Pneumothorax following transbronchial biopsy. Low diagnostic yield with routine chest roentgenograms

A chest roentgenogram is commonly obtained after a transbronchial biopsy to exclude a pneumothorax. We hypothesized that these routine chest roentgenograms rarely demonstrate a pneumothorax in patients who have neither symptoms nor fluoroscopic findings of lung collapse. To test this hypothesis, we studied 305 consecutive patients undergoing bronchoscopy with fluoroscopically guided TBB. No patient without symptoms and fluoroscopic findings suggesting lung collapse had a pneumothorax demonstrated on the post-biopsy chest roentgenogram. At the University of Virginia, routine chest roentgenograms failed to demonstrate a single unsuspected pneumothorax among all patients undergoing TBB during a period of nearly six years. Given this low incidence of unsuspected pneumothorax, we conclude that routine chest roentgenograms have a low diagnostic yield and may not be necessary in all patients after fluoroscopically guided TBB.     

The role of the chest roentgenogram in febrile neutropenic patients

In a retrospective review of patients with neutropenia and fever, we sought to determine how often roentgenograms detected pulmonary disease, especially pneumonia, not suggested by signs and symptoms. Further, we sought to determine how often therapy was changed as a result of roentgenographic findings. Overall, 41 (22%) of 187 chest roentgenograms obtained during initial febrile episodes, recurrent fevers, or persistent fevers were abnormal. While most patients had signs and symptoms suggesting the presence of pulmonary disease, 17% had roentgenographic abnormalities detected in the absence of such findings. During initial febrile episodes, therapy was not changed in response to findings on the chest roentgenogram. However, during episodes of persistent or recurrent fever, findings on chest roentgenograms led to changes in therapy in eight (61%) of 13 episodes of which six (40%) resulted in clinical improvement. Chest roentgenograms were therefore found to be an important diagnostic tool in evaluating recurrent or persistent fever in the neutropenic patient but of little use during initial febrile episodes.     

Immediate chest roentgenography following fiberoptic bronchoscopy

It is a common practice for some clinicians to obtain a chest roentgenogram immediately following FOB in an attempt to detect complications of the procedure, particularly pneumothorax; however, the roentgenogram adds substantially to the cost of FOB. It was our clinical impression that the diagnostic and therapeutic value of immediate chest roentgenography was minimal. Therefore, we reviewed 130 chest roentgenograms taken immediately after bronchoscopy that were obtained over 36 months. One hundred fourteen (88 percent) were unchanged from the most recent roentgenogram before bronchoscopy. Ten (8 percent) showed an increase in alveolar infiltrate due to bronchoalveolar lavage or hemorrhage. Five (4 percent) had changes presumably unrelated to the procedure. Only one patient had a pneumothorax on the roentgenogram taken immediately after bronchoscopy; however, the patient was symptomatic, and the pneumothorax was detected by fluoroscopy prior to the chest roentgenogram. Management of the patient's condition was not altered in a single case based upon findings on the chest roentgenogram. We conclude that the immediately postbronchoscopic chest roentgenogram rarely provides clinically useful information or detects a complication that is not suspected clinically; furthermore, it appears to have minimal impact, if any, on the management of a patient's condition.     

A case of chronic necrotizing pulmonary aspergillosis]

A 70-year-old woman with diabetes mellitus who was following a therapeutic diet showed an infiltrative shadow in the right upper lung field on chest roentgenogram in April, 1986. She was diagnosed as having pneumonia and was treated for five months with several antibiotics, but the abnormal shadow on chest roentgenograms increased in size. Therefore, she was admitted to our hospital in October 1986. Although tubercle bacilli were not isolated from her sputum or from materials obtained by bronchoscopic examination, we made an initial diagnosis of pulmonary tuberculosis based on the findings of chest roentgenograms, tomographs and CT scanning. In spite of treatment with antituberculous drugs, the infiltrative shadow with cavity on chest roentgenograms continued to increase in size, and the patient developed occasional hemoptysis. Percutaneous needle biopsy was performed in February 1987 to establish a definite diagnosis, and the presence of Aspergillus fumigatus was confirmed by microscopic examination and culture. After treatment with miconazole and 5-FC for 3 to 4 months, the abnormal shadow on the chest roentgenogram gradually disappeared and was almost undetectable one year later. The clinical course of this patient was considered to be strongly indicative of chronic necrotizing pulmonary aspergillosis, which was described by Binder et al. in 1982.     

