Rituximab is indicated for the treatment of low-grade lymphoma. Pulmonary toxicity related to rituximab is exceptional.Here we report a patient with non-Hodgkin lymphoma treated with "CHOP" chemotherapy (cyclophosphosphamide, adriamycin, vincristine and prednisolone) and rituximab who developed an interstitial pneumonia with acute respiratory failure. The differential diagnosis of this clinical and radiological diagnosis is discussed.Although cases of interstitial pneumonia associated with rituximab are rare, they may be severe and thus any patient experiencing respiratory symptoms on this therapy should be monitored closely.

Cette observation rapporte le cas d’un patient âgé de 65 ans qui, hospitalisé pour accident vasculaire de la fosse cérébrale postérieure, a brutalement présenté un œdème pulmonaire unilatéral. Alors que la forme radiologique habituelle des œdèmes pulmonaires neurogéniques (OPN) est associée à des opacités alvéolaires bilatérales, la présentation unilatérale au cours de cette affection est extrêmement rare. Le diagnostic différentiel entre un OPN et un excès de remplissage vasculaire, une pneumopathie infectieuse, un œdème pulmonaire secondaire à l’inhalation de liquide gastrique ou un œdème pulmonaire cardiogénique, de même que le mécanisme pouvant être responsable de cette présentation, sont discutés.

Rituximab is indicated for the treatment of low-grade lymphoma. Pulmonary toxicity related to rituximab is exceptional.Here we report a patient with non-Hodgkin lymphoma treated with "CHOP" chemotherapy (cyclophosphosphamide, adriamycin, vincristine and prednisolone) and rituximab who developed an interstitial pneumonia with acute respiratory failure. The differential diagnosis of this clinical and radiological diagnosis is discussed.Although cases of interstitial pneumonia associated with rituximab are rare, they may be severe and thus any patient experiencing respiratory symptoms on this therapy should be monitored closely.

A vascular lesion was identified in the posterior cerebral fossa in a 65-Year-old stroke victim. The patient suddenly developed unilateral pulmonary edema. Bilateral alveolar opacities is the usual radiological aspect of neurogenic pulmonary edema but a unilateral presentation is extremely rare. The differential diagnosis includes excessive vascular filling, infectious pneumonia, gastric fluid aspiration edema, and cardiogenic pulmonary edema. The mechanisms underlying neurogenic pulmonary edema are discussed.

Cryptogenic organizing pneumonia (COP) is a clinicopathologic syndrome characterized by a good prognosis with steroid therapy, but frequent relapses when the dose of corticosteroid is reduced or stopped.The purpose of this study was to identify histopathologic features related to the relapse of COP. Six cases of COP that had been diagnosed using open lung biopsy were selected for evaluation. The 6 cases were put into two groups composed of 3 patients who relapsed and 3 who did not relapse. Their pathologic features were examined and compared.Interstitial fibrosis of the lung parenchyma could correspond to histopathologic characteristics of relapses in COP.

Introduction Rituximab is indicated for the treatment of low-grade lymphoma. Pulmonary toxicity related to rituximab is exceptional. Case report Here we report a patient with non-Hodgkin lymphoma treated with "CHOP" chemotherapy (cyclophosphosphamide, adriamycin, vincristine and prednisolone) and rituximab who developed an interstitial pneumonia with acute respiratory failure. The differential diagnosis of this clinical and radiological diagnosis is discussed. Conclusion Although cases of interstitial pneumonia associated with rituximab are rare, they may be severe and thus any patient experiencing respiratory symptoms on this therapy should be monitored closely.

Introduction Cryptogenic organizing pneumonia (COP) is a clinicopathologic syndrome characterized by a good prognosis with steroid therapy, but frequent relapses when the dose of corticosteroid is reduced or stopped.Case report The purpose of this study was to identify histopathologic features related to the relapse of COP. Six cases of COP that had been diagnosed using open lung biopsy were selected for evaluation. The 6 cases were put into two groups composed of 3 patients who relapsed and 3 who did not relapse. Their pathologic features were examined and compared.Conclusions Interstitial fibrosis of the lung parenchyma could correspond to histopathologic characteristics of relapses in COP.

