Abstract Paraneoplastic syndromes are diseases caused by malignancies without direct anatomical relationship with it and it is crucial to realize that paraneoplastic phenomena are not caused by metastases. A paraneoplastic phenomenon can be the first indicator of cancer in an undiagnosed individual, and in severe cases lead to fatality. Various paraneoplastic rheumatological syndromes are associated with malignant neoplasms. Although they occur within various forms of malignancy, they most often suceed lung cancer, and adenocarcinoma stands out as the most prevalent histological subtype within pulmonary cancer. This article focuses on the understanding of paraneoplastic syndromes, particularly regarding paraneoplastic rheumatic syndromes due to their challenging differentiation from idiopathic rheumatic disorders.
Abstract The pandemic of the coronavirus disease 2019 (COVID-19) has affected millions of people worldwide. Patients can develop a lot of different manifestations, from asymptomatic form to severe acute respiratory distress syndrome (ARDS). Pulmonary fibrosis, as a primary cause of mortality, is the main consequence of lung injury caused by acute respiratory distress syndrome. Unfortunately, effective treatment for pulmonary fibrosis has not yet been found; that’s why we found an essential anti-fibrotic agent in the early acute phase of severe COVID-19 to fight the infection outcomes. This narrative review presents the therapeutic strategy and the importance of fighting pulmonary fibrosis to help patients worldwide protect themselves against severe and fatal viral infections. To prevent long-term sequelae and early mortality, it’s necessary to test the efficacy of anti-inflammatory drugs.
Abstract The presence of sleep-related disorders, particularly obstructive sleep apnea syndrome (OSA), instigates pathological changes during sleep, giving rise to frequent hypoxic episodes that generate elevated levels of a broad spectrum of inflammatory cytokines. C-reactive protein (CRP), a biomarker signifying the presence and intensity of inflammation, is frequently detected in elevated serum or plasma concentrations, correlating with the number of respiratory events, especially in moderate and severe forms, across both adults and children. Various available therapeutic approaches demonstrate the capacity to diminish serum levels, although the minimum duration of usage typically extends between 2-6 months. In the case of older individuals, OSA commonly coexists with additional conditions, further augmenting the baseline inflammatory level. This accelerated disease progression amplifies mortality rates, incurs heightened costs, and significantly diminishes the overall quality of life.
Abstract Short wavelenght light (blue light) contributes to dysregulations of the circadian cycles. In an era where most of the light sources were replaced by Light Emitting Diodes (LEDs), a new problem regarding sleep quality and nictemeral cycle appears. Even though blue light is currently being used a treatment for sleep dysregulations and insomnia (through cycle altering), this stimuli activates the melanopsin secretory mechanism via photoreceptor cells and thus supresses the pineal secretion of melatonin. Melatonin plays a crucial role in provoking pre-sleep symptoms, inducing and maintaining sleep, improving sleep quality and multiple other effects dependant to the organ, such as being an antioxidant or its protective atribute against diabetes. This paper is a general review of the literature and brings to a single place multiple studies about the importance of sleep, physiology of melatonin secretion and the effect of light exposure on those aforementioned.
Abstract In the field of medical imaging, techniques like computed tomography (CT), magnetic resonance imaging (MRI), and X-rays are essential for diagnosing and monitoring diseases, particularly in pulmonary pathology. A significant development in this area is the application of automated segmentation and machine learning, enhancing the accuracy in diagnosing lung diseases, such as lung cancer. However, there remains a knowledge gap in fully understanding the potential and limitations of these technologies, especially across diverse clinical conditions and datasets. To address this gap, the paper delves into the integration of artificial intelligence with conventional imaging techniques, focusing primarily on the use of convolutional neural networks (CNNs) and transformer-based models in automated segmentation. This approach is pivotal in improving the detection rates and accuracy of diagnoses in complex pulmonary diseases. Findings indicate that AI-enhanced imaging significantly advances the early detection of pulmonary diseases, notably lung cancer, and reduces the time until diagnosis. Yet, challenges such as the necessity for diverse and comprehensive training data and the generalizability of algorithms, persist. Moreover, ethical considerations in the deployment of AI technologies in healthcare are crucial. In conclusion, while these technologies mark substantial progress in pulmonary imaging, it is essential to find the balance between technological advancements and ethical considerations. This balance is key to ensuring effective and equitable healthcare, maximizing the benefits of AI in medical imaging while maintaining patient trust and privacy.