Prospective study of corticosteroid as an adjunct in the treatment of endobronchial tuberculosis in adults

Abstract Although endobronchial tuberculosis frequently causes bronchial stenosis, there are no specific therapies to prevent the sequelae. The use of corticosteroids remains controversial and there have been no prospective comparative studies about the effectiveness of corticosteroids. This study was undertaken in order to determine the effectiveness of corticosteroids in the prevention of complications of endobronchial tuberculosis. Thirty-four patients with endobronchial tuberculosis who were admitted to Chung-Ang University hospital from March 1991 to December 1995 were evaluated prospectively to determine the effect of corticosteroid in the treatment of endobronchial tuberculosis. All patients were randomly divided into two groups: group 1 ( n =17, anti-tuberculosis chemotherapy only) and group 2 ( n = 17, combining anti-tuberculosis chemotherapy with oral corticosteroid). Serial bronchoscopies, pulmonary function tests and chest roentgenograms were analyzed every 2 months until the complete resolution of endobronchial tuberculosis. Before treatment commenced there were no significant differences between the two groups with respect to sex, mean age, pulmonary function, chest roentgenogram and morphologic patterns of endobronchial lesion. After treatment, the healing rate of bronchoscopic findings and changes in pulmonary function showed no significant differences between the two groups. Radiologic improvements were observed in all eight patients (five in group 1 and three in group 2) with segmental atelectasis on chest roentgenograms after 2 months of treatment. This study suggests that corticosteroid therapy would not influence the outcome of endobronchial tuberculosis and that prompt treatment with early diagnosis, before formation of fibrosis would be necessary to prevent complications of endobronchial tuberculosis, such as bronchostenosis.     

Hemoptysis. Indications for bronchoscopy

Indications for bronchoscopy in patients with hemoptysis and a normal or nonlocalizing chest roentgenogram continue to be controversial. We reviewed the records for 119 bronchoscopies performed for hemoptysis in patients with a normal (n = 75) or nonlocalizing (n = 44) chest roentgenogram. Bronchogenic carcinoma was identified in 2.5% of the bronchoscopies. Additional neoplasms were found in another 2.5%. The presence of nonlocalizing abnormalities was not associated with an increase in either the rate of bronchogenic carcinoma or in the diagnostic yield (specific anatomic diagnosis or bleeding site identified) at bronchoscopy when compared with patients with normal chest roentgenograms. The factors of male sex, age more than 40 years, and a more than 40 pack-year smoking history appear useful in identifying patients in whom the yield of bronchoscopy is likely to be high.     

Pronounced progression of interstitial pneumonia in a precious metal worker]

A 43-year-old man who had been engaged in the precious-metal processing industry for 18 years was admitted to our hospital because of shortness of breath on exertion. Chest roentgenograms disclosed ground glass opacities and annular-nodular shadows in the basal area of the right lung field and almost all of the left lung field. A video-assisted thoracoscopic lung biopsy was performed, and histologic examination disclosed usual interstitial pneumonia (UIP). Mineral analysis revealed high modes of silicon and aluminum, two elements consistent with the materials used in the patient's factory. The histopathological findings indicated interstitial pneumonia caused by the inhalation of dust particles. After corticosteroid therapy, computed tomographic scans disclosed that the ground glass opacities had subsided, but that honeycomb shadows remained. A chest roentgenogram taken 2 years earlier demonstrated only minute granular lesions in the basal area of right lung field. The interstitial shadows had progressed significantly over the intervening 2-year span. The findings in this case should be of value to the etiologic study of UIP.     

Screening for lung cancer

Lung cancer is the commonest cause of death from cancer in both men and women, with approximately 152,000 new cases and 139,000 deaths in 1988. The incidence and mortality rates are increasing rapidly in women. Two main tests have been used to screen for lung cancer: chest roentgenography and sputum cytology. Four recent controlled trials and one case-control study failed, however, to show that screening reduces lung cancer mortality even in high-risk persons (smokers). In the Mayo Lung Project, for example, the lung cancer death rate in high-risk men offered sputum cytology and chest roentgenogram every 4 months was 3.1 per 1000 person-years, compared with 3.0 per 1000 person-years in a control group. Chest roentgenograms and sputum cytology lead to false-positive test results in smokers of approximately 5% and 0.5%, respectively. Because of the lack of evidence of benefit and because of its potential harms and costs, screening for lung cancer is not recommended.     

