Initially, a flexible bronchoscope was used to inspect the airways while the patient was ventilated using a laryngeal mask airway. By visual inspection, we estimated that the distal trachea was 75% narrowed by a combination of extrinsic compression and endoluminal tumor. The endoluminal tumor originated from the right lateral tracheal wall and extended distally with complete occlusion of the right main bronchus. The left main bronchus was normal.A balloon-sheathed radial probe endobronchial ultrasound device (R-EBUS)(UM-BS20-26R-3; Olympus, Center Valley, PA) was then used to reassess the degree of tracheal obstruction. We positioned the transducer at the most obstructed level and inflated the balloon until we obtained an R-EBUS image, which was then saved using the endoscopy software (ProVation Medical, Minneapolis, MN). Similarly, R-EBUS images were taken just below the area of maximal …

MDR-TB has emerged in Israel following an immigrations wave from the Former Soviet Union (FSU) and Ethiopia. The purpose of this study was to outline characteristics and outcome of hospitalized MDR-TB patients. We retrospectively summarized charts of MDR-TB patients hospitalized in the national referral tuberculosis centers from January 2000 to December 2005, and followed them for 2 years. One hundred thirty-two patients were identified with a median age of 40 years and male predominance (77%). The majority of the patients were immigrants from FSU (83%) and Ethiopia (7.6%). They were characterized by alcohol (25.8%) and IV drug abuse (23.5%), presented with advanced disease manifested by hypoalbuminemia (50.8%) and smear positivity (70.5%). Cure was achieved in 50.3% and 30.4% died. Factors independently associated with death were patients’ age (OR = 1.036 for each year, 95%CI 1.0–1.1, p = 0.014), hypoalbuminemia (OR = 2.95, 95%CI 1.1–7.6, p = 0.025), smear positivity at diagnosis (OR = 3.7, 95%CI 1.2–11.4, p = 0.023), alcohol abuse (OR = 4.8, 95%CI 1.7–13.7, p = 0.004) and XDR-TB resistance pattern (OR 8.3, 95%CI 1.5–44.6, p = 0.014). This study brings out the poor prognosis of a highly vulnerable immigration population. Efforts should be focused on earlier diagnosis and treatment in a well controlled hospital environment and to professional support groups to attend to this population’s special needs.

Hepatic involvement is common in miliary and extra-pulmonary tuberculosis but is usually clinically silent. Therefore, it is rarely diagnosed. We report the case of a patient that presented with prolonged fever and hepatomegaly. Liver biopsy revealed non-necrotizing granulomas that led in turn to the diagnosis of generalized tuberculosis and HIV infection. The patient reported an old untreated tuberculosis and depression of the immune system provoked the reactivation of this old tuberculosis focus. We describe the clinical course of the disease and the challenges associated with the complexity of the treatment. Diagnosis of hepatic tuberculosis requires a high degree of suspicion especially in AIDS patients who show atypical presentations. However, it is a potential curable disease and good results have been obtained with the four drug regimen.

A 65-year-old man underwent lobectomy following a positron emission tomography (PET) scan showing increased uptake in a nodular lesion in the middle lobe (fig 1). A preoperative transbronchial biopsy specimen demonstrated lipoid pneumonia which was disregarded as a false positive (fig 2). No tumour was seen in the …

Background and study objective: Pneumothorax following flexible bronchoscopy (FB) with transbronchial biopsy (TBB) occurs in I to 6% of cases. Routine chest radiography (CXR) following TBB is therefore requested by most pulmonologists in an attempt to detect complications, particularly pneumothorax. The objective of this study was to determine if routine CXR after bronchoscopy and TBB is necessary.Patients and method: The study group included 350 consecutive patients who underwent FB with TBB at our institution between December 2001 and January 2004. Routine CXR was performed up to 2 h after the procedure in all cases. Additionally, the following information was recorded in all patients: sex, age, immune status, indication for bronchoscopy, total number of biopsies done, segment sampled, pulse oxygen saturation, and development of symptoms suggestive of pneumothorax.Results: Pneumothorax was diagnosed radiologically in 10 patients (2.9%). Seven patients had symptoms strongly suggestive of pneumothorax prior to CXR, including four patients with large (> 10'%) pneumothorax. The other three patients were asymptomatic, with only minimal pneumothorax (<= 10%), which resolved completely 24 to 48 h later.Conclusions: We conclude that routine CXR after bronchoscopy with TBB is necessary only in patients with symptoms suggestive of pneumothorax. In asymptomatic patients, pneumothorax is rare and usually small, so routine CXR is not necessary in this category of patients.

