Chylothorax is uncommon and transudative chylothorax is even rarer. In contrast to exudative chylothorax, the most common etiologies of transudative chylothorax are liver cirrhosis, congestive heart failure, nephrotic syndrome and superior vena cava thrombosis. We present 2 case reports of transudative chylothorax: The first case describes a man who had shortness of breath and orthopnea for 3 days, mimicking congestive heart failure. After a series of workups, nephrotic syndrome-related chylothorax was diagnosed, and diuretics and a low-salt diet were prescribed. No recurrence of dyspnea was noted during 1 year of followup. The second case involved a woman that suffered from progressive dyspnea for 2 months. After a thoracentesis study, we ruled out congestive heart failure and nephrotic syndrome. Liver cirrhosis-related chylothorax was later confirmed. However, the patient's symptoms recurred, even after receiving diuretic treatment and with low-salt diet control. We also reviewed the medical literature to remind clinicians of the importance of avoiding unnecessary workups if chylothorax is transudative.
This is a prospective study of peri-procedure and post-procedure complications and successful weaning of long-term mechanically-ventilated patients following video bronchoscopy-guided percutaneous dilatational tracheostomy (PDT).Video bronchoscopy guided PDT was performed for long-term mechanically-ventilated patients in a medical intensive care unit (ICU). Peri-procedure and post-procedure complications were prospectively observed and evaluated. The success of weaning and the factors affecting the outcomes of these patients after PDT were also investigated.A total of 107 patients with mechanical ventilation were enrolled. The average duration of trans-laryngeal intubation was 27.8 +/- 18.4 days which was longer than reported in previous studies. There were 70 men and 37 women, all of whom underwent bedside PDT at a medical ICU. The complication rates during and post-procedure were 8.4% and 14%, respectively. The most common complications were desaturation during the procedure and bleeding during the follow-up period. Only one death was procedure related (0.9%). After PDT, 50 patients (46.7%) were successfully weaned from mechanical ventilation. The rate of successful weaning (p = 0.02) increased while the days to achievement (p < 0.001) decreased with decreasing duration of trans-laryngeal intubation. Gender, age, body weight, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, duration of procedure, endotracheal tube diameter and position, and history of self-extubation were not related to successful weaning.PDT is a bedside procedure with relatively low complication and mortality rates when performed for patients on long-term mechanical ventilation in a medical ICU. The previous duration of trans-laryngeal intubation was an important determinant for successful weaning after PDT.
The cuff-leak test has been proposed as a simple tool to clinically predict stridor or respiratory distress secondary to laryngeal edema following extubation. However, the true incidence of laryngeal edema in patients on long-term mechanical ventilation is uncertain. The relationship between upper airway obstruction (detected by video bronchoscopy) and the cuff-leak test value for patients with prolonged translaryngeal intubation during percutaneous dilatational tracheostomy (PDT) was investigated.Prospective, clinical investigation.Intensive care unit of a university hospital.Ninety-five patients with prolonged translaryngeal intubation requiring PDT were enrolled during a 12-month period.Cuff-leak test, PDT, video bronchoscopy.The average duration of translaryngeal intubation was 28.1 +/- 17.6 days. The incidence of severe laryngeal edema was 36.8% (35/95). We chose 140 mL as the threshold cuff-leak volume below which edema is indicated. The rate of cuff-leak test positivity was 38.9% (37/95). The sensitivity and the specificity of the test were 88.6% and 90.0%, respectively. The positive and negative predictive values were 83.8% and 93.1%, respectively. Patients who developed severe laryngeal edema had a smaller leak volume than those who did not, expressed in absolute values (53.9 +/- 56.2 vs. 287.9 +/- 120.0 mL; p < .001) or in relative values (10.1 +/- 10.2 vs. 55.3 +/- 22.7%, p < .001). The occurrence of severe laryngeal edema was not associated with age, gender, body weight, respiratory failure due to pneumonia, duration of translaryngeal intubation, endotracheal tube diameter, Acute Physiology and Chronic Health Evaluation II score, or history of self-extubation.A reduced cuff-leak volume measured before PDT may signal the presence of severe laryngeal edema in patients on long-term mechanical ventilation.
Aortobronchial fistula after the graft replacement of a thoracic aorta is rare. We describe the case of a 69-year-old man who presented with recurrent hemoptysis. Thirteen years before he had had a type A aortic dissection, and had undergone a graft replacement of the thoracic aorta. Chest radiography and bronchoscopy showed non-specific abnormalities. The thoracic computed tomography (CT) scan and the CT angiography revealed a pseudoaneurysm formation in the proximal descending aorta with contrast medium leakage, and aortography revealed a pseudoaneurysm in the distal graft with contrast leakage. An aortobronchial fistula resulting from a pseudoaneurysm was diagnosed. Surgery was recommended and he was treated successfully. If aortobronchial fistulas are undetected, mortality is 100%. A high index of suspicion of an aortobronchial fistula should be maintained in any patient with hemoptysis after thoracic aorta surgery.
