Background . Pulmonary aspergillomas develop in patients with underlying structural lung diseases. The mainstay of therapy is surgery. Objectives . To assess treatment and clinical outcomes following diagnosis of potentially resectable pulmonary aspergilloma at the Tygerberg Hospital (TBH) between January 2013 and December 2015. Methods . This was a retrospective analysis conducted at TBH. Patients were followed up between 6 and 29 months following diagnosis to analyse outcomes. Results . Fifty-nine patients presented for surgery. The mean (SD) age was 44.5 (8.8) years. Thirty-six (61.0%) were male and 13 (22.0%) were HIV-positive. A previous history of pulmonary TB was identified in 83.1% of the patients. One or both upper lobes were involved in 58 patients (98.3%) and haemoptysis was the most frequent symptom, occurring in 56 patients (94.9%). Nine patients (15.3%) were considered unfit for surgery. As of June 2016, 23 (46.0%) of the remaining 50 patients had undergone surgery and 3 (6.0%) had died before surgery was performed. The median time from multidisciplinary discussion to surgery was 190 days (interquartile range 134 - 351). Twenty patients (87.0%) underwent lobectomy and 3 (13.0%) had pneumonectomy. There was no postoperative mortality. One patient developed bleeding, persistent air leak and aspiration pneumonia postoperatively. Three patients were hospitalised for >7 days postoperatively. Following surgery, only two patients reported ongoing respiratory symptoms by day 90. Conclusion . Less than half of the patients accepted for lung resection at TBH underwent surgery. Waiting times were long (>1 year in 25%) and were associated with mortality. Barriers to prompt surgery are complex, but should be addressed urgently.
INTRODUCTION:Recurrent tuberculosis (TB) occurring >2 years after completing treatment for a prior TB episode is most often due to reinfection with a new strain of M. tuberculosis.OBJECTIVES:We determined the prevalence and outcome of late recurrent TB among hospitalized patients in Kampala, Uganda.METHODS:We conducted a retrospective analysis of patients admitted to Mulago Hospital who had cough of >2 weeks' duration and completed TB treatment >2 years prior to admission. All patients had mycobacterial culture performed on two sputum specimens and vital status ascertained 2-months post-enrollment. We performed modeling to identify predictors of recurrent TB and of survival.RESULTS:Among 234 patients, 84 (36%) had recurrent TB. Independent predictors included younger age (aOR=0.64, 95% CI=0.42-0.97, p=0.04), chest pain >2 weeks (aOR=3.32, 95% CI=1.38-8.02, p=0.007), severe weight loss ≥5 kilograms (aOR=4.88, 95% CI=1.66-14.29, p=0.004) and presence of ≥1 WHO danger sign of severe illness (aOR=3.55, 95% CI=1.36-9.29, p=0.01). Two-month mortality was 17.8% (95% CI=10.5-29.2%), and was higher among patients not initiated on TB treatment (aHR=16.67, 95% CI=1.18-200, p=0.04), not on ART if HIV-positive (aHR=16.99, 95% CI=1.17-246.47, p=0.04) and with a history of smoking (aHR=1.20, 95% CI=1.03-1.40, p=0.02).CONCLUSION:The high prevalence of late recurrent TB likely reflects high levels of TB transmission in Kampala. Increased use of empiric TB treatment and early ART treatment initiation if HIV-positive should be considered in patients with a prior history of TB, particularly if young, with weight loss ≥5kgs, chest pain >2 weeks or ≥1 WHO danger sign of severe illness.
Vitamin D has traditionally been known for its role in bone homeostasis with its effects on calcium and phosphate absorption and secretion. However, new evidence is emerging of its effects on a number of other cells, especially the immune system. This article reviews the role of vitamin D as it pertains to the respiratory tract and respiratory diseases.
