Bronchiolitis obliterans organizing pneumonia

Bronchiolitis obliterans organizing pneumonia (BOOP) is increasingly recognized as an important cause of diffuse infiltrative lung disease. It is a diagnostic consideration in patients with a febrile flu-like illness of a few weeks' duration and a roentgenogram showing bilateral patchy infiltrates that are not responsive to a typical course of antibiotics. It is defined as granulated tissue plugs within lumens of small airways that extend into alveolar ducts and alveoli. Clinically, a flu-like illness, cough, and crackles are common. Pulmonary function studies of patients show a decreased vital capacity, normal flow rates (except in smokers), and a decreased diffusing capacity. It is generally idiopathic, but it may occur during the resolution of a viral or mycoplasma pneumonia. It is also associated with a variety of systemic illnesses and clinical settings. These include the connective tissue disorders, antineoplastic and other drugs, and immunological disorders, as well as bone marrow and lung transplantation. There are numerous related disorders, including human immunodeficiency virus infection, radiation therapy, thyroiditis, and alcoholic cirrhosis. In idiopathic BOOP, complete resolution occurs in 65% to 85% of patients treated with corticosteroid therapy. This type of therapy is often effective in patients with associated systemic disorders or in other clinical settings, but there may be limited or no response in patients with dermatomyositis, immunosuppression, or interstitial opacities at the lung bases. Respiratory failure leading to death may occur in 5% of patients. It is important to add BOOP to the differential diagnosis of febrile, noninfectious illnesses that are mimics of pneumonia.     

Bronchiolitis obliterans organizing pneumonia

Idiopathic BOOP is a clinicopathological entity defined histopathologically by the presence of granulation tissue in bronchioles, alveolar ducts and alveoli. 2 men and 6 women (mean age 47.2 years, range 22-66) with idiopathic BOOP have been observed, the mean period of observation being 31.1 months. In 7 cases the disease started with fever, cough and in 6 with progressive dyspnea. The interval between the onset of symptoms and the beginning of treatment ranged from 2 to 10 months. One woman was asymptomatic. The initial findings were: tachypnoea (6), crackles (7), decreased VC (6), reduced diffusing capacity (6), raised erythrocyte sedimentation rate (7). In 6 cases chest radiographs showed multiple alveolar patchy opacities of various size predominantly in the middle and lower lung zones. HRCT demonstrates peripheral distribution of changes. In one case diffuse reticulonodular infiltrates and in one case solitary tumor-like opacity with cavitation were observed. Seven subjects were given prednisone. Three subjects recovered completely, in 1 clinical and radiological improvement was observed. In 3 cases relapse occurred. The woman with the solitary tumor-like opacity was cured by surgical excision of the lesion.     

Bronchiolitis obliterans with organizing pneumonia

We present two cases of community acquired pneumonia (extra-hospital) of severe onset, secondary to Chlamydia psittaci of avian origin. Each patient have bought a parakeet in the same pet-shop, and took care of them personally. Both developed a respiratory insufficiency, one of them needing mechanical ventilation. Out of nine relatives to whom serological determinations were performed, there was evidence of infection in two of them, but only one referred an auto-limited febrile syndrome during that period of time. Psittacosis incidence is discussed as origin of community acquired pneumonias, as well as its epidemiology, diagnosis and treatment.     

Bronchiolitis obliterans syndrome in heart-lung transplantation: surveillance biopsies

Transbronchial biopsies (TBBs) are useful to diagnose acute rejection and infection in patients with lung transplants. The value of routine surveillance biopsies (S-TBBs) is not known, and such biopsies with a clinical indication are not without risk and are expensive. One hundred twenty-six 6-mo survivors of heart-lung transplantation (HLT) were studied to determine the effect of stopping S-TBBs on the development of bronchiolitis obliterans syndrome (BOS) and subsequent survival. Fifty-one received transplants while S-TBB was part of routine care (group A), and 75 received transplants after this practice was stopped (group B). There was no difference in patient characteristics. Group A had shorter graft ischemia (p < 0.01) and longer postoperative ventilation (p < 0.01). Maintenance immunosuppression was similar, but group A had more steroid pulses in the second 6 mo after HLT (p < 0.01). The number of patients free from any functional deterioration at 49 to 60 mo after HLT declined to 39% in group A and 64% in group B. The risk of developing BOS grade 1 in group A relative to group B was 1.63 (95% confidence intervals: 0.96-2.79, p = 0.07). Patient survival was similar in the two groups. A total of 86 TBBs were taken in the absence of any signs or symptoms and had low diagnostic yield. In summary, there was no increased incidence of BOS after stopping S-TBBs.     

Bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma

OBJECTIVE: The purpose of the study was to identify factors associated with an increased risk of complications after partial-thickness or full-thickness glaucoma surgery. DESIGN: A retrospective, cohort analysis. PARTICIPANTS: A total of 24,206 Medicare patients who were older than 65 years of age and who were enrolled in Medicare in 1994 underwent partial-thickness or full-thickness glaucoma surgical procedures in 1994. INTERVENTION: The authors obtained data on all glaucoma surgery claims to the Health Care Finance Administration in 1994 and analyzed complication rates using hierarchical logistic regression, separately smoothing four sets of regression coefficients (state-level effects, systemic and ocular diagnoses, prior ocular surgeries, and concomitant ocular surgeries). MAIN OUTCOME MEASURE: Patients were classified as having complications if their records showed at least one of the following occurrences after surgery: retinal detachment repair, endophthalmitis, scleral fistula revision-repair, or cyclodestruction. RESULTS: The risk of complications was greater for full-thickness procedures than for partial-thickness procedures (odds ratio [OR] = 1.51; 95% confidence interval [CI] = 1.07, 2.12). Compared to glaucoma surgeries performed without an additional intraocular procedure, glaucoma surgery with prior phacoemulsification (OR = 0.51; 95% CI = 0.35, 0.74) was associated with lower complication rates, as was glaucoma surgery with prior argon laser trabeculoplasty (OR = 0.62; 95% CI = 0.44, 0.88). A concomitant vitrectomy (OR = 1.86, 95% CI = 1.35, 2.56) was associated with greater odds of a complication. The mean follow-up of subjects was 184 days (standard deviation, +/- 107), whereas the mean time to a complication was 49 days (standard deviation, +/- 63). CONCLUSION: The risk of an early postoperative complication after full-thickness procedures appears to be greater than that after partial-thickness procedures. Concomitant intraocular procedures performed in conjunction with glaucoma surgery, such as a vitrectomy, can substantially increase the risk of retinal detachment repair, endophthalmitis, scleral fistula revision-repair, and/or cyclodestruction.     

Bronchiolitis obliterans in a patient with HIV infection

We sought to determine the relationship between an isolated choroid plexus cyst diagnosed antenatally and fetal aneuploidy in an unselected population at a district general hospital. Over a 5-year period all women attending for a detailed anomaly scan at 18-20 weeks' gestation were screened for evidence of a fetal choroid plexus cyst. All cases of choroid plexus cyst were recorded prospectively. The size, position and number of the cysts were noted and associated abnormalities seen on ultrasound were also recorded. Cases of choroid plexus cyst associated with fetal aneuploidy were noted. A total of 13,690 women were screened, and 84 cases of choroid plexus cyst were identified (0.6%). Of these, 41% underwent prenatal karyotyping by amniocentesis; 78 of 84 cases (93%) were isolated. Six had other markers for aneuploidy, and three of these fetuses had trisomy 18. All cases of isolated choroid plexus cyst resulted in chromosomally normal neonates. This was confirmed by either normal antenatal karyotype or postnatal examination by the pediatricians. The size, position and number of cysts did not appear to influence the risk of aneuploidy. We conclude that the risk of aneuploidy for a case of isolated choroid plexus cyst in an unselected population appears to be very low, and in this series was 0%. In this setting, we suggest detailed ultrasound examination is essential, rather than routine karyotyping.     