Interobserver variance in clinical scoring for cystic fibrosis

Multicenter clinical research would benefit from a simple, reliable scoring system for comparison of the clinical status of patients at different centers. In this study, five physicians performed simultaneous, independent scoring of 41 individuals with cystic fibrosis using the Doershuk modification of the Shwachman-Kulczycki scoring system for history, physical examination, and nutrition, and the Birmingham scoring system for chest roentgenograms. These were added together to obtain a clinical score. Interobserver variance of the scores was calculated. Mean individual observer variance from the consensus mean was 1.6-2.9 score points of a possible 25 for each category, 4.5-6.0 of a possible 100 for the total score. Coefficient of variance about the mean was approximately 10 percent for the individual categories, 6.7 percent for the total score. We concluded that the interobserver variance of this scoring system is within acceptable limit for most clinical studies. The total consensus score correlated with the NIH clinical score, chest roentgenogram score alone, and predicted values for forced vital capacity and FEV1 with a high degree of confidence.     

Roentgenographically atypical Pneumocystis carinii pneumonia.

Two patients with renal transplants were admitted for evaluation of fever. During the course of hospitalization both had hectic fever and arthralgia. Pulmonary symptoms were absent or minimal. In one patient the admitting chest roentgenogram was entirely normal and in the other only a small focal abnormality was apparent. Hypoxemia occurred even in the presence of normal or nearly normal chest roentgenograms. The diagnosis of Pneumocystis carinii infection was made by bronchoscopic brush biopsy in both patients. Therapy with pentamidine isethionate was successful. It is suggested that in patients with renal transplants and in others with similar immonosuppression, even with a normal chest roentgenogram, Pneumocystis carinii infection be considered as the cause of a fever of unknown origin. This should be evaluated initially with blood gas studies; if these are abnormal, further studies, including biopsy, are justified.     

Risk stratification of ambulatory patients suspected of Pneumocystis pneumonia

To determine whether aspects of clinical history, physical examination, and laboratory studies improve the diagnostic accuracy of the chest roentgenogram in the diagnosis of Pneumocystis carinii pneumonia (PCP), we followed up 302 consecutive patients with respiratory symptoms and risk factors for human immunodeficiency virus. Of the 279 patients (92%) with follow-up information available, 31 (11%) were diagnosed with PCP. Only 68% of patients with PCP had typical chest roentgenograms. Regression analysis identified four independent predictors of PCP: diffuse or perihilar infiltrates, presence of mouth lesions, lactate dehydrogenase level more than 220 U/L, and erythrocyte sedimentation rate 50 mm/h or more. Using these four predictors, patients could be stratified into low-, intermediate-, and high-risk groups for PCP. We suggest that examination of the mouth, chest roentgenogram, lactate dehydrogenase level, and erythrocyte sedimentation rate be part of the evaluation of ambulatory patients with respiratory symptoms at risk for human immunodeficiency virus.     

Pulmonary disease associated with L-tryptophan-induced eosinophilic myalgia syndrome. Clinical and pathologic features

Tablets and capsules containing the essential amino acid L-tryptophan are currently being investigated as a cause of the newly recognized eosinophilia/myalgia syndrome. In the five histologically documented cases reported herein, L-tryptophan ingestion was associated with prominent pulmonary complications. All patients were women ranging from 34 to 65 years, and all presented with respiratory symptoms that began after one to nine months of L-tryptophan therapy. Peripheral eosinophilia was present in four patients as were bilateral interstitial infiltrates on chest roentgenograms. One patient had a normal chest roentgenogram. Lung biopsies were done in all patients and biopsy specimens showed a vasculitis and perivasculitis associated with a mild chronic interstitial pneumonitis and eosinophilia. Three patients had clinical and/or histologic evidence of pulmonary hypertension, and one had a follicular bronchiolitis. Four patients recovered promptly with steroid therapy and discontinuation of L-tryptophan therapy, and one patient has had minimal symptomatic improvement.     