Abstract Spinal tuberculosis is the most common form of skeletal extrapulmonary tuberculosis (EPTB). Extensively drug-resistant TB (XDR-TB) is a rare type of multidrug-resistant tuberculosis (MDR-TB) that is resistant to isoniazid and rifampicin, plus any fluoroquinolone and at least one of three second-line injectable drugs (SLI) (i.e., amikacin, kanamycin, or capreomycin) as per the old guidelines. We present the case of a 13-year-old girl, with lower back pain for 6 months, without other symptoms. She was radiologically diagnosed with tuberculous osteomyelitis without confirmation of acid-fast bacilli. Due to our endemic area, the initial tuberculosis treatment was empiric. The patient received treatment from a private hospital but after 6 months developed lower limb weakness. She was referred to our center where XDR-TB was confirmed by bacteriological examination. She was managed with extended second-line antituberculous chemotherapy according to the new WHO recommendation with a good evolution in the first months of therapy. Appropriate sensitivity-antituberculosis agents and good patient compliance are the keys to ensuring effective treatment of the XDR-TB condition.
Abstract Introduction The immune response in patients with SARS-CoV2 infection is an incompletely elucidated pathophysiological challenge. There are more and more cases in which COVID-19 vaccination induces autoimmune side effects, of course, in a selected population. What are the criteria that induce such a response? How can it be prevented? These are questions that the medical world must answer. Material and Methods A 28-year-old male patient presented with repeated small hemoptysis accompanied by pleuritic pain, which started suddenly 2 days prior. From the patient’s history, we note autoimmune thyrotoxicosis triggered by the administration of the second dose of the anti-SARS-CoV2 vaccine, but also a recent COVID-19 episode. At the time of hospitalization, slightly elevated serum values of D-dimers were noted, and the CT examination identified multiple unilateral filling defects in the middle and small right pulmonary arteries, accompanied by a ground-glass opacity suggestive of a pulmonary infarction and possible bilateral stenosis of the subclavian arteries. The extended immunological panel was negative, but genetic tests have identified two thrombophilic gene mutations. Functionally, a discrete decrease in lung volumes and a slight impairment of alveolo-capillary diffusion was observed. The clinical, imaging and functional evolution was favorable under anticoagulant treatment. Discusions The predisposition for thrombosis in COVID-19 is determined by at least two distinct processes, subsegmental and segmental vessel occlusion and microvascular in situ immunothrombosis. Pulmonary thromboembolism occurs more frequently in the first weeks after diagnosis, but cases farther from the acute moment have also been reported in literature, including in patients with mild forms of the disease. Certain adjuvant components of the vaccines, as well as the SARS-CoV2 virus itself, can trigger autoimmune reactions in genetically predisposed individuals. Conclusion Patients with active or recently recovered COVID-19 should be considered at an increased risk of pulmonary embolism when they present with specific symptoms, even without the existence of other risk factors.
