Pulmonary & Respiratory Medicine

Sarcoidosis is a systemic disease with a 90% predilection for the lungs, but any organ can be involved. Sarcoidosis of the colon is rare. When this organ system is involved, it can be a feature of systemic disease or in isolated cases. Gastrointestinal sarcoid can resemble a broad spectrum of other disease processes, thus it is important for health care providers to be familiar with the various GI manifestations. Patients can have symptoms of fever, nausea, vomiting, unintentional weight loss, diarrhea, hematachezia, and severe abdominal pain. We report a case of sarcoidosis of the colon that responded to methotrexate and a MEDLINE search of 22 reported cases of colon sarcoid based on a compatible history and the demonstration of non-caseating granulomas. We describe the clinical manifestations of symptomatic colon sarcoid in relation to the endoscopic findings. Elevated serum ACE level, presence of CARD 15 mutations, and certain intestinal and extra-intestinal clinical features are helpful in differentiating between colon sarcoidosis and Crohn’s regional ileitis. Steroids remain the mainstay of treatment, however methotrexate should be considered as alternative treatment.

Introduction: Recruitment and activation of inflammatory cells contributes to the pathophysiology of Cystic Fibrosis (CF). Recruitment is initiated, in part, by engagement of the CXCR2 receptor on neutrophils and other inflammatory cells.

Materials and Methods: Levels of CXCR2 agonists (CXCL 1, 3, 5, 7, 8), and systemic biomarkers of inflammation (fibrinogen, CC-16, SP-D, IL-1β, and MMP-9) were measured in the serum of stable outpatients with cystic fibrosis compared to normal healthy age-, gender, and racially-matched non-smoking control subjects. Secondary objectives included characterization of pulmonary function assessed by spirometry, Impulse Oscillometry (IOS), R5-R15 peripheral resistance, R5 total resistance and R25 large airway resistance; frequency dependent reactance as indicators of reactive capacitance properties of the lung (X5, resonant frequency, Fres, AX) in patients with CF compared with controls. Health outcomes scores in patients with CF were assessed using the Cystic Fibrosis Questionnaire.

Population: Single center, prospective, two visit study. 48 subjects were enrolled. Forty-two subjects (28 patients with CF and 14 healthy controls matched 2:1 (age, gender, and race) were evaluable.

Results: Blood fibrinogen levels in CF patients were significantly elevated compared with controls (3.9 g/L vs. 3.0 g/L [p=0.0004]); similar differences were seen in levels of CXCL8 (CF patients=10.2 pg/mL and controls=5.9 pg/mL [p=0.0065]). A trend was noted for CC-16, CXCL1, and SP-D. As expected, lung functions assessed by spirometry and IOS values were significantly different in the patient population compared to the control group. Mean FEV1 and mean reactance were 2.4L (67% predicted) vs. 3.5L (99% predicted) and 0.174 kPa/(L/sec) vs. –0.085 kPa/(L/sec) in CF patients vs, controls, respectively(p=0.0002 and p<0.0001)). No age or gender trends were noted among CF patients or controls.

Conclusions: The study demonstrated elevation of CXCR2 agonists in stable patients with CF. We also confirmed the potential utility of IOS, an effort-independent lung function test. Finally, the study suggests that subject matching for age and gender may not be necessary in future CF trials assessing these biomarkers.

Background: Various medications have been examined to reduce fentanyl-induced cough. We studied the efficacy and safety of premedication with dextromethorphan or clonidine versus placebo prior to intravenous fentanyl injection on the cough reflex.

Methods and Materials: In a randomized double-blind placebo controlled trial, 360 adult patients of American Society of Anesthesiologists physical status I-II, scheduled for elective surgery under general anesthesia were randomly allocated into three groups receiving clonidine (0.2 mg tablet orally),dextromethorphan (15 mg orally), or placebo 60 minutes before induction of anesthesia. The incidence of cough was recorded for 1 minute after fentanyl injection and graded as none (0), mild (1–2), moderate (3–5), and severe (>5 cough). Seventy three (20.3%) exhibited vigorous cough attacks during intravenous fentanyl administration.

Results: The overall incidence of coughing in clonidine group (15.0%) and dextromethorphan (11.7%) group was lower than the placebo group (34.2%). Also, 3.3% of cases in the clonidine group and none of the patients in the dextromethorphan suffered from severe coughing, while 8.3% of the cases in the placebo group considered to have severe cough. Pretreatment with clonidine or dextromethorphan was positively associated with reduced incidence of fentanyl-induced cough after adjustment for potential confounders. Vital signs were all significantly lower following clonidine administration compared to both pretreatment regimens including dextromethorphan and placebo before and after intravenous fentanyl injection.

Conclusion: Administering dextromethorphan or clonidine reduces the incidence of fentanyl-induced cough with better haemodynamic stability following the use of clonidine than dextromethorphan.

Idiopathic Pulmonary Fibrosis (IPF) is a chronic, progressive, fatal form of diffuse interstitial lung disease, which is associated with substantial mortality and morbidity. Lung transplantation has become one of the treatments of choice for patients with advanced IPF and has shown a 75% reduction in risk of death compared with patients who remained on the waiting list. Patients undergoing lung transplantation are required to participate in preoperative and postoperative pulmonary rehabilitation. This case report describes palliative and end of life care in a patient with end stage pulmonary fibrosis listed for lung transplantation and discusses the transition from curative restorative care and palliative care to end of life care. The goals of care of patients waiting for lung transplantation should be reviewed regularly and clarified as the clinical condition of the patient changes. End of life care should not only be considered in terminally ill patients or patients who do not fulfil the criteria for lung transplantation, but should also be raised with patients on the lung transplant waiting list. The goal of palliative care is to “enhance quality of life for patient and family, optimize function, and help with decision making” and thus it can be delivered concurrently with life prolonging care.

Consolidation and Ground-Glass Opacities (GGO) are common findings on chest Computed Tomographic (CT) scans. Consolidation and GGO can be divided into segmental, non-segmental and interstitial pneumonia types based upon distribution pattern. The aim of this review is to highlight the importance of the non-segmental distribution pattern, and to explain its relevancy in various conditions. Non-segmental distribution pattern presents as lobar pneumonia histologically, whereas segmental distribution appears as bronchopneumonia. The different diagnoses that can be derived from non-segmental distribution consist of infectious pneumonias caused by S. pneumoniae, K. pneumoniae and L. pneumophila, Chlamydophila psittaci, M. pneumoniae, measles, viral pneumonia and tuberculosis, as well as non-infectious inflammatory diseases including Cryptogenic Organizing Pneumonia (COP), Chronic Eosinophilic Pneumonia (CEP) and Pulmonary Alveolar Proteinosis (PAP), and other conditions including Anti-Neutrophil Cytoplasmic Antibody (ANCA) related pulmonary hemorrhage and Bronchoalveolar Carcinoma (BAC). A detailed analysis and correlation of non-segmental distribution with other CT findings (e.g., ground-glass opacity, interlobular septal thickening, fibrosis, pleural effusion, air trapping, nodular lesions, and air bronchiologram and air bronchogram) can facilitate the accurate diagnosis of these respiratory diseases. Specifically of interest is L. pneumophila infection, which first presents as bronchopneumonia but later converts into lobar pneumonia. The mechanism behind this conversion involves inflammatory exudates that can pass through Kohn’s pores and Lambert’s channel during L. pneumophila infection. Therefore, L. pneumophila pneumonia pattern first presents as segmental at the start of infection and after 2 weeks or more converts into non-segmental type. Overall, this review demonstrates that the nonsegmental distribution pattern can be very valuable in making respiratory disease diagnosis.