Stability of 5-aminolevulinic acid in aqueous solution

OBJECTIVE: To assess and contrast the role of interventional therapy for two types of cavitating pneumonias: lung abscess and necrotizing pneumonia. MATERIALS AND METHODS: We retrospectively reviewed the imaging, interventional therapy, and outcome of 14 children seen between February 1987 and January 1996 with lung abscess and 9 with necrotizing pneumonia. All children were treated with antibiotics prior to intervention. Pulmonary parenchymal fluid was percutaneously aspirated from ten lung abscesses and three necrotizing pneumonias. Percutaneous catheters drained five lung abscesses. Pleural drainage was performed for three lung abscesses and eight necrotizing pneumonias. RESULTS: All 14 children with lung abscesses had positive Gram stains of the pulmonary fluid; 13 cultures were positive. All 14 defervesced within 48 h of intervention. None developed a bronchopleural fistula. All nine necrotizing pneumonias were presumed to be sequelae of prior pneumonia. Streptococcus pneumoniae was the only organism as documented by pleural fluid latex fixation in three patients, gram stain in two, and culture in only one. Seven of these children developed pneumatoceles, five developed bronchopleural fistulae, and three required long-term chest tubes for persistent pneumothoraces. CONCLUSION: Aggressive interventional therapy can be diagnostic and therapeutic in the infected lung abscess. Interventional therapy can be harmful in postinfectious necrotizing pneumonia.     

A case of spontaneous hemopneumothorax occurred after thoracic drainage

A 21-year-old man; complaining of left chest pain and dyspnea, was admitted to our hospital with a diagnosis of spontaneous pneumothorax. Though chest X-ray on admission did not show hemothorax, chest drainage revealed intrapleural bleeding. As chest X-ray on the following day showed evident fluid level, emergency operation was carried out with a diagnosis of spontaneous hemopneumothorax. Bleeding point was a ruptured vessel between parietal pleura and bulla in apex of lung. The bulla was resected following hemostasis. After improvement of complicating postoperative re-expansive pulmonary edema, the patient was discharged on the 18th postoperative day. On treatment of spontaneous hemopneumothorax, existence of such a case as ours should be taken into account.     

A case of video-assisted thoracic surgery for congenital esophago-bronchial fistula

A 42-year-old male was admitted to our hospital because barium esophagograpm showed an esophago-bronchial fistula with an esophageal deverticulum. He has had frequent episodes of cough at drinking water since childhood. A chest CT scan showed mild inflammatory change and bronchiectasis in the right S6. Division of the fistula by video-assisted thoracoscopic surgery (VATS) was performed. There was no evidence of inflammation and adherent lymph nodes around the fistula. This case was diagnosed as a congenital esophago-bronchial fistula by operative findings and clinical course. The fistula was dissected easily and divided by an auto-suturing instrument. The affected lung could be preserved. The patient was discharged on the 10th postoperative day. VATS is an effective treatment for the patients of congenital esophago-bronchial fistula (Braimbrige type I and II), if they are not accompanied with pulmonary abscess or pleural empyema.     

Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children

OBJECTIVE: To describe the use of percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. DESIGN: Retrospective case series. SETTING: A 24-bed pediatric intensive care unit. PATIENTS: Patients with tension pneumatocele, secondarily infected pneumatocele, or lung abscess. Tension pneumatocele was defined as an expanding intraparenchymal cyst compressing adjacent areas of the lung. Infected pneumatocele and lung abscess were defined, respectively, as intraparenchymal thin-walled cyst or thick-walled cavity containing an air-fluid level and purulent fluid. INTERVENTIONS: Seven pneumatoceles/lung abscesses were percutaneously drained in five patients. After computed tomography of the chest was obtained to localize the optimum site for drainage, a modified Seldinger technique was used to insert an 8.5-Fr soft catheter percutaneously into the cyst/cavity. The catheter was left in place until drainage (fluid and air) stopped. MEASUREMENTS AND MAIN RESULTS: All patients had clinical and radiologic improvement and were afebrile within 24 hrs after drainage. Bacterial culture grew aerobic bacteria from three cysts/cavities, anaerobic bacteria from one, and mixed bacteria from three. One patient had three secondarily infected pneumatoceles. Four of five secondarily infected pneumatoceles were under tension in two patients receiving mechanical ventilation. In both patients, the trachea was extubated within 24 hrs of drainage after prolonged mechanical ventilation. The number of days the catheter was in place ranged from 1 to 20 days. CONCLUSIONS: Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess can be performed safely and effectively in children. Early drainage is helpful, both as a diagnostic and therapeutic procedure. Drainage of tension pneumatocele may assist in weaning from mechanical ventilation. Computed tomography of the chest is helpful in determining the optimum site for percutaneous drainage.     