Background. A substantial excess risk of certain malignancies has been demonstrated after organ transplantation. Immunosupressive treatment to prevent allograft rejection is probably the main cause. Methods. We reviewed retrospectively all medical records of the 121 patients that underwent lung and heart-lung transplantation from 1992 until December 2004. We compared our results to the International Society for Heart and Lung Transplantation (ISHLT) registry data and previous reports concerning lung transplantation. Results. 102 of the 121 patients survived for 3 months to 12 years. Malignancies developed in 16 patients, as follows: lymphoproliferative disorder in 3, Kaposi's sarcoma in 3, other nonmelanoma skin cancers in 7, urinary bladder transitional cel carcinoma in 3, and colon cancer in 1. Patients with malignancy were older at transplantation than those without (mean ± SD, 54.1±7.8 vs. 49.5±14.2 years; P=0.03). Fourteen had smoked in the past. Four died of bronchiolitis obliterans. In comparison with the ISHLT, we observed more skin cancer and transitional cell carcinoma (12.8% vs. 0.7% and 3.8% vs. 0.03%, respectively) and a similar frequency of posttransplant lymphoproliferative disease. Conclusions. We conclude that malignancy is a common complication after lung transplantation. In Israel, which is sunny most of the year, skin cancers and transitional cell carcinoma of bladder are more common. Modification of the immunosuppression late posttransplantation may reduce the risk of cancer. Patients should also be counseled to avoid sun exposure and ensure adequate hydration.

The shortage of organs for lung transplantation has led to the growing use of "marginal" donors. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, recent data suggest that they may be suitable in selected cases. This article describes the successful transplantation of two lungs from a single donor who had been receiving long-term hemodialysis treatment. In the absence of other causes of pulmonary diseases, such as smoking or lung infection, lungs from dialysis-dependent patients may be acceptable for lung transplantation.

Background: New drugs have significantly improved the prognosis and quality of life of patients with pulmonary arterial hypertension. However, PAH associated with autoimmune disease, particularly progressive sclerosis, remains a very serious problemObjectives: To evaluate whether the course of the disease and survival is significantly different in patients with PAH related to autoimmune disease as compared to other patients with PAH and to determine the prognostic factors in these patients.Methods: We retrospectively compared 24 patients with PAH associated with autoimmune disease to 42 patients with other causes of PAH. We focused on the clinical and hemodynamic parameters and on the outcome.Results: The early mortality rate was slightly higher in patients with PAH associated with autoimmune disease (13% after the first year, 25% after the fifth year). The prognostic factor was a shorter distance on the 6 minute walking distance test (r = 0.2, P= 0.01).Conclusions: The early detection of PAH associated with autoimmune disease should encourage earlier and more aggressive treatment than in idiopathic PAH.

Background:Pulmonary hypertension is a severe pulmonary vascular disease leading to rapid deterioration and death. Histological and clinical evidence suggests that smooth muscle proliferation is part of the pathogenesis of the disease. Human herpesvirus 8 (HHV-8) is a γ-herpesvirus that is implicated in malignancies and in Kaposi’s sarcoma. Recently, the association of HHV-8 with idiopathic pulmonary arterial hypertension (PAH) has been found. Objective: The aim of this study was to investigate the presence of HHV-8 in the lung tissue of Israeli patients with PAH. Method: The presence of HHV-8 sequences was investigated by polymerase chain reaction examination in 6 biopsies of patients with pulmonary hypertension. Three patients had idiopathic pulmonary hypertension, 2 patients pulmonary venoocclusive disease, and 1 patient pulmonary hypertension associated with mixed connective tissue disease. Result: We did not find any association between HHV-8 and PAH in these Israeli patients, as all the samples were negative for polymerase chain reaction. Conclusion: Our findings, together with the epidemiological data of HHV-8 prevalence and incidence rates of Kaposi’s sarcoma and PAH in Israel, provide further evidence which argues against an association between HHV-8 infection and PAH.

