email: [email protected]
Value of bronchoalveolar lavage in the differential diagnosis of interstitial lung disease
100
Tubercle and Lung Disease: Supplement
chest x-ray detected pulmonary affections in 27 % , CT in 57% of patients. In group III all patients had pulmonary abnormalities seen on the chest x-ray and the CT scan. CT was superior to chest x-ray in the differentiation between air space and interstitial disease. HRCT did not detect additional foci of disease, but improved classification and localization. In 14 of 29 patients pneumonia was proved by microbiology. Pneumocystis carinii pneumonia (PCP) was the most common type (n = 6) exhibiting symmetrical or patchy mosaic ground glass attenuations. The same appearance was found in another five patients, and they were treated for PCP without microbiological proof. Bacterial (n = 4) and varicella (n = 1) pneumonia, atypical (n = 2) and typical (n = 1) tuberculosis showed nonspecific CT-patterns with focal opacifications, consolidations and reticular interstitial thickening as did suspected pneumonias (n = 10). Concomitant pleural thickening or effusion was commonly appreciated on CT (n = 23) in comparison with the chest x-ray (n = 9). HIV-related lymphona (n = 1) and Kaposi’s sarcoma (n = 1) were suspected from CT and confirmed by biopsy. Mediastinal lymphadenopathy was found in all patients. The nodes measured between l-l.5 cm in 51, more than 1.5 cm in 13 patients. Additional axillary lymphadenopathy (size > 1 cm or n > 4) was found in 45 % of patients. Conclusion: We recommend chest CT in HIV-patients with non-specific symptoms and normal chest x-ray. In patients with respiratory distress chest x-ray alone will show pulmonary infiltrations. If the chest x-ray is abnormal, CT will demonstrate the extent and assess the type of pneumonia or malignant disease. Treatment for PCP can be relied on the CT. HRCT is useful for demonstration of anatomical detail and lesion characterization, but will not increase overall sensitivity.
369 PULMONARY AIDS
KAPOSI’S SARCOMA IN
Fruttaldo, L., Gatti, G., Mongid, F., Schettino, G., Deambrogio, V.; Department of Infectious Disease, Santo Spirit0 Hospital - V. le Giolitti no 2Casale M. To
In subjects affected from AIDS, one of the most common pathology, is the Kaposi’s sarcoma. Generally the sarcoma shows him at skin’s level or a mucosas’ level, occasionally it can have location not very common. In an our patient (27 years old) who has been admitted in our departement because of AIDS, heroin addict (wit a diagnose of pancreatitis, hepatitis and retinitis from citomegalovirus). Has been appeard an worsening of symptomatology with pein on the reight thorax. With a readiography we put evidence a great and round homogenous opacity (3 cm.) at the 3rd midle of the pulmonary field. A next tomography may us see that the lesion has been located on the back tomography plain, and got confused in the context of the chest’s thoracic cage. It was suggest a presence of a pulmonary Kaposi’s sarcoma. The diagnose was confirmed next of the histological exam of the lesion post mortem.
370 RELATIONSHIP BETWEEN LUNG MECHANICS AND BREATHING PATTERN IN PATIENTS WITH INTERSTITIAL LUNG DISEASE (ILD) Koziorowski, A., Radwan, L., Maszczyk, Z.; Dept. of Resp. Pathophysiology, Institute of Tuberculosis and Lung Diseases. WarsawlPI
We examined lung volumes and mechanics, breathing pattern and mouth occlusion pressure in 32 patients with ILD. 12 age matched subjects were in the control group. We found that ILD patients differ significantly from the control group by higher breathing frequency, mean inspiratory flow and mouth occlusion pressure. Tidal volume was smaller and total inspiratory and expiratory times were shorter. TilTtot index did not differ in ILD from the control group. A significant correlation was found between static lung compliance and breathing frequency, tidal volume and mouth occlusion pressure. We conclude that neuromuscular inspiratory output was enhanced in ILD as a function of elastic load of the lung.