Abstract Introduction Despite the evolving knowledge about COVID-19 convalescents, there is still not enough data to validate simple methods of identifying the non-improvers. Our objective: to look for bad prognostic factors in long-COVID. Methods We conducted a prospective observational study among previously hospitalized patients with COVID-19. Individual characteristics were gathered and pulmonary function tests - spirometry and lung transfer for carbon monoxide (TL,CO) – were performed twice, approximately one and three months after hospitalization from COVID-19. Control radiological examinations were repeated and compared at the time of the study. Results After dividing the study group (30 patients) according to improvement in forced vital capacity (FVC) and/or TL,CO we observed that the forced expiratory volume in the first second (FEV1) acquired from spirometry accurately indicates clinical improvement with the area under the curve (AUC) of 0.892 (95% CI 0.73 – 1). Notable differences were found in estimated total lung capacity (eTLC) and radiological score as well. Conclusions Our findings suggest that simple spirometry with FEV1 assessment performed in the post-COVID period helps select individuals with impaired recovery that should presumably be referred to a respiratory specialist and pulmonary rehabilitation.
Abstract Pneumocystis jirovecii pneumonia, previously known as Pneumocystis carinii Pneumonia (PCP), is a fungal infection most commonly encountered in immunocompromised patients and, in some cases, can be life-threatening. Patients at risk include those with cancer, HIV positive, transplant recipients, and those under immunosuppressive therapies. There are no specific signs or symptoms for PCP and its differential diagnosis includes other viral or bacterial pneumonias and also Tuberculosis, the latter especially in high endemic areas. We present the case of a 32 year-old female patient who presented to the hospital for dyspnea and cough, treated for Pulmonary Tuberculosis, and eventually diagnosed with Pneumocystis Pneumonia, in spite of her multiple false-negative HIV tests.
Abstract Interstitial lung diseases (ILDs) comprise a large number of different diseases, some of the patients having a progressive evolution toward irreversible fibrosis. The aim of this study is to identify baseline clinical, functional, and imaging characteristics at the date of the diagnosis, that could predict the evolution toward fibrosis. This is a retrospective descriptive study that included 126 patients diagnosed and followed-up in Department 5 of the Institute of Pneumophtisiology “Marius Nasta” Bucharest between 2014 and 2022. The authors recorded baseline demographics, symptoms, lung function tests (forced vital capacity – FVC and diffusion capacity – DLCO), high resolution CT (HRCT) imaging features. Patients were followed-up at 6 and 12 months. According to decline in lung function or imaging worsening, patients were divided in2 groups: progressors (60 patients) and non-progressors (26 patients). Baseline characteristics of the 2 groups were compared. Results: There is an important delay since onset of symptoms to diagnosis (a mean of 17 months). Lower baseline FVC, smoking history, presence of traction bronchiectasis and/or honeycombing and male gender were associated to progressive lung fibrosis.
Abstract The authors present a miniseries of two clinical cases of bilateral diaphragmatic paralysis, of different etiologies, which provide the opportunity to discuss the particularities of the clinical manifestations, the paraclinical investigations necessary to establish a positive diagnosis, the elements of differential diagnosis, the general therapeutic principles addressed to respiratory failure secondary to diaphragmatic paralysis.
Abstract Pulmonary embolism (PE) is defined by the obstruction of pulmonary arteries by thrombi or emboli (malignant, grease, air). Most frequently, thrombi arise from deep veins of lower limbs. Pulmonary embolism is a medical emergency with a high death risk. Early mortality is high, sudden death occurs in about a quarter of the patients. On long term, it can lead to post-embolic pulmonary hypertension and recurrent pulmonary embolia. The high risk of death in acute phase and on long-term depends on the severity of the acute phase, on the recurrence, and on the co-morbidities. PE can be the first manifestation of on occult malignancy, or it may complicate an already diagnosed cancer. We present a retrospective analysis on PE associated to malignancy, on 106 patients, with classic anticoagulant treatment (low weight molecule heparin and/or antivitamin K agents) or novel oral anticoagulants (NOAC) and compare the early and late mortality associated to PE and anticoagulant treatment. Our observations note a higher percentage of recurrences but significantly lower mortality in patients treated with NOAC as compared to classic treatments.