High-resolution ultrafast chest CT in the clinical management of febrile bone marrow transplant patients with normal or nonspecific chest roentgenograms

Plain chest roentgenograms may be normal or show nonspecific abnormalities during the frequent febrile episodes that occur in patients after bone marrow transplantation. In this group, ultrafast 10-mm and 3-mm high-resolution CT scans were prospectively performed in 33 patients to determine if useful information was provided that either changed the patient's clinical management or added confidence to the clinical diagnosis. The 36 symptomatic episodes that occurred in 33 patients included fever in 20 episodes and fever combined with cough, dyspnea, chest pain, or rales in 16. Fourteen chest roentgenograms were interpreted as normal, and 22 were interpreted as demonstrating nonspecific changes; however, none of the roentgenograms was considered helpful in that they did not provide sufficient information for further management. In 2 of 14 episodes in patients with normal chest roentgenograms and in 9 of 22 episodes in patients with nonspecific chest roentgenograms, CT scanning resulted in a change in clinical management that included performing bronchoscopy, increasing or changing antibiotic coverage, starting white blood cell transfusions, requesting surgical biopsy, or a combination of these. In 1 of 14 episodes in patients with normal chest roentgenograms and in 8 of 22 episodes in patients with nonspecific roentgenograms, CT added confidence to the diagnosis. In the remaining 16 episodes, CT scans provided no additional information. We conclude that in many instances, noncontrast ultrafast chest CT scans can provide information that may either change a patient's clinical management or more clearly establish the extent of pulmonary disease.     

Predictive value of bronchoalveolar lavage in pulmonary sarcoidosis

We investigated whether analysis of cellular composition (including lymphocyte subsets) in bronchoalveolar lavage (BAL) fluid at the start of follow-up in patients with untreated sarcoidosis has any predictive value for further evolution of the disease. The outcome was evaluated by the chest roentgenograms, the lung volumes, and the single breath diffusing capacity for CO (DCO) after 22 to 36 months. In contrast to the general belief, patients who improved radiologically had a significantly higher T4 cell count (as percentage of BAL lymphocytes) (p less than 0.02) and a higher T4-T8 ratio in the initial BAL sample (9.3 vs 3.2; p less than 0.05) than those whose chest roentgenogram showed deterioration or remained unchanged. Total cell count and the percentage of lymphocytes in BAL fluid were not different between both groups. The change in DCO at the end of the follow-up period correlated positively with the baseline BAL T4 cells (Rs = 0.44; p less than 0.05) and with the BAL T4-T8 ratio (Rs = 0.51; p less than 0.03) and negatively with the baseline BAL T8 cells (Rs = -0.48; p less than 0.04). In only three patients progression of the disease necessitated steroid therapy, and they all had a low to normal T4-T8 ratio in the initial BAL sample. Bronchoalveolar lavage was repeated at least once in ten patients. Improvement of the chest roentgenograms in these patients was accompanied by a decrease of the BAL T4 cell count (as percentage of lymphocytes) and of the T4-T8 ratio. We conclude that a high lymphocyte count, a high T4 cell count (as percentage of lymphocytes), and a high T4-T8 ratio in BAL fluid reflect an intense alveolitis at the time of the procedure, but they are not indicators of poor prognosis on which therapeutic decisions can be based.     

A case of alveolar hydatid disease of the lung in the Kansai district of Japan]

A 78-year-old man was admitted to hospital because of episodes of high grade fever and multiple nodular shadows on chest roentgenogram. He had a past history of percutaneous drainage and partial resection of the left lobe of the liver for liver abscess of unknown origin in 1987. The high grade fever was secondary to sepsis due to Citrobacter freundii. The sepsis improved with antibiotic therapy, but the abnormal shadows on chest roentgenogram did not improved. Immunoserological tests indicated a probable diagnosis of alveolar hydatid disease of the lung, which is very rare in the Kansai district of Japan. Open lung biopsy was performed and the diagnosis of alveolar hydatid disease of the lung was confirmed.     

Roentgenograms in primary care patients with acute low back pain: a cost-effectiveness analysis

For patients visiting a primary care office practice for acute low back pain, we compared the benefits, risks, and costs of obtaining a roentgenogram of the lumbar spine routinely at the initial visit with performing a roentgenogram only if the patient's pain does not improve during and eight-week follow-up period. The cost-effectiveness analysis indicated that, to avert one day of physical suffering in a population of patients, the population would have to be subjected to the additional risk of 3,188 mrad of radiation and an additional cost of $2,072. While, in the individual case, circumstances might lead to a different conclusion, in general, the risks and costs of obtaining lumbar roentgenograms at the initial visit in patients with acute low back pain do not seem to justify the relatively small associated benefit.     