Pulmonary infiltration with eosinophilia and increased serum levels of squamous cell carcinoma-related antigen and neuron specific enolase

We report a case of pulmonary infiltration with eosinophilia (PIE), associated with increased serum levels of squamous cell carcinoma-related antigen (SCC) and neuron specific enolase (NSE). The diagnosis of PIE was confirmed by examination of bronchoalveolar lavage fluid and specimens of transbronchial lung biopsy. It was suggested that PIE was probably induced by a course of amoxicillin for a sore throat. Corticosteroid therapy resulted in clinical improvement of symptoms, resolution of pulmonary infiltrates on chest roentgenogram and reduction in serum levels of SCC and NSE.     

A case of huge abscess extended from anterior neck to left lung and lateral chest wall

62-year-old woman admitted our hospital with pain of left upper extremity from the left chest and dysphasia. Chest X-ray showed the huge mass shadow in the left lung field. Diabetes mellitus and inflammatory reaction such as high fervor, leukocytosis, CRP and ESR accentuation were recognized. Conservative therapy was done at first, but mass shadow on X-ray increased, and swelling appeared from the neck to the left lateral chest wall. And the same site appeared like subcutaneous emphysema. Computed Tomography showed mass shadow which was enlarged and spread in lung parenchyma and left chest wall with bubble image. Incision and open drainage was performed for the left chest wall but origin bacteria was detected in neither anaerobic nor aerobic culture of pus. Inflammation and mass shadow of left upper lung field have decreased gradually. The patient discharged without bronchoalveolar fistula. Abscess extending from the neck or chest wall with diabetes mellitus is very rare.     

Hemilateral hydrothorax and atelectasis during laparoscopic Nissen fundoplication

A 57-year-old woman, weighing 75 kg, with gastroesophageal sliding hernia, received laparoscopic Nissen fundoplication under general anesthesia. Although artificial ventilation was carried out uneventfully when the surgery started, sudden decreases in SpO2 and thoraco-pulmonary compliance were noted after insufflation of CO2. Breath sound was not audible on the left lung. We suspected that inadvertent pneumothorax was produced, but chest X-ray and transesophageal echocardiography at the end of surgery revealed the presence of left hemilateral hydrothorax with pulmonary atelectasis. She was ventilated artificially and given diuretics and albumin solution for 3-days before extubation. We speculated on two reasons for the event: a possibility of perforation of the diaphragm manipulated by surgeons, and that of transition of fluid used for irrigation just below the diaphragm. Pulmonary atelectasis could be induced with hemilateral lung ventilation because cephalad shifting of the diaphragm might follow the intraperitoneal insufflation. We conclude that laparoscopic surgery with insufflation of gas and irrigation with fluid requires careful attention if the laparoscopic surgery is sustained with insufflation and irrigation.     

2 cases of solitary pulmonary arteriovenous fistula presenting in the neonatal period

Two case reports of pulmonary arterio-venous fistulae presenting in the neonatal period are described. One child had severe respiratory distress with cardiac failure and the other presented with cyanosis and a continuous murmur. In both, chest X-ray demonstrated a localised lesion and the presence of an arteriovenous fistula was confirmed by pulmonary angiography. Lobectomy cured both children.     