PURPOSE: Plasma brain natriuretic peptide (BNP), which serves as a noninvasive marker of left-side heart failure, was recently reported to increase in proportion to right ventricular dysfunction in patients with pulmonary hypertension. Pro BNP is a prohormone cleaved into the inactive N terminal portion (NT pro-BNP) and the active BNP. The aim of this study was to determine whether the NT pro- BNP is a potential indicator of the disease severity for pulmonary hypertension and may be a guide for efficacy of treatment.

Objective: Corticosteroids play a key role in immunosuppression after transplantation. However, because chronic steroid treatment may cause significant morbidity and mortality, steroid-free immunosuppression remains a desirable goal. To the best of our knowledge, there are no reports on successful steroid withdrawal (SW) in lung transplant recipients.Methods: The study group included 35 patients who underwent heart-lung, double-lung or single-lung transplantation. Criteria for initiation of SW were stable pulmonary function tests and absence of clinical or bronchoscopic evidence of acute or chronic rejection in the last 6 months. Pulmonary function, blood pressure and metabolic parameters were compared between the patients who underwent SW and those who did not.Results: Eight patients (23%) underwent SW. Median follow-up was 19 months (range 11-23 months). Compared to the non-withdrawal group, the withdrawal group was older (60 +/- 6 +/- vs. 52 +/- 13 years, P = 0.01, r = 0.49), had higher rates of emphysema (88% vs. 18%, P = 0.01) and use of a cyclosporine-based regimen (62% vs. 26%, P = 0.0001), and had longer time from transplantation to the withdrawal attempt (70 +/- 13 vs. 29 26 months, P = 0,0002). The SW group showed no adverse effects in graft function and no deterioration on pulmonary function tests. SW had a beneficial metabolic effect, with a decrease in mean cholesterol level from 229 +/- 45 to 194 +/- 25mg/dl (P = 0.02) and no significant change in weight, systolic blood pressure or glucose level. In the non-withdrawal group, mean cholesterol levels increased from 175 +/- 34 to 209 +/- 57mg/dl (P=0,0005), weight increased from 72 +/- 15 to 80 +/- 14kg (P = 0.0001), and systolic blood pressure increased from 125 +/- 15 to 139 +/- 16 mmHg (P = 0.001); glucose levels did not change. There was a significant correlation between total cholesterol level and weight in both groups (P = 0.0006, r = -0.56 and P = 0.01, r = -0.46, respectively).Conclusions: Late SW is safe in stable patients after lung transplantation. There was no evidence of rejection or a deterioration in pulmonary function. Lipid profile improvement and blood pressure stabilization accompanied the termination of steroid therapy. (c) 2004 Published by Elsevier Ltd.

D-dimer, a degradation product of fibrin, is being increasingly used as a marker and prognostic factor in various thrombotic diseases. Previous reports have shown that obstructive sleep apnea is associated with platelet activation and hypercoagulability. The aim of the study was to assess the potential role of the plasma D-dimer test in patients with obstructive sleep apnea. We designed a prospective group comparison study in a tertiary-care, university-affiliated medical center. One hundred and three patients of mean age 57 years (range 50-76 years) with symptoms suggestive of obstructive sleep apnea were included. Polysomnography was performed in all cases, and blood was collected for plasma D-dimer measurement by MiniQuant turbidmetric assay. The demographic and polysomnograph data were compared between patients with normal and high (> 250 ng/ml) D-dimer levels. The group with higher D-dimer values had lower mean minimal oxygen saturation (72.1 +/- 16.4 vs. 81.7 +/- 11.6%, p = 0.008) and a longer mean period of oxygen saturation below 90% (84.1 +/- 86.2 vs. 38.5 +/- 70.8 minutes, p = 0.032). There was no correlation of respiratory disturbance index and sleep architecture with D-dimer values. We concluded that sleep apnea syndrome is associated with fibrinolytic activity. Oxygen desaturation seems to be one of the mediatory factors in the putative connection between obstructive sleep apnea and hypercoagulability state.