Objective . To evaluate the use of inhaler therapy, primarily focusing on the source of the initial inhaler training and the effects of regular monitoring of inhaler use. Methods . We conducted a prospective study of 200 adult patients using either a metered dose inhaler (MDI) or dry powder inhaler (DPI), attending a private pulmonology practice for the treatment of asthma, chronic obstructive pulmonary disease (COPD) or asthma-COPD overlap. Each patient was evaluated once, and assessed by the investigators irrespective of the patient’s background and inhaler technique training. Results. The MDI and DPI techniques were found to be 45% and 79% adequate, respectively ( p <0.001). Patients who had initial training in a specialist or pulmonology practice showed 100% adequacy. In stark contrast, inadequate technique was observed where initial MDI training was performed by family members, general practitioners, hospital staff, pharmacy staff and self ( p <0.05). Similarly, inadequate technique was seen in the DPI group when taught by family members, general practitioners, hospital staff and pharmacy staff ( p <0.001). The Accuhaler was used by 59% of the patients using a DPI; 41% used the Turbuhaler. The percentage of inadequate inhaler technique in the Accuhaler was 28%, while the percentage of inadequate inhaler use in the urbuhaler group was lower at 10% ( p <0.001). Conclusion . In an urban private practice environment, the adequacy of inhaler technique was shown to be suboptimal. DPI technique was found to be superior to MDI technique, and the Turbuhaler was employed more adequately than the Accuhaler. There was no correlation between the duration of inhaler use and technique, but patients initially taught by non-pulmonology specialists and pulmonologists showed superior technique to that of other groups, i.e. patients taught by family members, general practitioners and hospital staff.
The interaction between vitamin D and clinical course in asthma pathogenesis is an active area of research presently. A previous systematic review on maternal vitamin D and childhood asthma, wheeze and eczema showed no correlation between low maternal vitamin D levels and childhood wheeze and asthma.[1] A new systematic review and meta-analysis of observational studies was performed to evaluate the prevalence of vitamin D deficiency in asthmatic children.[2] A total of 23 studies (with 13 160 participants) were analysed. The association with asthma incidence, asthma control, and lung function was determined. The mean vitamin D levels were lower in asthmatics v. non-asthmatics; however, there was a poor correlation between vitamin D levels and incidence of asthma, with one study showing an inverse association at 4 years, and no association with asthma severity at 8 years. There was also a poor correlation with lung function tests between low levels of vitamin D and asthma control. There is a need for further well-randomised, controlled trials in children before we decide whether asthmatic children can benefit from vitamin D supplementation, or not.
In this issue of SARJ, Narsingh et al. [1] highlight the alarming and burgeoning problem of multidrug-resistant tuberculosis (MDR-TB).[2] More recently, this has been supplanted by an increasing burden of extensively drug-resistant TB (XDR-TB),[3] and resistance beyond XDR-TB.[3] The problem of programmatically incurable TB and its spread, in our communities, from home-discharged index cases has recently been highlighted.
Lymphangiomatosis is a rare disorder and the underlying aetiology is poorly understood. The diagnosis is difficult, and relies on various clinical, radiological and histological features. Therapy is diverse, with combinations of treatment required to achieve disease control. The prognosis is guarded, and currently a vast amount of work is being undertaken to understand the disease, and to find focused therapy. We present a case of histologically, and radiologically proven lymphangiomatosis in a 4-year-old child who presented with nonspecific symptoms.
Interstitial lung disease (ILD) is one of the major extramuscular manifestations of polymyositis (PM) and dermatomyositis (DM). Presentation of PM and DM with ILD is not uncommon, but its clinical and radiological features can be similar to other conditions and can be challenging to diagnose. The presence of anti-aminoacyl tRNA synthetase antibodies in the presence of ILD is diagnostic of antisynthetase syndrome. A delayed diagnosis can be associated with the progression of pulmonary involvement and potentially increased morbidity. Timely diagnosis leads to appropriable lifesaving treatment. We report on a patient with chronic respiratory symptoms who had positive anti-Jo-1 antibodies and presented in respiratory failure, requiring non-invasive ventilation.