Extensive fetal intrathoracic injuries sustained in a motor vehicle accident

Motor vehicle accidents are the primary nonobstetric cause of maternal and subsequent fetal mortality. We present a case in which blunt abdominal trauma sustained by a pregnant woman in a motor vehicle accident caused extensive intrathoracic fetal injuries consisting of bilateral hemothorax, severe bilateral interstitial pulmonary hemorrhages, hemopericardium, and subepicardial hemorrhages, in addition to fetal cranial injuries. To the best of our knowledge, this is the first report of fetal intrathoracic injuries sustained with blunt maternal trauma. The underlying mechanism of intrathoracic trauma was thought to be similar to that of blast injury with transmission of excessive hydrostatic forces throughout the amniotic fluid with severe impact on the elastic fetal chest. This case supports the concept of in utero blast injury to the fetus as a possible cause for fetal soft tissue trauma associated with blunt trauma to the maternal abdomen.     

Infected emphysematous bullae in a patient with diabetes mellitus

A 42-year-old woman with diabetes mellitus was admitted to our hospital because of fever, coughing, and dyspnea. Coarse crackles were audible and respiratory sounds were weak in the right lung field. Laboratory examination revealed a high erythrocyte sedimentation rate, a high level of serum C-reactive protein, a high blood sugar level, and hypoxemia. A chest roentgenogram revealed cystic lesions with fluid levels, and an infiltration shadow in the right lung field. A chest computed tomographic scan revealed many cystic lesions with fluid levels and an infiltration shadow. Our diagnosis was infected emphysematous bullae. A tube was inserted percutaneously for drainage and to allow injection of antibiotics into the cystic lesion. The cystic lesion then vanished. Percutaneous drainage and washing with antibiotics can be used to treat infected emphysematous bulla that have thick closed cystic walls.     

Treatment of hemopneumothorax under thoracoscopic guidance: a case report

A 32-year-old man was admitted to our hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemithorax. Shock developed following drainage of 1,500 ml hemorrhagic pleural fluid. Following blood transfusion, emergency surgery was carried out. At operation under thoracoscopic guidance, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noted. The artery was successfully ligated with surgical clip, and the bulla was resected using EndoGIA. This case report indicates that hemopneumothorax can be safely operated on under thoracoscopic guidance after the patient has recovered from shock by adequate blood transfusion.     

Lung function after recovery from empyema treated by closed chest tube drainage

In 32 patients 8 years after recovery from unilateral empyema treated by chest tube drainage the pulmonary function was studied. The most frequently occurring abnormalities were diminished dynamic lung compliance, diffusion capacity and perfusion evaluated by scintigraphy. Restrictive patterns were observed only in 2 patients. The greatest abnormalities were observed in patients with extensive empyema, in patients with delay in drainage and with residual radiological changes after recovery.     

Surgical management of pulmonary aspergilloma

Between 1983 and 1996., 79 patients'--operated on for pulmonary aspergilloma--clinical data has been analysed. The patients were comprised of 67 males and 12 females, with a mean age of 49 years (range, 24 to 69). Previous lung disorders were observed in about half of the cases (most frequently tuberculosis), while in the other half aspergilloma was developed on the basis of (sub)-acute infections. The most common symptom was haemoptysis (in 45% of cases). Aspergilloma was diagnosed preoperatively (especially by typical chest x-ray) in 62 patients. In the other cases tb, lung cancer, pyosclerosis were suspected. 67 patients underwent pulmonary resection (50 lobectomies, 12 wedge resections, 5 pneumonectomies), 12 cavities were opened by cavernostomy. The postoperative mortality rate was 10.1%. The most frequent complications were bleeding, prolonged air leak, pleural rest space, empyema, bronchial fistula and wound infection, which were occurred in cases with bigger cavities near chest wall. In most cases with pulmonary aspergilloma surgery remains the only effective treatment. Operation has a lower risk in asymptomatic patients, without chest wall involvement. In several cases cavernostomy might be applied successfully.     