STUDY OBJECTIVES:To compare the accuracy of virtual bronchoscopy (VB) with fiberoptic bronchoscopy (FOB) and pulmonary function testing (PFT) for the assessment of tracheal stenosis and bronchial anastomotic stenosis.DESIGN:Prospective case series.SETTING:Pulmonary institute of major tertiary university-affiliated center.PATIENTS:The study group included 10 lung transplant recipients and 13 patients with central airway stenosis.INTERVENTIONS:All patients underwent PFT, VB, and FOB. All cases were graded by each modality on a scale of 1 to 3, and the findings were compared between modalities.RESULTS:Mean +/- SD stenosis score was 2.0 +/- 0.79 for PFT, 1.62 +/- 0.73 for FOB, and 1.82 +/- 0.77 for VB. A statistically significant correlation was found between VB and FOB scores (p < 0.0001, r = 0.76) and between VB scores and PFT (p = 0.03, r = 0.45). There was no correlation between PFT and FOB.CONCLUSIONS:VB grading of tracheobronchial stenosis is well correlated with PFT. VB may be used to evaluate patients with known tracheobronchial stenosis after treatment and thereby reduce the frequency of repeated invasive FOB performed for that purpose. The correlation of VB with PFT may improve the reliability of this approach.

INTRODUCTION:Smoking can cause a variety of pulmonary interstitial diseases. Pulmonary fibrosis has traditionally been considered a non-smoking-related disease. Recently, however, evidence of smoking-induced fibrosis has emerged. SUBJECTS AND METHODS:A group of eight patients from the pulmonary clinic in Rabin Medical Center with a combine presentation of fibrosis and emphysema was identified retrospectively. All patients underwent chest computed tomography and pulmonary function tests. One patient underwent lung-heart transplantation and a complete review of his lung pathology was obtained. Transbronchial biopsy was performed in 3 additional patients and echocardiography was performed to evaluate the pulmonary vasculature. RESULTS:Upper-lobe emphysema with bulluos changes was found in all patients. In addition, a basal interstitial process was recognized, ranging from ground glass opacities to severe pulmonary fibrosis, with honeycombing. The radiological findings matched the pathological results of combined emphysema and usual interstitial pneumonia. Pulmonary function tests were also in accord, showing severe hypoxemia with mild obstruction, normal-to-mildly reduced lung volumes and a severe decrease in diffusion capacity. Most of the patients had moderate-to-severe pulmonary hypertension as well as diffuse coronary artery disease. CONCLUSION:Our findings are in line with emerging evidence that the spectrum of interstitial damage caused by smoke includes not only Langerhans cell hystiocytosis, respiratory bronchiolitis or desquamative interstitial pneumonia but also advanced usual interstitial pneumonitis as well. We believe that in some patients smoking plays a destructive role by a variety of mechanisms and can cause emphysema, lung fibrosis as well as pulmonary vasculopathy and hypertension. Future studies are needed to define the genetics and pathophysiology of this uncommonly reported clinical syndrome.

Short-term improvement in lung function was observed in 5 of 6 lung transplant recipients with bronchiolitis obliterans syndrome (BOS) who were treated with oral azithromycin. We assessed the long-term effect (mean duration 10 months) of treatment with oral azthromycin in 11 lung transplant recipients with BOS. Mean forced expiratory volume in 1 second (FEV1) was 40 +/- 9% at initiation of azithromycin treatment, 39 +/- 10% after I month, 39 +/- 12% after 4 months, 38 +/- 10% after 7 months and 38 +/- 10% after 10 months, respectively (statistically non-significant for all data). We conclude that long-term administration with oral azithromycin does not reverse BOS in lung transplant recipients, but may slow progression of the disease.