To the Editor: We appreciate the comments of Hiyama and colleagues on our article in CHEST (August 2000).1Boulay F Berthier F Sisteron O et al.Seasonal variation in cryptogenic and noncryptogenic hemoptysis hospitalizations in France.Chest. 2000; 118: 440-444Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar They stated that the percentage of cryptogenic hemoptysis (42%) was particularly high in our study compared with other previously published studies and with their own results (12%). The distribution of causes of hemoptysis differed greatly in different studies,2Hirshberg B Biran I Glazer M et al.Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital.Chest. 1997; 112: 440-444Abstract Full Text Full Text PDF PubMed Scopus (330) Google Scholar depending on geographic setting, time, and design of the study, and patient inclusion (or exclusion) criteria. Hiyama and colleagues studied a clinical series of 51 patients hospitalized for hemoptysis during a 6-year period, with detailed information and prospective follow-up. In contrast, we performed a retrospective epidemiologic study, covering a broad population (6,349 subjects who had, during a 3-year period, received a discharge diagnosis of spontaneous hemoptysis, with less detailed information collected from a large electronic discharge data file. This also explains why we had no information on smoking history or on the amount of expectorated blood. Furthermore, in our study, patients were not selected, and our data file included all kinds of patients, regardless of their age, the completeness of the etiologic investigation, and the amount and/or duration of bleeding. It is possible that a small number of the cases could have been erroneously classified as cryptogenic hemoptysis, but it is noteworthy that, in the study by Adelman et al,3Adelman M Haponik EF Bleecker ER et al.Cryptogenic hemoptysis: clinical features, bronchoscopic findings, and natural history in 67 patients.Ann Intern Med. 1985; 102: 829-834Crossref PubMed Scopus (66) Google Scholar cryptogenic hemoptysis was identified in approximately 30% of all patients. In the second part of their letter, Hiyama and colleagues commented about smoking, but they did not specify whether they considered tobacco an etiologic factor or a triggering factor of cryptogenic hemoptysis. Indeed, as with coronary atherosclerosis,4Goldberg RJ Epidemiologic aspects of circadian patterns of cardiovascular disease and triggers of acute cardiac events.Cardiol Clin. 1996; 14: 175-184Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar tobacco use could, with a long latent period, lead to the creation of an underlying lesion, or it could transform this underlying lesion to clinically detectable bleeding. Due to the small number of patients with cryptogenic hemoptysis (only six patients), any conclusions about the etiologic factors should be drawn very cautiously. Furthermore, among the 51 hospitalized patients described by Hiyama and colleagues, the percentage of patients with hemoptysis who smoked was low, and the status of smokers (history of smoking or current smoking) was not precisely specified. So it is possible that some of the nonsmoking patients may have stopped smoking in reaction to the respiratory disease that caused their hemoptysis (lung cancer, chronic bronchitis, bronchiectasis). An argument for the role of tobacco as a triggering factor of hemoptysis would be that active smoking follows a seasonal pattern identical to cryptogenic hemoptysis. As a matter of fact, in contrast with respiratory infections, seasonal variations have never been described for active smoking. So we agree with Aldelman et al3Adelman M Haponik EF Bleecker ER et al.Cryptogenic hemoptysis: clinical features, bronchoscopic findings, and natural history in 67 patients.Ann Intern Med. 1985; 102: 829-834Crossref PubMed Scopus (66) Google Scholar that the hypothesis of infection is the most likely explanation of the seasonal pattern of cryptogenic hemoptysis. Cryptogenic Hemoptysis and SmokingCHESTVol. 121Issue 4PreviewTo the Editor: Full-Text PDF

Both volume preset and pressure preset ventilators are available for domiciliary nasal ventilation. Owing to their technical characteristics, it has been suggested that impaired ventilatory mechanics might cause a drop in the tidal volume (Vt) delivered by pressure preset devices, thereby placing mechanical ventilation at risk of inefficacy. We have assessed two ventilator systems (one pressure preset and one volume preset) with regard to the tidal volume and end-tidal carbon dioxide tension (PetCO(2)) changes that may be achieved in a group of awake patients with stable chronic respiratory failure (CRF). Eleven patients with stable CRF were ventilated in the assist/control mode for two consecutive one-hour periods. One ventilator was tested each hour, in random order. The VIGIL'AIR(R) system was used to record Vt, Respiratory Rate (RR), and Inspiratory/Expiratory ratio (I/E). The deviation E (E=preset value - measured value) was calculated for each measurement. Changes in PetCO(2) and arterial oxygen saturation were determined respectively by a capnometer and a pulse oximeter. Comparison of the mean deviation of Vt calculated for the two ventilators revealed a difference in patients with chronic obstructive pulmonary disease (COPD). The deviation was greatest with the pressure preset ventilator (PPV), which gave mean measured values higher than the mean preset values. The same comparison failed to reveal any difference in restrictive CRF. Comparison of the volume preset and pressure preset ventilators for RR, I/E and PetCO(2) did not reveal any difference. Compared to the volume preset ventilator, the efficacy of PPV to ventilate is not affected by the restrictive or obstructive nature of CRF. Our results show that pressure-preset ventilator is an adequate alternative to the volume-preset device for daytime non invasive ventilation in chronic respiratory insufficiency.