Bronchiolitis obliterans after bone marrow transplantation: evaluation with lung scintigraphy

Hypophosphatasia is a rare disorder characterised by low levels of serum alkaline phosphatase activity resulting in abnormal phosphorylated metabolites and varying skeletal abnormality. We have followed a patient with adult type hypophosphatasia for over ten years who has also shown a persistently elevated tartrate resistant acid phosphatase activity (TRAP) without any obvious cause. Characterisation of this TRAP by polyacrylamide gel electrophoresis (pH 4.0) showed migration to band 5 position. Molecular weight determination by FPLC and an estimate of the molecular weight by gradient gel electrophoresis gave a molecular weight of 29,000-43,600. This molecular weight makes it unlikely for this to be a IgG/TRAP complex persisting in the circulation. Paranitrophenylphosphate was the preferred substrate. This characterises the enzyme as type 5 acid phosphatase which is of the mononuclear/phagocyte type, possibility of osteoclastic origin, though the tissue source remains unknown.     

Bronchiolitis obliterans organizing pneumonia in a patient with AIDS

A 35-year-old homosexual man who had a remote history of cocaine abuse presented to the hospital with fever, chills, drenching night sweats, and progressive dyspnea of 3 months' duration. His condition had been diagnosed as AIDS 1 1/2 years before presentation. Multiple blood cultures and serological tests failed to yield an infective etiology. Bronchoscopy with transbronchial biopsy, both performed twice, also failed to reveal an etiology. Empirical treatment for infection with the Mycobacterium avium complex yielded no response; empirical treatment, based on abnormalities revealed by gallium scanning, for Pneumocystis carinii pneumonia led to some clinical improvement. Because of rapid respiratory deterioration at the end of this treatment course, a thoracoscopic lung biopsy was performed; this procedure demonstrated classic bronchiolitis obliterans organizing pneumonia. Corticosteroid therapy resulted in a rapid salutary response. It is important to aggressively pursue a definitive diagnosis for selected patients with a nonidentifiable infectious cause so that patients receive the correct treatment.     

Osteoporosis in men. New insights into aetiology, pathogenesis, prevention and management

Osteoporosis is increasingly recognised in men. Low bone mass, risk factors for falling and factors causing fractures in women are likely to cause fractures in men. Bone mass is largely genetically determined, but environmental factors also contribute. Greater muscle strength and physical activity are associated with higher bone mass, while radial bone loss is greater in cigarette smokers or those with a moderate alcohol intake. Sex hormones have important effects on bone physiology. In men, there is no abrupt cessation of testicular function or 'andropause' comparable with the menopause in women; however, both total and free testosterone levels decline with age. A common secondary cause of osteoporosis in men is hypogonadism. There is increasing evidence that estrogens are important in skeletal maintenance in men as well as women. Peripheral aromatisation of androgens to estrogens occurs and osteoblast-like cells can aromatise androgens into estrogens. Human models exist for the effects of estrogens on the male skeleton. In men aged > 65 years, there is a positive association between bone mineral density (BMD) and greater serum estradiol levels at all skeletal sites and a negative association between BMD and testosterone at some sites. It is crucial to exclude pathological causes of osteoporosis, because 30 to 60% of men with vertebral fractures have another illness contributing to bone disease. Glucocorticoid excess (predominantly exogenous) is common. Gastrointestinal disease predisposes patients to bone disease as a result of intestinal malabsorption of calcium and colecalciferol (vitamin D). Hypercalciuria and nephrolithiasis, anticonvulsant drug use, thyrotoxicosis, immobilisation, liver and renal disease, multiple myeloma and systemic mastocytosis have all been associated with osteoporosis in men. It is possible that low-dose estrogen therapy or specific estrogen receptor-modulating drugs might increase BMD in men as well as in women. In the future, parathyroid hormone peptides may be an effective treatment for osteoporosis, particularly in patients in whom other treatments, such as bisphosphonates, have failed. Men with idiopathic osteoporosis have low circulating insulin-like growth factor-1 (IGF-1; somatomedin-1) concentrations, and IGF-1 administration to these men increases bone formation markers more than resorption markers. Studies of changes in BMD with IGF-1 treatment in osteoporotic men and women are underway. Osteoporosis in men will become an increasing worldwide public health problem over the next 20 years, so it is vital that safe and effective therapies for this disabling condition become available. Effective public health measures also need to be established and targeted to men at risk of developing the disease.     