Abstract The article aims to explore how a Complex Network (CN) computer-aided technique targeted for interstitial lung disease (ILD) approach can enhance the work of clinicians and if a CN-based computer-aided diagnosis can provide new data to help manage ILDs more successfully. The CN technique is used to evaluate the progression of the disease by analyzing relevant axial HRCT slices and dynamic CN evaluation using the relative speed for each layer. The article presents the results from a study of 65 patients with interstitial lung disease (ILD), comprising 18 females with a mean age of 59.35 years (ranging from 34 to 76). The initial clinical diagnosis was idiopathic pulmonary fibrosis (IPF) in 28 patients (43.07%), Non-Specific Interstitial Pneumonia (NSIP) in 11 patients, and other ILDs in the remaining patients. Each CT scan fulfilled the criteria for high-resolution CT with constant characteristics across the group. All patients underwent imagistic follow-up for at least 11 months, and additional data were provided for each investigation. The cohort was chosen based on concordant lung function decline and imaging evolution decline. The article concludes that the complex network approach provides both a qualitative visual map and quantitative metrics to enhance ILD diagnosis and progression tracking. The results suggest that a CN-based computer-aided diagnosis can provide new required data to manage ILDs more effectively. This approach may enable clinicians to make more precise conclusions regarding the structure of the analyzed lung area, which can help tailor disease management strategies to individual patient profiles.
Abstract Introduction Severe asthma remains refractory to optimised therapy with oral/systemic corticosteroids even after addressing contributing factors, impacting the patients’ health-related quality of life (HRQoL) and increasing the risk for comorbidities and mortality. Several biologics are available for severe asthma treatment; however, their use remains heterogenous across Europe. Aims To generate real-world data on the characteristics of adult patients with severe asthma in Romania and their eligibility for biologics. Methods The European, non-interventional, multicenter RECOGNISE study (NCT03629782) evaluated patient characteristics, asthma medication and control, health care resource use, and HRQoL as assessed by St. George’s Respiratory Questionnaire (SGRQ) in patients with severe asthma, as well as their eligibility for biologic treatment. We report data from the Romanian cohort. Results Of the 117 enrolled patients, 103 were included in the analyses. Almost all patients (90.29%) were treated by specialists. Most patients were female (64.08%) and had never smoked (83.50%). In all, 15 (14.56%) patients had chronic oral corticosteroids (OCS) use. Totally, 89 (86.41%) patients were assessed as eligible for biologic treatment by investigator’s judgement (per label criteria: 79.61%). In the previous year, 77.53% and 78.57% of eligible and non-eligible patients, respectively, had exacerbations of severe asthma, and 53.33% and 15.91% were hospitalised. More eligible patients had poorly controlled asthma (92.13% vs 57.14%) and more impaired HRQoL (mean total SGRQ score: 63.2% vs 47.34%). Conclusion A large proportion of Romanian patients with severe asthma are eligible for biologic treatment. New strategies are needed to further increase the availability of biologics and to improve the management of severe asthma.
Abstract Neutrophil counts and, especially, neutrophil/lymphocyte ratio (NLR) seem to be a reliable biomarker to distinguish an active tuberculosis (TB) from a latent one or a pulmonary tuberculosis from a bacterial community-acquired pneumonia. In conditions of systemic inflammation, the rise in neutrophil count occurs due to reduced apoptosis of these cells. Consequently, the neutrophil-to-lymphocyte ratio increases, which correlates with elevated mortality rates. We conducted a retrospective study and we included 105 patients with a diagnosis of pulmonary tuberculosis who have been continuously admitted to the Pneumology/TB Department. The NLR average value was 6,92 and we observed increased values in patients with cachexia as comorbidities associated. Smoking status was another item that elevated NLR levels. Ratio value at discharge was lower than the NLR value at admission. The age group over 65 had the highest values. NLR has proven to be a valuable prognostic tool, correlating independently with mortality in various diseases like tuberculosis, pneumonia, COVID-19, and cancer.
