[A case of piperacillin-induced pneumonitis].
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Abstract:
A 43-year-old woman was treated with piperacillin (PIPC) for spiking fever. Although she was afebrile, fever recurred on the 18th day of PIPC administration with progressive dyspnea and diffuse ground glass shadows on the chest X-ray. Bronchoalveolar lavage fluid (BALF) showed marked increase of total cell number and percentage of lymphocytes and a reduction of the ratio of CD4/CD8. Transbronchial lung biopsy (TBLB) specimen revealed interstitial infiltration of lymphocytes and histiocytes with granulomatous lesions. The drug lymphocyte stimulation test (DLST) was positive for PIPC. Based on these findings, the diagnosis of PIPC-induced pneumonitis was made. Recently, the incidence of drug-induced pneumonitis has increased, but to our knowledge this is a rare case report of PIPC-induced pneumonitis.Keywords:
Hypersensitivity pneumonitis
Interstitial pneumonitis
Pneumonitis
Lymphocytosis
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A 43-year-old woman was treated with piperacillin (PIPC) for spiking fever. Although she was afebrile, fever recurred on the 18th day of PIPC administration with progressive dyspnea and diffuse ground glass shadows on the chest X-ray. Bronchoalveolar lavage fluid (BALF) showed marked increase of total cell number and percentage of lymphocytes and a reduction of the ratio of CD4/CD8. Transbronchial lung biopsy (TBLB) specimen revealed interstitial infiltration of lymphocytes and histiocytes with granulomatous lesions. The drug lymphocyte stimulation test (DLST) was positive for PIPC. Based on these findings, the diagnosis of PIPC-induced pneumonitis was made. Recently, the incidence of drug-induced pneumonitis has increased, but to our knowledge this is a rare case report of PIPC-induced pneumonitis.
Hypersensitivity pneumonitis
Interstitial pneumonitis
Pneumonitis
Lymphocytosis
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In an attempt to evaluate the diagnostic help of bronchoalveolar lavage cell data in drug-induced pneumonitis (D.I.P.), we collected through the world literature 167 cases of D.I.P. In 122 cases, data were available for individual analysis (68 associated with amiodarone prescription and 54 with other drugs). 28 drugs were incriminated. Apart from 13 cases with normal BAL cell profile, the most prominent feature in the other 109 was a lymphocyte alveolitis either pure or associated with neutrophil and/or eosinophil alveolitis along with an imbalance in T-lymphocyte phenotype. These characteristics closely resembled those observed in hypersensitivity pneumonitis due to inhalation of organic dust. Nonetheless, about one third or more of cases displayed no lymphocytosis but neutrophil and/or eosinophil alveolitis. Taken together, these findings are in no way specific for D.I.P. but could be of interest to help diagnosis and understanding of iatrogenic alveolitis, especially when a provocation test coupled with sequential BAL is performed.
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Lymphocytosis
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Lungs have rarely been reported to be affected by any side effects of BCG therapy. Interstitial pneumonitis, though, is known to occur under such circumstances, but its pathogenesis is still debated between an infectious and a hypersensitivity mechanism. We report here 3 cases of pulmonary complications of BCG therapy evaluated by bronchoalveolar lavage (BAL). Cellular data obtained from all 3 patients were characterized by a markedly increased alveolar lymphocytosis. The T4/T8 ratio was elevated compared with that in normal subjects and with the T4/T8 ratio of circulating lymphocytes. Furthermore, alveolar lymphocytes were highly sensitized to PPD, as evaluated by their proliferation and their production of interleukin 2 in the presence of PPD. Mycobacteria were not found in the 3 patients. We conclude that interstitial pneumonitis occurring during BCG therapy could be explained by a hypersensitivity phenomenon, leading to an intense immune and lymphocyte-mediated response within involved organs.