Background . Early effective management of drug-resistant tuberculosis (TB) is important for the patient, and for infection control. The Xpert MTB/RIF (Cepheid, USA) assay detects Mycobacterium tuberculosis DNA and the presence of rifampicin resistance. Objective . To assess the prevalence and initial management of rifampicin-resistant pulmonary TB (PTB), confirmed by the Xpert MTB/RIF assay, in hospitalised adult patients. Methods. This retrospective descriptive study assessed adult patients from March 2011 to February 2013. Data was obtained from the National Health Laboratory Service database and patient records. Management comprised the submission of additional confirmatory sputum tests, initiation of appropriate anti-TB drug therapy, patient isolation, and proper referral. Results . The prevalence of rifampicin resistance was 10.6% (n=77) of 729 positive assays. The initial management was assessed for 70 patients with complete records. However, of these 70 patients, 12 patients had been discharged and 5 patients had died prior to receiving their results. The management of the total cohort, and of the 53 remaining inpatients, was analysed separately. The overall confirmatory sputum submission rates were 76%, 60%, 60% and 26% for TB microscopy, Line Probe Assay, TB culture, and drug-susceptibility testing, respectively, and 87%, 72%, 68% and 30%, respectively for the 53 remaining patients. Overall, 33% of patients received appropriate anti-TB treatment, 50% were isolated, and 49% were appropriately referred. For the 53 remaining patients, 43% received appropriate drug treatment, 66% were isolated, 64% were appropriately referred, and 19% were not referred. The inpatient mortality rate was 19%. Conclusions. Rifampicin-resistant TB prevalence in-hospital was more than double the national rate. The initial management of patients with rifampicin-resistant PTB was substandard. Submission of paired sputum samples and educating healthcare professionals and healthcare users are of paramount importance to improve the management of drug-resistant TB.
Neuroendocrine hyperplasia of infancy (NEHI) syndrome is a rare type of interstitial lung disease in children, the exact incidence of which is unknown. The diagnosis of NEHI syndrome can be made on particular geographical findings on a computed tomography scan in a patient with a suggestive clinical picture, after exclusion of more common disorders. The gold standard of diagnosis is lung biopsy with bombesin staining. There is no current treatment for NEHI syndrome and symptoms usually resolve with time. We present a case of biopsy-proven NEHI in an infant who presented with dyspnoea on exertion.
There are several recognised clinical and radiographic presentations of eosinophilic lung disease. These include simple pulmonary eosinophilia (SPE), chronic eosinophilic pneumonia (CEP), acute eosinophilic pneumonia (AEP), allergic bronchopulmonary aspergillosis (ABPA) and pulmonary eosinophilia associated with a systemic disease. [1] Systemic diseases implicated include eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome (CSS) and the hypereosinophilic syndrome (HES). Eosinophilic pneumonias may be idiopathic or secondary to a known cause. Causes may include drugs, irradiation, toxins and infections. The infections may be fungal, parasitic or mycobacterial in nature. AEP, CEP and ABPA have radiographic features that may be suggestive, if not pathognomonic, in several instances. In addition, varying degrees of pulmonary eosinophilia may be associated with diffuse lung diseases, neoplasia and connective tissue diseases. Finally, a hallmark of eosinophilic lung diseases (with the exception of HES) is their exquisite sensitivity to corticosteroids. The eosinophil leukocyte is of obvious importance. It is a granulocyte named for its abundance of eosinophilic granules in the cytoplasm. Mature eosinophils circulate for approximately 24 hours before being recruited into target tissues where they undergo rapid apoptosis if no survival factors are present. [2]