Abstract Introduction EGFR-TKI is the treatment of choice in non-small cell lung cancer (NSCLC) with EGFR mutation in exon 19 or 21. The influence of EGFR-TKI therapy on lung function is still unrecognizable in NSCLC patients. Objectives This prospective study aims to examine the influence of EGFR-TKI therapy on lung function of lung adenocarcinoma patients with a single mutation in EGFR exon 19 or 21 at Persahabatan National Respiratory Center Hospital Jakarta, Indonesia. The pulmonary function test (PFT), including spirometry and diffusing capacity (DLCO), was performed before and after three months of EGFR-TKI therapy. After three months, the patients were divided into groups based on the Response Evaluation Criteria in Solid Tumors (RECIST) criteria and the change of PFT was compared before and after therapy. Results Among twenty lung cancer patients enrolled, we found increase of predicted mean FVC value from 60.6% to 68.25% (p=0.03), mean predicted FEV1 value from 59.7% to 67.05% (p=0.036), mean DLCO from 11.55 ml/minute/mmHg to 13.72 ml/min/mmHg (p=0.004), and predicted DLCO from 53.4% to 63.85% (p=0.03). The increase of mean predicted DLCO was greatest in the partial response group, which was 16.43% (p=0.056). Conclusion This study found that the majority of NSCLC patients with single EGFR exon 19 or 21 mutation had significantly improved lung function after EGFR-TKI therapy. Lung function test might become a beneficial tool to evaluate the effectiveness of EGFR-TKI in NSCLC patients, especially in clinical setting where computerized tomography (CT) scan is not available.
Abstract Introduction Tuberculosis (TB) can be located in any segment of the osteoarticular system, being the most common in the spine, with approximately 50% of cases. In only 10% of the cases of osteoarticular TB the location is multiple; generally, it is monoarticular or located at the level of a single segment of the spine. The diagnosis can be delayed in the early stages due to its varied and hidden presentation and the probability of being confused with other pathologies of the osteoarticular system. Delay in diagnosis can lead to chronic pain, joint destruction and progression to symptomatic bony ankylosis. Case Presentation A 64-year-old man presented with left lower limb, coccyx pain and peri-anal discharge. CT scan of the pelvis showed recto-integumentary perianal fistulous trajectory externalised on the left side of the anus and osteomyelitis. Left ankle CT: Cystic image of approximately 4.2/6/10 cm well-demarcated, with some central microcalcifications, located in the postero-tibial soft parts, communicating with the tibiotalar joint. Conclusion This case highlights the importance of considering TB as a diagnosis if unusual sites are involved.
Abstract Introduction We analyse anthropometric, somnopolygraphic and comorbidities data in patients with OSA syndrome, OSA with COPD, and OSA with COPD and obesity. Material and method 2644 OSA patients, three groups: I – OSA (2112 pts., 79.9%); II – OSA and COPD (116 pts., 4.4%); III – OSA, COPD and obesity (416 pts., 15.7%). Results significantly older (p < 0.01, p = 001, p < 0.01); more men: 68.4% vs. 80.2% vs. 78.8%; smokers 59.4% vs. 70.7% vs. 74.3%; larger neck circumference: 42.74 ± 5.08 cm vs. 40.57 ± 3.97 cm vs. 45.90 ± 4.92 cm; higher BMI; lower O2 saturation: p < 0.01, p= 123, P < 0.01; higher desaturation index: 30.65 ± 26.96 vs. 18.94 ± 20.28 vs. 42.28 ± 29.02; lowest O2 saturation: (p < 0.01 0, p = 024, p< 0.01); higher AHI: p= 0.001, p < 0.01, p < 0.01; coronary artery disease: p < 0.01, p = 195, p < 0.01; heart failure: p < 0.01, p = 760, p < 0.01; arrhythmias: p < 0.01, p = 796, P < 0.01; stroke: unsignificant; diabetes mellitus: p = 0.252, p = 0.007, p = 0.794; systemic hypertension: p < 0.01, p = 0.786, p < 0.01. Conclusion COPD in OSA is more severe, with more diabetes and longer hypertension duration, but not significantly different for O2 saturation, CAD, heart failure, arrhythmia, stroke and systemic hypertension. Obesity adds to overlap OSA–COPD significant burden for all recorded data, with the exception of stroke and diabetes.