Pulmonary hypertension. Response of vasoactive peptides to a nonionic contrast medium in patients undergoing pulmonary angiography

A 46-years-old male was admitted to our hospital because of productive cough and infiltrates on the chest roentogenogram. The patient had a history of left upper bullectomy ten years prior to the admission. The CT scan of the chest on admission showed infiltrats with cavitation in the left apex and multiple bullae in almost whole lung. Microscopical examination of smears of sputum and bronchoalveolar lavage fluid revealed acid-fast bacilli. They were identified as Mycobacterium szulgai by DNA-DNA hybridization method. The patient was treated with isoniazid, streptomycin and rifampicin. After treatment for about a month, the culture of sputum converted to negative for M. szulgai. After about three months hospitalization, the infiltrates decreased and the cavity wall became thin, and no recurrence sign has been observed after the discharge. There are a few case reports of pulmonary infection due to M. szulgai associated with bullous disease of the lung in Japan.     

Mechanical removal of the smear layer

Complications after nonoperative management of hepatic trauma are rare but include persistent biliary fistula in 4% of cases. Therapy usually involves surgical drainage or hepatic resection to control the fistula. The authors present a case of hepatic biliary fistula treated nonoperatively with percutaneous drainage and endoscopic sphincterotomy. A 16-year-old girl suffered a grade III parenchymal liver fracture to the right lobe in an automobile accident. She was hemodynamically stable with no coexistent injuries and was treated nonoperatively. Over 2 weeks her total bilirubin rose to 3.2 mg/dL, and alkaline phosphatase was 463 U/L. Ultrasound showed free intraperitoneal fluid, and 2 L of bilious fluid were retrieved by paracentesis. A radionuclide scan confirmed massive extravasation of isotope from the right lobe. Two drains percutaneously placed over the parenchymal fracture produced 500 to 600 mL of bile daily. Endoscopic retrograde cholangiopancreatography (ERCP) 1 week later showed a normal extrahepatic biliary system. A 1-cm sphincterotomy was performed without difficulty. Within 72 hours, percutaneous drains produced only 35 mL per day. The follow-up radionuclide scan showed no evidence of extrahepatic biliary extravasation, and 3 weeks later the drains were removed. Six months after the accident, results of the computerized tomography scan and liver function tests were normal. It was believed that endoscopic sphincterotomy reduced fistula output by decreasing the intrabiliary pressure caused by the ampulla, thus favoring internal drainage. This case demonstrates the effectiveness of endoscopic sphincterotomy as an alternative to direct surgical intervention for the management of posttraumatic biliary fistula.     

Treatments for hepatocellular carcinoma in cirrhosis : practical aspects]

A 44-year-old woman was admitted to our hospital for evaluation of an abnormal lung shadow. Chest computed tomography (CT) revealed a tumor surrounded by air-space and an infiltrative shadow in the right S2. Right upper lobectomy was performed and pulmonary sclerosing hemangioma was diagnosed. Usually, pulmonary sclerosing hemangioma shows a solitary round nodule on a chest CT scan. We report a case of pulmonary sclerosing hemangioma with an unusual shadow on a chest CT scan, and review the literature.     

Flap of the musculus latissimus dorsi to prevent alveolar air leakage from sectional plane of the lung after resection of metastatic pulmonary and chest wall tumor