OBJECTIVES: Fixed-dose combination formulations, which simplify the administration of drugs and prevent the development of drug resistance, have been recommended as a standard anti-tuberculosis treatment regimen.However, the composition and dosage recommendations for fixed-dose combination formulations differ from those for separate formulations.Thus, questions about the effectiveness and side effects of combination formulations remain.The aim of this study was to compare the safety and efficacy of these two types of antituberculosis regimens for pulmonary tuberculosis treatment.METHOD: A prospective, randomized controlled study was conducted using the directly observed treatment short-course strategy.Patients were randomly allocated to one of two short-course regimens.One year after completing the treatment, these patients' outcomes were analyzed.ClinicalTrials.gov:NCT00979290.RESULTS: A total of 161 patients were enrolled, 142 of whom were evaluable for safety assessment.The two regimens had a similar incidence of adverse effects.In the per-protocol population, serum bilirubin concentrations at the peak level, at week 4, and at week 8 were significantly higher for the fixed-dose combination formulation than for the separate formulations.All patients had negative sputum cultures at the end of the treatment, and no relapse occurred after one year of follow-up.CONCLUSIONS: In this randomized study, transient higher serum bilirubin levels were noted for the fixed-dose combination regimen compared with the separate formulations during treatment.However, no significant difference in safety or efficacy was found between the groups when the directly observed treatment shortcourse strategy was used.
Background The clinical characteristics of Q fever are poorly identified in the tropics. Fever with pneumonia or hepatitis are the dominant presentations of acute Q fever, which exhibits geographic variability. In southern Taiwan, which is located in a tropical region, the role of Q fever in community-acquired pneumonia (CAP) has never been investigated. Methodology/Principal Findings During the study period, May 2012 to April 2013, 166 cases of adult CAP and 15 cases of acute Q fever were prospectively investigated. Cultures of clinical specimens, urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila, and paired serologic assessments for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Q fever (Coxiella burnetii) were used for identifying pathogens associated with CAP. From April 2004 to April 2013 (the pre-study period), 122 cases of acute Q fever were also included retrospectively for analysis. The geographic distribution of Q fever and CAP cases was similar. Q fever cases were identified in warmer seasons and younger ages than CAP. Based on multivariate analysis, male gender, chills, thrombocytopenia, and elevated liver enzymes were independent characteristics associated with Q fever. In patients with Q fever, 95% and 13.5% of cases presented with hepatitis and pneumonia, respectively. Twelve (7.2%) cases of CAP were seropositive for C. burnetii antibodies, but none of them had acute Q fever. Among CAP cases, 22.9% had a CURB-65 score ≧2, and 45.8% had identifiable pathogens. Haemophilus parainfluenzae (14.5%), S. pneumoniae (6.6%), Pseudomonas aeruginosa (4.8%), and Klebsiella pneumoniae (3.0%) were the most common pathogens identified by cultures or urine antigen tests. Moreover, M. pneumoniae, C. pneumoniae, and co-infection with 2 pathogens accounted for 9.0%, 7.8%, and 1.8%, respectively. Conclusions In southern Taiwan, Q fever is an endemic disease with hepatitis as the major presentation and is not a common etiology of CAP.
There are only a limited number of reports comparing the Abrams needle with the Trucut needle in diagnosing pleural effusion of an undetermined etiology. This retrospective study aimed to investigate whether ultrasound-assisted Tru-cut biopsy is superior to standard Abrams needle pleural biopsy, especially in an area with a high prevalence of tuberculosis. Of 193 patients with pleural effusion of an undetermined etiology after initial thoracentesis, 116 received Abrams needle biopsy and 77 underwent ultrasound-assisted Tru-cut biopsy. The results of both biopsy procedures were compared. There were no immediate or late complications among the patients, except 1 in the Tru-cut group who had minimal pneumothorax. The size of the specimen obtained by the Abrams needle was significantly larger than that from the Tru-cut needle (34 vs. 5 mm^3, p＜0.001). There was no difference in the sensitivity of diagnosing tuberculous pleurisy (56% vs. 53%, p=0.723) and malignancy (47% vs. 31%, p=0.312) between the 2 biopsy procedures. However, the rate of diagnosis of tuberculous pleurisy was higher using the Abrams needle than by Tru-cut biopsy when tissue culture was done (79% vs. 53%, p=0.027). In conclusion, both Abrams needle and ultrasound-assisted Tru-cut needle pleural biopsies are useful in diagnosing patients with pleural effusions of undetermined etiology with minimal complications. Abrams needle biopsy is more likely to obtain a large amount of pleural tissue and has a higher TB culture rate, so it should be the choice for closed biopsy in diagnosing pleural tuberculosis. (Thorac Med 2012; 27: 150-158)
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