Should sedation holidays be given in the paediatric intensive care unit?Although sedation interruption in the intensive care unit (ICU) is recommended in the literature for adults, its place in paediatrics has been much debated.The arguments for not using sedation interruption protocols include the danger of extubation, ventilatorassociated pneumonia, safety, comfort and, most importantly, synchronisation with the ventilator.ere are also con icting reports and a poor evidence base for the use of this strategy, with only two published randomised controlled trials comparing daily sedation interruption and protocolised sedation.An article by Vet et al. [1] presented the results of a multicentre, randomised controlled trial in the Netherlands on this much-debated issue.e aim of their study was to compare daily sedation interruption plus protocolised sedation (DSI + PS) with protocolised sedation (PS) only in critically ill children.ey excluded premature neonates born at <37 weeks gestational age and children with cardiac, neurological or respiratory conditions who would not tolerate inadequate sedation.How this was determined is unclear and is an important confounder in this study, as only 132 (12%) of 1 059 patients screened over a 5-year period could be assigned to the intervention arm of either DSI + PS (n=66) or PS (n=63).Unfortunately, the study was terminated prior to the expected recruitment total of 200 patients because of low recruitment rates, making the interpretation of the results -using a primary endpoint of number of ventilator-free days at day 28 -di cult.eir results showed no di erence in ventilator-free days; 24.0 days in both groups.e median ICU and hospital length of stay were similar in both groups: DSI + PS 6.9 days (interquartile range (IQR) 5.2 -11.0) v. PS 7.4 days (IQR 5.3 -12.8) (p=0.47), and DSI + PS 13.3 days (IQR 8.6 -26.7) v. PS 15.7 days ).Mortality at 30 days was higher in the DSI + PS group than in the PS group (6/66 v. 0/63, respectively, p=0.03), though no causal relationship with the intervention could be established.e median cumulative midazolam dose did not di er: DSI + PS 14.1 mg/kg (IQR 7.6 -22.6) v. PS 17.0 mg/kg (IQR 8.2 -39.8) (p=0.11).This surprising finding of increased mortality could not be explained by the authors but is a signal of possible harm as a result of drug interruption in children, in contrast to the experience among adults.us, DSI in the paediatric ICU is currently not recommended, as the adverse e ects are well known and should be minimised and avoided.
This edition of the journal features an interesting article on cytokine/chemokine profiles in HIV exposed infants with hypoxic pneumonia.
Background. Transbronchial needle aspiration (TBNA) is a minimally invasive bronchoscopic technique that is cost-effective and safe for diagnosing mediastinal and hilar adenopathy in lung cancer, other malignancies, sarcoidosis and infectious processes such as tuberculosis. Few studies have analysed the sensitivity, specificity and predictive values of TBNA for diagnosing lymphoma. Objective. To evaluate the diagnostic yield of TBNA for diagnosing mediastinal and hilar adenopathy in suspected lymphoma. Methods. We performed a retrospective analysis of collected data of patients with mediastinal and hilar adenopathy adjacent to the tracheobronchial tree detected by thoracic computed tomography, who underwent TBNA at Tygerberg Hospital between July 2010 and June 2013. We included 25 patients with suspected or proven lymphoma. Histology was used as the gold standard. Results. Adequate samples for cytological evaluation were obtained for 22 (88%) patients. Cytological diagnosis was possible for 8 (32%). For 17 (68%) who could not be diagnosed by TBNA alone, histology provided final diagnosis. Rapid on-site examination (ROSE) was performed in 23 (92%). In 17/23 (74%) cases, these had similar results to formal cytology. Only 4 (16%) had flow cytometry requested. Twelve (48%) had lymphoma confirmed on histology. TBNA cytology had 100% specificity and positive predictive value for suspicion of lymphoma. Sensitivity was 33% and negative predictive value 62%. Conclusion. TBNA is an appropriate first-line diagnostic procedure in evaluating mediastinal and hilar lymphadenopathy in suspected lymphoma. Biopsy should be the immediate second-line procedure when ROSE/cytology is suspicious of lymphoma or shows atypical cells. Patients with negative TBNA cytology, but high clinical or radiological suspicion of lymphoma, should be further investigated.
1 Department of Physiology, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa 2 Department of Internal Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa 3 Department of Radiology, School of Medicine, Faculty of Health Sciences, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
‘Children are not small adults’ is a common adage we were taught at medical school. This was recognised as far back as the first century, when the Roman medical encyclopaedist Celsus wrote, ‘In general, boys should not be treated in the same way as men.’
Current strategies to reduce the burden of tuberculosis (TB) are symptom- and patient-centred, and mainly focus on accurate diagnosis of cases, adequate follow-up, adherence to treatment and contact tracing.