371 VALUE OF BRONCHOALVEOLAR LAVAGE IN THE DIFFERENTIAL DIAGNOSIS OF INTERSTITIAL LUNG DISEASE Miiller-Quernheim, _I.,* Zissel, G., * Lorenz, J.; III. Medizinische Universitatsklinik, Abteilung Innere Medizin, Schwerpunkt Pneumologie, Langenbeckstr. I, 55131 Mainz, Germany * Present affiliation: Research Institut Borstel, Medical Hospital, Parkallee 35, 23845 Borstel
Bronchoalveolar lavage (BAL) is frequently used to gauge the inflammatory activity of insterstitial lung diseases (ILD), i. e. sarcoidosis (SAR), idiopathy pulmonary fibrosis (IPF) and hypersensitivity pneumonitis (HSP). In case of non-diagnostic or contraindicated transbronchial biopsy additional diagnostic approaches are desired. Elevated numbers sof BAL lymphocytes (ly) with an heightened CD4/CD8 ratio are characteristic for SAR. To evaluate this pattern as a diagnostic criterion we retrospectively analysed 222 BALs, performed in the course of diagnosing suspected ILD, in comparison to 18 controls ([CON] 7 healthy individuals and 11 patients retrospectively free of ILD). CON exhibited 5.9 + 5.1% BAL-ly (mean + standard deviation, range: 2-21%) with a CD4/ CD8 ratio of 1.6 t 0.5 (range: 1.1-3.3) which differ significantly from SAR (BAL-ly: 16.1 i 11.8%; range l-62%; CD4/CD8 ratio: 3.7 1- 3.2; range: 0.4-18; n = 132). However, 13 non-SAR patients presented with a CD4/CD8 ratio > 5.0 (5 IPF, 2 tuberculosis, 2 lymphangitic type of metastasis, 1 histiocytosis X, 1 M. Wegener, 1 HSP, 1 pulmonary lupus erythematosus) and 11 with a CDWCD8 ratio > 4.0 and < 5.0 (4 IPF, 2 metastasis, 1 M. Wegener, 1 dirty chest, 1 HSP, 1 tuberculosis and 1 undefined alveolitis). A CD4/CD8 ratio > 4.0 in combination with elevated BAL-ly (> 40%) was seen in 4 nonSAR patients (2 IPF, 1 HSP and 1 tuberculosis). 17032 SAR patients displayed a CD4/CD8 ratio > 5.0 and 91132 patients a ratio > 4.0 and < 5.0. Only 3/132 SAR patients exhibited a CD4/CD8 ratio > 4.0 in combination with elevated BAL-ly (> 40%). If a CD4/CD8 ratio of > 4.0 would have been accepted for this cohort a high percentage of false positive results would have been obtained including patients with contraindications for corticosteroids. On the basis of the presented data we discourage the use of BAL for the diagnosis of sarcoidosis.
Tubercle and Lung Disease: Supplement
chest x-ray detected pulmonary affections in 27 % , CT in 57% of patients. In group III all patients had pulmonary abnormalities seen on the chest x-ray and the CT scan. CT was superior to chest x-ray in the differentiation between air space and interstitial disease. HRCT did not detect additional foci of disease, but improved classification and localization. In 14 of 29 patients pneumonia was proved by microbiology. Pneumocystis carinii pneumonia (PCP) was the most common type (n = 6) exhibiting symmetrical or patchy mosaic ground glass attenuations. The same appearance was found in another five patients, and they were treated for PCP without microbiological proof. Bacterial (n = 4) and varicella (n = 1) pneumonia, atypical (n = 2) and typical (n = 1) tuberculosis showed nonspecific CT-patterns with focal opacifications, consolidations and reticular interstitial thickening as did suspected pneumonias (n = 10). Concomitant pleural thickening or effusion was commonly appreciated on CT (n = 23) in comparison with the chest x-ray (n = 9). HIV-related lymphona (n = 1) and Kaposi’s sarcoma (n = 1) were suspected from CT and confirmed by biopsy. Mediastinal lymphadenopathy was found in all patients. The nodes measured between l-l.5 cm in 51, more than 1.5 cm in 13 patients. Additional axillary lymphadenopathy (size > 1 cm or n > 4) was found in 45 % of patients. Conclusion: We recommend chest CT in HIV-patients with non-specific symptoms and normal chest x-ray. In patients with respiratory distress chest x-ray alone will show pulmonary infiltrations. If the chest x-ray is abnormal, CT will demonstrate the extent and assess the type of pneumonia or malignant disease. Treatment for PCP can be relied on the CT. HRCT is useful for demonstration of anatomical detail and lesion characterization, but will not increase overall sensitivity.