Selective criteria may increase lumbosacral spine roentgenogram use in acute low-back pain

Eleven clinical criteria have been proposed to limit use of lumbosacral spine roentgenograms in patients with acute low-back pain who are at risk for vertebral cancer, osteomyelitis, acute fracture, or herniated disk. We retrospectively applied the criteria to 471 patients with acute low-back pain in three teaching hospital walk-in clinics. Roentgenograms were obtained at the initial visit in 99 patients (21.1%); the number would have increased to 217 (46.1%) if the criteria had been used. The following four patient characteristics were associated with actual roentgenogram use: older age, longer duration of symptoms, reflex asymmetry, and point vertebral tenderness. Adoption of the 11 criteria studied herein may inadvertently increase roentgenogram use, thereby raising health care costs and exposing more patients to gonadal irradiation. The standard of practice in these three clinics seemed to entail use of less broad roentgenogram selection criteria. Other published guidelines for roentgenograms emphasize clinical follow-up, reserving further evaluation for patients who fail to improve after a trial of bed rest and analgesics.     

Decision analysis, public health policy, and isoniazid chemoprophylaxis for young adult tuberculin skin reactors

As part of a plan to eliminate tuberculosis in America, tuberculin skin testing was advised for all US citizens, with isoniazid chemopreventive therapy administered to appropriate positive reactors. Implementation of this plan, however, may be limited by concerns over which skin test reactors should receive isoniazid therapy. Recent decision analyses suggest that, contrary to American Thoracic Society guidelines, asymptomatic skin test reactors under age 35 years with normal chest roentgenograms and no predisposing conditions to tuberculosis reactivation will not benefit from isoniazid chemopreventive therapy. Repeated analysis of these studies reveals that calculated life expectancy depends on estimates of the probability of certain chance outcomes. If the isoniazid-related hepatitis case-fatality rate is below 1%, isoniazid chemopreventive therapy appears to be beneficial. A literature review suggests that this rate is indeed this low. If the tuberculosis case-fatality rate is above 6.7%, also supported by the literature, the advantages of isoniazid therapy are further increased. This repeated analysis should reassure physicians that isoniazid chemoprophylaxis for tuberculin skin test reactors is beneficial to the individual and consonant with public health policies.     

Recurrent pulmonary edema associated with obstructive sleep apnea syndrome]

A 70-year-old non-obese man with no history of cardiopulmonary disease presented 4 times to the emergency room because of sudden onset of seizure during sleep. Each time he recovered within a few hours without any medication. Nocturnal polysomnographic recording revealed severe obstructive sleep apnea syndrome (OSAS, AHI 52.4/Hr). Nasal continuous positive airway pressure (n-CPAP) therapy was performed with 10cmH2O of pressure. His symptoms of severe daytime sleepiness and seizure were diminished. CPAP was decreased from 10cmH2O to 6 cmH2O later, because the patient complained with its high pressure. He then felt daytime sleepiness and suffered seizures during sleep again, and was re-admitted to our hospital. Chest roentgenogram taken at this admission showed remarkable pulmonary edema. We found that the pulmonary edema was recognized every time on his chest roentgenogram taken when he complained seizure. In addition, subsequesnt roentgenograms also showed that the pulmonary edema was diminished soon. On the other hand, his AHI was high (24.7/hr) even when he was under 6cmH2O of n-CPAP. We concluded that incompletely treated OSAS might lead not only to pulmonary edema, but also to seizures in this patient.     

Bronchoscopy to evaluate hemoptysis in older men with nonsuspicious chest roentgenograms

Six of 106 older men with hemoptysis and a nonsuspicious chest roentgenogram who underwent fiberoptic bronchoscopy were found to have cancer. Four of the five bronchogenic carcinomas appeared to be surgically resectable. Cancer patients were significantly older, had smoked within the last five years, and had a significantly higher frequency of central abnormalities on chest roentgenogram. Six additional bronchogenic carcinomas were diagnosed at follow-up. Two of these were probably present but not detected at the time of bronchoscopy. We conclude that (1) hemoptysis with a nonsuspicious chest roentgenogram carries an appreciable risk of cancer in older men with substantial smoking histories, (2) these cancers are often resectable, (3) a chest roentgenogram in which the central lung fields are obscured in any way should not be considered negative in patients with hemoptysis, and (4) a negative bronchoscopic examination does not exclude the possibility of cancer in these patients.