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We report five cases of pneumonitis induced by sho-saiko-to. The patients complained of coughing (4/5), dyspnea (4/5), and pyrexia (3/5). The duration of sho-saiko-to treatment ranged from 4 to 1155 days. Abnormal laboratory findings included high levels of C-reactive protein (4/5), leucocytosis (4/5), severe hypoxemia (4/5), low vital capacity (3/5), and low diffusing capacity (5/5). Chest X-ray and CT films revealed diffuse reticulonodular or ground-glass shadows in both lung fields (4/5). Bronchoalveolar lavage was done in three cases, and revealed lymphocytosis in two cases and abnormally low CD4/8 ratios in three cases. The results of lymphocyte stimulation tests against sho-saiko-to and its component were positive in 3 of 5 cases. After discontinuation of sho-saiko-to, corticosteroids were given in all cases. Symptoms were relieved, and laboratory data and chest X-ray findings returned forward normal. Sho-saiko-to toxicity should be included in the differential diagnosis of pneumonitis. If drug-induced pneumonitis is suspected, administration of sho-saiko-to should be stopped and corticosteroid therapy should be given immediately.
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Purpose: Our knowledge on bronchoalveolar lavage (BAL) of methotrexate-induced pneumonitis (MTX-P) is fragmentary and based on data that are sometimes apparently conflicting. Aim of this review was to provide a comprehensive overview on the BAL features of MTX-P arising from cases published to date, and to determine the cytological patterns and any differences between cancer and rheumatoid arthritis patients, the two patient subsets among which this complication more often occurs. Methods: English-language articles published up to November 2013 were systematically searched through PUBMED, EMBASE, and other databases. Adult patients with a proven diagnosis of MTX-P and careful mention of each BAL parameter were examined. Results: Seventeen articles for a total of 47 patients were included. Four BAL patterns with a variably combined lymphocytosis and two with prominent neutrophilia were identified. A more intense lymphocytosis (P=0.004) and a more depressed CD4/CD8 ratio (P=0.01) were found in cancer patients compared with rheumatoid arthritis patients. Conclusions: In MTX-P, cytological analysis of BAL may disclose up to six different patterns. In MTX-P affecting cancer patients, BAL tends to show the typical features of hypersensitivity pneumonitis, while, in rheumatoid arthritis patients, it is more heterogeneous, with a less intense lymphocytosis, a more pronounced neutrophilia, and a higher CD4/CD8 ratio. These differences could be related to a disparity in baseline pulmonary conditions between the two background diseases, i.e., to the presence of previously healthy lungs in cancer patients, and lungs already involved by the immune-mediated inflammatory processes, often not manifestly, in rheumatoid arthritis patients. Keywords: Adverse drug reaction, bronchoscopy, connective tissue disease, cytology lung, drug-induced lung disease, methotrexate lung toxicity.
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Introduction: Acute hypersensitivity pneumonitis (HP) is typically characterized by lymphocytic alveolitis. Bronchoalveolar lavage (BAL) is also discussed to be crucial in the diagnostic workup of chronic HP (cHP) to differentiate from other fibrotic ILDs. However, data on the association of BAL cell differentiation to survival in cHP are sparse. We therefore aimed to assess the prognostic impact of BAL in cHP patients. Methods: The database of a tertiary referral centre for ILD was reviewed for BAL cell differentiation and survival in cHP patients. Results: 211 patients with cHP were identified (mean age 63 years, 53 % male, FVC mean 73%, mean DLCO SB 44%), mean follow up was 32 months. 194 received BAL with lymphocytes < 20 % n=111, lymphocytes >20 % n=100, lymphocytes >30% n=73, lymphocytes >40 % n=61. BAL lymphocytes >30% (p=0.009) and >40% (p=0.020) were associated with improved survival compared to pts without BAL lymphocytosis (<20%). Logistic regression of BAL lymphocyte categories and HRCT pattern revealed that honeycombing was associated with BAL lymphocytes >20% (p=0.037), while NSIP-pattern on CT was predictive of BAL lymphocytes >30% (p=0.045) and traction bronchiectasis was predictive of BAL lymphocytes >40% (p=0.027). There was no significant association of BAL lymphocytes count and immunosuppression on survival. Conclusion: BAL lymphocytosis is significantly associated with an improved survival, therefore BAL should be considered not only for diagnostic but also prognostic reasons in the work-up of cHP.
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