369 PULMONARY AIDS
KAPOSI’S SARCOMA IN
Fruttaldo, L., Gatti, G., Mongid, F., Schettino, G., Deambrogio, V.; Department of Infectious Disease, Santo Spirit0 Hospital - V. le Giolitti no 2Casale M. To
In subjects affected from AIDS, one of the most common pathology, is the Kaposi’s sarcoma. Generally the sarcoma shows him at skin’s level or a mucosas’ level, occasionally it can have location not very common. In an our patient (27 years old) who has been admitted in our departement because of AIDS, heroin addict (wit a diagnose of pancreatitis, hepatitis and retinitis from citomegalovirus). Has been appeard an worsening of symptomatology with pein on the reight thorax. With a readiography we put evidence a great and round homogenous opacity (3 cm.) at the 3rd midle of the pulmonary field. A next tomography may us see that the lesion has been located on the back tomography plain, and got confused in the context of the chest’s thoracic cage. It was suggest a presence of a pulmonary Kaposi’s sarcoma. The diagnose was confirmed next of the histological exam of the lesion post mortem.
370 RELATIONSHIP BETWEEN LUNG MECHANICS AND BREATHING PATTERN IN PATIENTS WITH INTERSTITIAL LUNG DISEASE (ILD) Koziorowski, A., Radwan, L., Maszczyk, Z.; Dept. of Resp. Pathophysiology, Institute of Tuberculosis and Lung Diseases. WarsawlPI
We examined lung volumes and mechanics, breathing pattern and mouth occlusion pressure in 32 patients with ILD. 12 age matched subjects were in the control group. We found that ILD patients differ significantly from the control group by higher breathing frequency, mean inspiratory flow and mouth occlusion pressure. Tidal volume was smaller and total inspiratory and expiratory times were shorter. TilTtot index did not differ in ILD from the control group. A significant correlation was found between static lung compliance and breathing frequency, tidal volume and mouth occlusion pressure. We conclude that neuromuscular inspiratory output was enhanced in ILD as a function of elastic load of the lung.
371 VALUE OF BRONCHOALVEOLAR LAVAGE IN THE DIFFERENTIAL DIAGNOSIS OF INTERSTITIAL LUNG DISEASE Miiller-Quernheim, _I.,* Zissel, G., * Lorenz, J.; III. Medizinische Universitatsklinik, Abteilung Innere Medizin, Schwerpunkt Pneumologie, Langenbeckstr. I, 55131 Mainz, Germany * Present affiliation: Research Institut Borstel, Medical Hospital, Parkallee 35, 23845 Borstel
Bronchoalveolar lavage (BAL) is frequently used to gauge the inflammatory activity of insterstitial lung diseases (ILD), i. e. sarcoidosis (SAR), idiopathy pulmonary fibrosis (IPF) and hypersensitivity pneumonitis (HSP). In case of non-diagnostic or contraindicated transbronchial biopsy additional diagnostic approaches are desired. Elevated numbers sof BAL lymphocytes (ly) with an heightened CD4/CD8 ratio are characteristic for SAR. To evaluate this pattern as a diagnostic criterion we retrospectively analysed 222 BALs, performed in the course of diagnosing suspected ILD, in comparison to 18 controls ([CON] 7 healthy individuals and 11 patients retrospectively free of ILD). CON exhibited 5.9 + 5.1% BAL-ly (mean + standard deviation, range: 2-21%) with a CD4/ CD8 ratio of 1.6 t 0.5 (range: 1.1-3.3) which differ significantly from SAR (BAL-ly: 16.1 i 11.8%; range l-62%; CD4/CD8 ratio: 3.7 1- 3.2; range: 0.4-18; n = 132). However, 13 non-SAR patients presented with a CD4/CD8 ratio > 5.0 (5 IPF, 2 tuberculosis, 2 lymphangitic type of metastasis, 1 histiocytosis X, 1 M. Wegener, 1 HSP, 1 pulmonary lupus erythematosus) and 11 with a CDWCD8 ratio > 4.0 and < 5.0 (4 IPF, 2 metastasis, 1 M. Wegener, 1 dirty chest, 1 HSP, 1 tuberculosis and 1 undefined alveolitis). A CD4/CD8 ratio > 4.0 in combination with elevated BAL-ly (> 40%) was seen in 4 nonSAR patients (2 IPF, 1 HSP and 1 tuberculosis). 17032 SAR patients displayed a CD4/CD8 ratio > 5.0 and 91132 patients a ratio > 4.0 and < 5.0. Only 3/132 SAR patients exhibited a CD4/CD8 ratio > 4.0 in combination with elevated BAL-ly (> 40%). If a CD4/CD8 ratio of > 4.0 would have been accepted for this cohort a high percentage of false positive results would have been obtained including patients with contraindications for corticosteroids. On the basis of the presented data we discourage the use of BAL for the diagnosis of sarcoidosis.