Alveolar air leakage after pulmonary resection usually heals with adequate pleural drainage, but must be more actively treated if leakage may be severe. If left untreated, the postresection space can lead to empyema. We used a muscle flap to prevent alveolar air leakage from a large sectional plane of the lung resected because of metastases in the lung and chest wall. A 48-year-old man complained of pain and a mass on the right side of his back. He had undergone resection and chemotherapy for clear cell sarcoma that originated on the back of the left hand when 43 years of age, wedge resection of the right lower lobe of the lung for a metastatic pulmonary tumor at 46 years, and lobectomy of the same lobe for a recurrence of the metastatic pulmonary tumor at 47 years. The diagnosis was of a metastatic tumor to the right chest wall with peripheral pulmonary tumors of the right upper and middle lobes. Resection of the chest wall and the lung including the tumors was done. Much air leakage from the extensive sectional plane of the right upper and middle lobes was seen intraoperatively, and this plane was therefore covered with a flap of the musculus latissimus dorsi. Chest tubes were removed on day 7 postoperatively when air leakage was no longer seen. Subcutaneous emphysema, which appeared on day 14 postoperatively, required redrainage of the pleural air space, but pleurodesis was effective. Use of a muscle flap was simple and effective for covering of a sectional plane of the lung, and should be considered when alveolar air leakage may be extensive.     

Radiological evidence of involvement of dust exposure in pathogenesis of pulmonary alveolar proteinosis

A 52-year-old man was admitted because of increasing dyspnea on exersion and presence of pulmonary infiltrates. The patient had pulmonary tuberculosis at the age of 31, which resulted in volume loss and calcified foci in the upper lobe of his left lung. As a construction worker for more than 20 years, he had been exposed to inorganic dusts. Chest radiographs showed a symmetrical consolidation of infiltrates in both lungs with the exception of the left upper lobe, where no apparent infiltrates were shown. A computed tomographic scan of the chest revealed widely panlobular consolidation with the exception of the left upper lobe. A diagnosis of pulmonary alveolar proteinosis (PAP) was established by analysis of bronchoalveolar lavage fluid. Although the patient underwent segmental bronchoalveolar lavage four times under general anesthesia, he suffered frequent pulmonary infection and died two years after the onset his symptoms. Interestingly, the patient had a markedly narrowed orifice in the left upper lobe, as demonstrated by fiberoptic bronchoscopy. Chest radiographs of this lung field revealed no infiltrative shadows. These results suggest that some inhalative agent was involved in the pathogenesis of PAP in this case. In addition, significantly increased levels of KL-6 detected in both serum and bronchoalveolar lavage fluid were attributable to overproduction of KL-6 by Type II pneumocytes that had been stimulated or damaged by PAP.     

Surgical treatment of lung abscesses

The authors analysed a group of patients with lung abscesses that received surgical treatment, as well as the characteristics of their evolution. Seventeen patients with lung abscesses which underwent surgical therapy from 1984 to 1995 were analysed. The group was composed of 12 male and 5 female. The age varied from 25 to 78 years (mean-50.1 years). The etiologies were: post-pneumonic, tuberculosis, foreign-body, empyema. Two types of surgical procedures were performed: pulmonary resection and transthoracic drainage. The indication of surgery was based on the failure of clinical treatment, massive hemoptysis, pleural empyema and residual cavity wider than 2 cm after 6 weeks of clinical treatment. The patients with poor clinical conditions were selected to transthoracic drainage, the less invasive procedure. Most patients had a satisfactory post-operative evolution (58.9%). Five patients had complications (29.4%) as empyema and air leak for more than three weeks and two patients died (11.9%). Regarding the surgical technics, the pulmonary resection (lobectomy and segmentectomy) showed no morbidity and mortality. The usage of external chest tube drainage of the abscess had a morbidity of 40% and mortality of 20%. In conclusion, the complicated lung abscess is still a surgical pathology and the best approach seems to be the resection of the pulmonary segment affected. The drainage has specific indication, mainly in patients with deteriorating condition, but this procedure has high mortality and morbidity rates.     

Endometriosis of the lung diagnosed with videothoracoscopy

A case of non symptomatic pulmonary endometriosis appearing as multiple nodules on chest X ray and chest CT scan is reported. 43 year old woman was admitted to surgical department because of suspicion of neoplastic dissemination of unknown origin. Non invasive diagnostic procedures were not effective. Diagnosis of pulmonary endometriosis was established with thoracoscopy with lung sampling, confirmed with histopathologic evidence.