Our study aimed to assess the impact of acute respiratory failure (ARF) on survival of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) plus nasal intermittent positive pressure ventilation (NIPPV). Survival was analysed retrospectively in 24 patients with severe COPD initiated to NIPPV in addition to LTOT. Fourteen patients were established on NIPPV following exacerbation of acute respiratory failure which has required mechanical ventilation (group 1). Ten patients (group 2) have never been hospitalized for ARF. Comparison of clinical details at baseline, 6 months, 1, 2, and 3 years for the two groups failed to reveal any difference with the exception of prior episodes of ARF. The probability of survival at 3 years was 65% (95% confidence interval [CI] 43-86) for the overall population, 46% (95% CI 15-77) in group 1, and 74% (95% CI 42-105) in group 2. The difference between the two groups was statistically significant. We show that ARF requiring mechanical ventilation appears to be a factor that is negatively correlated with survival for patients treated by LTOT plus NIPPV. This data suggests that NIPPV should be tried before ARF arising in COPD patients who present a deterioration in chronic respiratory failure with hypercapnia.

Although venous escape of cement has been frequently noted during percutaneous vertebroplasty, no case of pulmonary embolus directly linked to this manoeuvre has been described in the literature. We report a case of pulmonary embolus of acrylic cement occurring immediately after the procedure. Outcome was favorable following anticoagulant therapy despite the persistence of some vascular obstruction suggesting the association of residual fibrinous matter in the pulmonary artery.

Silicone endoprostheses are used to replace loss of support in tracheobronchial cartilage. The main silicone stents are similar to those of the Montgomery T tube, the Westaby, Dumon and Cooper-Hood prostheses. The major indications are malignant tumours and benign stenosis after anastomotic resection or graft. All have in common a degree of narrowing greater than 50%. An initial bronchoscopy enables a precise assessment of the zone to support. The prostheses are then put in place using a rigid bronchoscope. An annual bronchoscopic review is recommended associated with clinical supervision. Their removal is simple even after being in position for a long period. A multicentre study (Marseille, Saint-Etienne, Brescia and Barcelona) report their experience of 1574 prostheses positioned in 1058 patients. The localisation was tracheal (54%), left main bronchus (21%), right main bronchus (18%). The average time in place was 1.2 years for benign tumours(maximum 6.2 years) and four months for malignant tumours (maximum 4.7 years). Complications were rare and included migrations (9.5%), granulomas (7.9%) and obstructions (3.6%). Thanks to their being well tolerated, their simplicity in handling, silicone prostheses are currently an essential choice to re-establish patency of the airways in patients presenting with benign or malignant tracheobronchial pathology.

This multicentre study was set up to compare the efficacies of two long-acting beta 2-agonists, oral bambuterol (20 mg nocte) and inhaled salmeterol (50 micrograms b.i.d.), for the treatment of moderate to severe asthmatics who were considered to be on optimal steroid/bronchodilator therapy, but continued to have troublesome nocturnal symptoms. The study was of double-blind, parallel-group design and comprised a 2-week run-in on previous maintenance therapy followed by a 6-week study treatment period. There were 117 randomized asthmatic patients aged 20-70 years (65 women and 52 men with a mean age of 45 and predicted FEV1 of 64%), who had been taking 800-2000 micrograms inhaled steroid and/or up to 20 mg oral steroid per day for at least 4 weeks. They were asked to complete daily diary cards, recording morning and evening PEF, daily symptoms, nocturnal awakenings, rescue medication and subjective tremor. There was a significant increase in both morning and evening PEF respectively, on bambuterol (28 l min-1, 20 l min-1, P < 0.05) and salmeterol (29 l min-1, P < 0.001; 23 l min-1, P < 0.01) when compared with run-in. The mean percentage fall in overnight PEF was reduced by 8.3% (P < 0.001) on bambuterol and by 6.8% (P < 0.001) on salmeterol. Nocturnal awakenings and daytime symptoms due to asthma were significantly lowered by both treatments, as was the consumption of rescue bronchodilator. Tremor scores were very low during both run-in and study treatments. No significant treatment difference between bambuterol and salmeterol was detected for any of the above variables. Once-daily oral bambuterol provides a highly effective alternative to twice-daily inhaled salmeterol for relief of nocturnal symptoms in patients with moderate to severe asthma.