Abstract Primary ciliary dyskinesia (PCD) is a congenital disorder with genetic determinism, characterized by chronic infections of the upper and lower respiratory tract. The triad of situs inversus, chronic sinusitis and bronchiectasis is called Kartagener Syndrome. PCD is a predominantly autosomal recessive disease, involving more than 40 mutations of genes. Abnormal cilia movement leads to defective mucociliary clearance resulting in chronic cough, nasal congestion, recurrent otitis, chronic sinusitis, male infertility and other rare conditions. First presented case is one of a 17-year-old girl with chronic treatment for asthma for the last 5 years. Respiratory functional tests were performed: the patient didn’t present variable airflow obstruction. The diagnosis of PCD was suspected because of chronic respiratory infections in a situs-inversus patient. The second case is a 4-year-old patient with a clinical history highly suggestive of ciliary dyskinesia, who received a recommendation for genetic testing to confirm the diagnosis. The third case is an 8-year-old boy with wet cough from neonatal period, bronchiectasis and sinusitis. Both his symptoms and the fact that his adult brother presented situs inversus, chronic sinusitis and bronchiectasis led us to raise suspicion of PCD. These case reports aim to highlight the real-life difficulties in a rather low-resource setting in diagnosing PCD, a genetic syndrome with long term impact on airways. The second objective was outlining the clinical manifestations that are highly suggestive of PCD and also to develop a diagnostic algorithm for a real-life scenario involving a pulmonologist with reduced access to high-performance tools like TEM (transmission electron microscopy) and complex genetic tests. Because not all PCD cases have known genetic mutations and some don’t have ultrastructural abnormalities we could still rely on the old saccharin test in order to select patients that are candidates for nasal NO. A high index of suspicion for PCD should be present in any patient with non-cystic fibrosis bronchiectasis patient. PCD remains a rare and underdiagnosed genetic syndrome in real-life paediatric setting in countries with limited neonatal screening programs. Increasing awareness of this condition and accessible diagnostic tools are desirable in order to find patients with high-likelihood of PCD and to refer these selected patients to specialized centres. Authors provide an age-dependent approach of PCD patients in a low resource setting.
Abstract Chronic Obstructive Pulmonary Disease (COPD), the third leading cause of death worldwide and the fifth-ranked cause of chronic disability is usually associated with significant concomitant chronic diseases, Gastroesophageal Reflux Disease (GERD) being the commonest. Exacerbations of COPD (AECOPD) are episodes of worsening of symptoms, the frequency of which increases with the severity of COPD. AECOPD is triggered mainly by respiratory infections, bacterial or viral or both. Human rhinoviruses (HRV) are the top viral pathogen in triggering AECOPD, and experimental infection has provided significant new evidence in establishing a causal relationship between virus infections and AECOPD. Proton pump inhibitors (PPI), the most potent acid suppressants, are commonly prescribed for isolated GERD or GERD complicating COPD. There has been a breakthrough in Pulmonary Medicine in that PPI, in addition to their well proven role in acid suppression, has emerged as a promising interventional tool in the prophylaxis and symptom control of AECOPD. This efficacy is not limited to patients with COPD complicated by GERD, since PPI also independently and significantly reduced the risk of developing frequent AECOPD in those with COPD alone, delaying disease progression and improving clinical outcomes. Although the studies conducted so far regarding effectiveness of PPI had promising results, current evidence is insufficient to determine to what extent their long-term use is safe. Large scale multi-center studies are warranted to assess their long-term safety profile and clinical outcomes. The objective of this study is to identify a possible role of PPI in prophylaxis and symptom control of AECOPD.