Bronchiolitis obliterans and no radiographic abnormalities in a patient with rheumatoid arthritis

In a case-control study, we evaluated the association of the risk of menstrual disorders with four periconceptional factors: short preceding interpregnancy interval (< 6 months), low (< or = 19 years) or high (> or = 40 years) maternal age at conception, and month of conception. We divided 919 women who had visited a fertility clinic between 1991 and 1995 into three categories: cases (with mean menstrual cycle length > or = 42 or < or = 21 days, or a variation of > or = 14 days between cycles, or amenorrhea, N = 294), controls (with cycles within a range of 25-35 days and variation < or = 7 days, N = 520), and intermediates (N = 105). A self-administrable questionnaire was mailed, asking for information about maternal reproductive history and age, and potential confounders such as smoking, exercise, and level of education. Response (77%) differed little among cases, intermediates, and controls. We found elevated risks for short pregnancy intervals [adjusted odds ratio (OR) = 2.04; 95% confidence interval (CI) = 1.04-4.02] and advanced maternal age (OR = 3.24; 95% CI = 1.27-8.30) but not for low maternal age (OR = 0.58; 95% CI = 0.11-3.14) (cases vs controls). We found similar effects for intermediates vs controls. The distribution of month of conception did not differ much from controls for both cases and intermediates. The results indicate that conception after short pregnancy intervals or at advanced maternal age increases the risk of menstrual disorders in daughters. The precise etiology is unclear, but it may lie in the quality of the oocyte at conception.     

Photoaging and topical tretinoin: therapy, pathogenesis, and prevention

Repeated exposure to UV radiation from the sun causes premature skin aging. This photoaging is characterized by wrinkles, mottled pigmentations, dry and rough skin, and loss of skin tone. Since the clinical demonstration that the use of topical tretinoin can improve photoaged skin, a great deal of knowledge that may explain wrinkle effacement has been acquired. Central to this pursuit has been dermal collagen. In this article, we summarize evidence (mainly from humans) that implicates a deficiency of superficial dermal collagen as the cause of the dermal aspects of photoaging. In addition, a mechanism through which UV radiation can lead to reduced collagen is presented. Through our understanding of the pathophysiological mechanism of photoaging, our ability to treat and possibly prevent this skin condition is enhanced.     

Bronchiolitis obliterans in a patient with localized scleroderma treated with D-penicillamine

D-penicillamine-associated bronchiolitis obliterans (BO) is a rare but well-known pulmonary complication in patients with rheumatoid arthritis or progressive systemic sclerosis. It has been assumed that in most, if not all cases, BO is a complication of the underlying disease rather than a side-effect of treatment. We report the case of a 46 year old man with scleroderma localized to his lower legs (morphea), who received a daily dose of 750 mg D-penicillamine. During the treatment of 1 yr duration, he developed progressive shortness of breath due to a worsening obstructive ventilatory defect suggesting BO, which was confirmed by surgical lung biopsy (constrictive BO). Bronchial obstruction progressed over the next 5 yrs and did not respond to corticosteroids. The patient finally underwent a successful single left lung transplantation. The histological features of constrictive BO were confirmed in the explanted lung. This observation suggests that D-penicillamine may induce bronchiolitis obliterans in the absence of a systemic connective tissue disease.     