Silicone endoprostheses are used to replace loss of support in tracheobronchial cartilage. The main silicone stents are similar. to those of the Montgomery T tube, the Westaby, Dumon and Cooper-Hood prostheses. The major indications are malignant tumours and benign stenosis after anastamotic resection or graft. All have in common a degree of narrowing greater than 50%. An initial bronchoscopy enables a precise assessment of the zone to support. The prostheses are then put in place using a rigid bronchoscope. An annual bronchoscopic review is recommended associated with clinical supervision. Their removal is simple even after being in position for a long period. A multicentre study (Marseille. Saint-Etienne. Brescia and Barcelona) report their experience of 1574 prostheses positioned in 1058 patients. The localisation was tracheal (54 %), left main bronchus (21 %). right main bronchus (18 %). The average time in place was 1,2 years for benign tumours(maximum 6,2 years) and foils months for malignant tumours (maximum 4.7 years). Complications were rare and included migrations (9.5 %), granulomas (7.9 %) and obstructions (3.6 %). Thanks to their being well tolerated, their simplicity in handling silicone prostheses are currently an essential choice to restablish patency of the airways in patients presenting with benign or malignant tracheobronchial pathology.

Increased severe asthma could be linked to a repeated exposure to House Dust Mite (HDM) often responsible for therapeutic failures. HDM allergens are actually among the most potent determinants of asthma. It can provoke the maintenance of inflammatory process, an important bronchial epithelial damage and could induce a reduction of glucocorticoïd receptor (GCR) binding affinity and the appearance of very severe asthma poorly controlled by glucocorticosteroïd therapy. Therefore, HDM avoidance seems to be essential for the control of severe allergic asthma, it can be achieved by living at altitude where humidity and temperature are relatively low. In many studies, the evaluation of climatic stay results demonstrates an improvement of clinical score, a decrease of total and specific IgE to HDM, specific and non specific BHR and a significant reduction of eosine cationic protein (ECP). The quality of life is highly better. However, several questions have to be answered concerning the becoming of asthmatics after moving back home, the cost-benefit, and the psychological effect of separating children from family environment. These findings support that climatic stay free of HDM and molds can be recommended for allergen avoidance permitting to stop the inflammatory process, the epithelial alteration and could restore the possibility to manage poorly controlled severe asthma by carrying out asthma rehabilitation in adequate conditions.

Ciliated respiratory epithelial cells have to tolerate variations in local pH caused by the respiratory cycle and potential ventilation-perfusion mismatches. We showed previously that peripheral bronchiolar cilia beat at a lower frequency than bronchial cilia, and have now investigated whether they show differences in tolerance to changes in pH. Using the image analysis system applied in the previous study, we compared variations in the ciliary beat frequencies (CBF) of bronchi and bronchioles sampled from human lung resections at various pH in vitro. Application of nonparametric tests (the variance of samples was not similar) indicated that CBF was not significantly modified when pH was varied between 7.5 and 10.5 for bronchi, and between 5.5 and 10.5 for bronchioles. Reversible and significantly lower CBF were observed below pH 7.0 for bronchi and below pH 5.0 for bronchioles. Extreme pH values such as 11.0 or 3.0 were lethal within a few minutes. Thus, respiratory ciliary beating is able to tolerate external pH variations between 3.5 and 10.5 without permanent impairment. In addition we found that alkaline pH values are more favourable than acidic ones and that bronchiolar ciliated cells are more tolerant to acidic pH than bronchial cells.

We report a case of acute respiratory insufficiency with acute cor pulmonale and a fatal outcome. Right cardiac catheterisation enabled a diagnosis of precapillary pulmonary arterial hypertension to be made with a mean pulmonary arterial pressure of 61 mmHg and a pulmonary capillary pressure of 12 mHg. An autopsy was carried out and this revealed a microscopic pulmonary tumour emboli with lymphangitis carcinomatosis. In particular, it showed an association of fibrocellular proliferation at the level of the intima in the small calibre pulmonary arteries and arterioles permitting the unusual diagnosis of thrombosing pulmonary microangiomathy due to tumour. The physiopathological mechanism of this particular form of pulmonary tumour emboli is discussed; it would be secondary to an activation of the coagulation systems by the embolic tumour cells. Once activated, it is the lesions in the intima and not the carcinoma cells which generate the pulmonary arterial hypertension by vascular obstruction.