BACKGROUND: Pregnancy is contraindicated in cases of pulmonary hypertension, a highly morbid disease affecting young women of childbearing age.CASES: We describe the pregnancies of 3 patients with pulmonary arterial hypertension (idiopathic, Eisenmenger syndrome, and related to systemic lupus erythematosus). They received epoprostenol and low-molecular-weight heparin throughout pregnancy. The patient with Eisenmenger syndrome started epoprostenol in gestational week 16. Cesarean delivery under general anesthesia was performed at 28-33 weeks of gestation; early delivery was necessary in the patient with Eisenmenger syndrome because of fetal growth restriction. All deliveries were uneventful, and birth weights were 1,700, 1,500, and 795 g. There were no postpartum complications.CONCLUSION: Pregnancy in women with pulmonary hypertension should still be considered high risk for both mother and child, but stable patients on epoprostenol may successfully complete pregnancy.

BACKGROUND:Unexplained pulmonary hypertension is assumed to occur mainly in young adults.OBJECTIVE:To describe the features of the disease in older patients and compare them to those in PHT patients of all ages.METHODS:We conducted a retrospective evaluation of the files of patients over 65 years of age in whom UPHT was diagnosed between 1987 and 1999 at two PHT centers serving a population of 4 million. Patients were followed for survival until March 2003. Clinical variables of the study patients were compared with those in PHT patients of all ages.RESULTS:The study group included 14 patients, 10 females and four males, with a mean age of 70.5 +/- 6.7 years. The calculated mean annual incidence of UPHT for the study population was one new case per year per million persons. Seven patients (50%) had systemic hypertension. The mean interval from onset of symptoms to diagnosis was 8.3 months. At diagnosis, 64% of patients had functional capacity of III-IV according to the New York Heart Association classification, and 43% had right heart failure. Mean systolic pulmonary artery pressure was 80 +/- 21 mmHg, peripheral vascular resistance 11.7 +/- 7 mmHg/L/min, cardiac index 2.16 +/- 0.81, and mean right atrial pressure 10.5 +/- 5.9 mmHg. Median survival time was 43 months; survival rates for 1 year, 3 years and 5 years were 92.6%, 50% and 40%, respectively. Compared to data from the U.S. National Institute of Health Registry, UPHT in older patients is more common in females, but the incidence as well as clinical, hemodynamic and survival parameters are similar to those in PHT patients at any age.CONCLUSIONS:UPHT occurs in the elderly more frequently than previously thought, with similar features in PHT patients of all ages. The coexistence of systemic and pulmonary hypertension warrants further investigation.

Recipients of organ transplants are at increased risk for infection owing to their immunosuppressed state and the possibility of contamination of the donor organ. We report a case of multidrug resistant tuberculosis (MDR) transmission via a donor lung. After medical treatment with four drugs had failed, the patient underwent right upper lobectomy. There were no signs of disease on follow up more than 2 years later. To our knowledge, this is the first report of MDR tuberculosis in a lung transplant recipient. The need for a non-conservative approach, including pulmonary resection, to eradicate the infection is emphasised.

Cystic fibrosis (CF) is the indication for transplantation in approximately 15% of recipients worldwide, and Cystic Fibrosis Lung Transplant Recipients (CFLTRs) have excellent long-term outcomes. Yet, CFLTRs have unique comorbidities that require specialized care. The objective of this document is to provide recommendations to CF and lung transplant clinicians for the management of perioperative and underlying comorbidities of CFLTRs and the impact of transplantation on these comorbidities. The Cystic Fibrosis Foundation (CFF) organized a multidisciplinary committee to develop CF Lung Transplant Clinical Care Recommendations. Three workgroups were formed to develop focused questions. Following a literature search, consensus recommendations were developed by the committee members based on literature review, committee experience and iterative revisions, and in response to public comment. The committee formulated 32 recommendation statements in the topics related to infectious disease, endocrine, gastroenterology, pharmacology, mental health and family planning. Broadly, the committee recommends close coordination of care between the lung transplant team, the cystic fibrosis care center, and specialists in other disciplines with experience in the care of CF and lung transplant recipients. These consensus statements will help lung transplant providers care for CFLTRs in order to improve post-transplant outcomes in this population.