Bronchiolitis obliterans organizing pneumonia. Experience in a second level hospital

PURPOSE: To determine if the pattern of publication of contact lens articles in the ophthalmic literature has changed in recent years. METHODS: We searched the literature of the past 5 years and reviewed the abstracts of all published papers that presented information on contact lenses. The journals reviewed included the American Journal of Ophthalmology, Archives of Ophthalmology, Ophthalmology, and The CLAO Journal. We determined whether articles were positive, negative, or neutral. RESULTS: We reviewed a total of 1,189,451 articles and 48,811 (4.10%) eye articles; of the latter, 987 (2.02%) discussed contact lenses. Only 86 total contact lens articles were published in the three major ophthalmology journals, of which almost 40% presented negative information (e.g., complications of contact lens usage). The CLAO Journal published 136 contact lens articles during the same time period (39.7% were positive and 30.1% were negative). CONCLUSIONS: In the past 5 years, fewer contact lens articles have appeared in the ophthalmic literature than had appeared in the previous five years, and, in addition, more of these articles were negative. The CLAO Journal continues to publish the largest number of contact lens articles, although the percentage of positive articles has decreased somewhat, from 50% to 39.7%.     

Bronchiolitis obliterans with organizing pneumonia. Retrospective study of 19 cases

We report a series of 19 cases of bronchiolitis obliterans with organized pneumonitis (BOOP) observed in two pneumology units at the Strasbourg University Hospital between July 1987 and June 1997. Mean patient age was 60 years. Clinical features included dry cough, exercise-induced dyspnea, and a flu-like syndrome in three-quarters of the cases. Standard chest x-ray showed a diffuse non-systemized alveolar syndrome with a air bronchogram in 18 cases and an interstitial syndrome in one-third of the cases. computed tomography of the thorax visualized bronchial dilatations by traction of the alveolar syndrome in one-third of the cases. Pulmonary function tests showed moderate restriction. Lymphocytes predominated in bronchio-alveolar lavage fluid. Pathology examination of surgical lung specimens (5 cases), transbronchial biopsies (5 cases) and scan-guided transparietal punctures (4 cases) provided the diagnosis. In 5 cases the diagnosis was based on the radiological and clinical presentation and favorable course on corticosteroid therapy. Recurrence was observed at corticosteroid withdrawal or dose reduction in 7 cases. In this series, bronchiolitis obliterans with organized pneumonitis was probably secondary to rheumatoid arthritis (1 case), breast radiotherapy (3 cases), and drugs (amiodarone: 1 case: sotalol: 2 cases: betaxolol: 1 case). An association with betaxolol has not been previously reported in the literature.     

Bronchiolitis obliterans with organizing pneumonia in a patient treated with amiodarone]

Bronchiolitis obliterans organizing pneumonia (BOOP) is a well-defined clinicopathological entity. The aetiology of BOOP is generally unknown, although it has been associated with specific diseases or various pharmaceutical drugs. The amiodarone is one of them. We report a patient with BOOP secondary to amiodarone therapy, who presented with cough, fever and sputum production, dyspnoea and night sweats lasting for two months. A chest radiograph showed bilateral patchy and interstitial infiltrates. Lymphocyte phenotyping of bronchoalveolar lavage fluid showed decreased ratio of CD4+:CD8+ lymphocytes. Transbronchial lung biopsy established the diagnosis of BOOP. After stopping amiodarone therapy, symptoms disappeared and the chest radiograph remained normal within two months.     

Thrombosis and malignancy: pathogenesis and prevention

Comparative mutagenic and genotoxic effects of three antimalarial drugs, chloroquine, primaquine and amodiaquine, were assessed in the Ames mutagenicity assay (in strains TA97a, TA100, TA102 and TA104) and in vivo sister chromatid exchange (SCE) and chromosome aberration (CA) assays in bone marrow cells of mice. These are the most commonly used antimalarial drugs available at present throughout the world. The results of the bacterial mutagenicity assays showed a very weak mutagenic effect of all three drugs in Salmonella strains TA97a and TA100 both with and without S9 mix and in TA104 only with S9 mix. The results of the in vivo SCE and CA assays indicate that these three drugs are genotoxic in bone marrow cells of mice.     

The hepatic porphyrias: pathogenesis, manifestations, and management

Sexual activities and attitudes of a group of adolescents, who have been followed from early infancy as a part of the New York Longitudinal Study, are reported. Adolescents in the study evince a more matter-of-fact, less fearful attitude than that of previous generations, but do not seem more prone to casual sexual encounters. Sexual conflicts are seen to occur only in relation to overall psychological conflict.