Amyloidosis with pleural involvement

Although amyloidosis of the respiratory tract is well recognized, pleural involvement is very rare with only two cases being reported in the past. We report a case of primary amyloidosis with pleural effusion and suggest that pleural involvement and pleural effusion be added to the classification of pulmonary amyloidosis, and that amyloidosis be added to the list of causes of a pleural effusion.     

Amyloidosis and inflammatory bowel disease

Surprisingly little has been written about the association of amyloidosis with inflammatory bowel disease. On reviewing the literature it appears that there is a correlation between amyloidosis and Crohn's disease, but little definitive evidence of such a relationship with ulcerative colitis could be found. No specific features emerge as aetiological factors in the amyloidosis of inflammatory bowel disease. The amyloidosis may arise after only a short duration of bowel disease, and there is evidence that the association may be commoner than is realized. The need for a prospective systematic search in a large number of patients with inflammatory bowel disease is emphasized.     

Amyloidosis. Also a heart disease

The term cardiac amyloidosis refers to the involvement of the heart as a result of amyloid deposition in heart tissue either in the context of a systemic disease or as a localized form. Several proamyloid proteins can produce amyloid deposits in the heart. Each of these amyloidoses has characteristic clinical (cardiac and extracardiac) features, its own course, and a specific diagnosis and treatment. Since cardiac involvement may be the first-manifestation of amyloidosis, the cardiologist may be the first healthcare professional to see the patient and must always consider this diagnosis. In this review, we consider the amyloidosis characteristics that may present with cardiac involvement, from the cardiologist's viewpoint and in light of our experience. We review in detail when and how to establish the diagnosis and how to treat these patients’ cardiac involvement and the underlying amyloid disease.Full English text available from: www.revespcardiol.org     

Drug-induced pleural disease

Drug-induced pleural disease is uncommon and less known to clinicians than drug-induced parenchymal lung disease. Pleural reactions from drugs manifest as pleural effusions, pleural thickening, or pleuritic chest pain, and may occur in the absence of parenchymal infiltrates. The clinician should be cognizant of the possibility of a drug-induced pleural reaction. A detailed drug history, temporal relationship between symptom onset and initiation of therapy, and pleural fluid eosinophilia should raise the suspicion of a drug-related process. We suspect that as new drugs are marketed in the United States, the number of drugs that result in pleuropulmonary toxicity will continue to increase. Moreover, if the cause of an exudative pleural effusion is not clinically obvious after pleural fluid analysis, drug therapy withdrawal should be a consideration if clinically appropriate before initiating an extensive diagnostic evaluation that may entail unnecessary economic burden and discomfort for the patient.     

Imaging of pleural disease

Imaging plays an important role in the diagnosis and subsequent management of patients with pleural disease. The presence of a pleural abnormality is usually suggested following a routine chest x-ray, with a number of imaging modalities available for further characterization. This article describes the radiographic and cross-sectional appearances of pleural diseases, which are commonly encountered in every day practice. The conditions covered include benign and malignant pleural thickening, pleural effusions, empyema and pneumothoraces. The relative merits of CT, MRI and PET in the assessment of these conditions and the role of image-guided intervention are discussed.     

胸膜疾病相关肺复张不全

胸膜疾病相关肺复张不全首例报道为肺结核继发气胸患者,主要与瘢痕牵拉和肺纤维化及支气管阻塞和胸膜增厚致肺顺应性下降有关[1]。现今概念主要指胸膜疾病经胸腔穿刺、置管引流及相关治疗后肺无法复张至正常状态,肺容量部分减少甚至完全不张,包括胸腔积液引流后的液气胸,胸痛等原因所致引流不彻底,或虽经引流但存在支气管腔内阻塞、通气不畅等。表现为两种形式,其一为陷闭肺(trapped lung),主要由于胸膜炎症致纤维膜形成,胸膜明显增厚而阻碍肺复张;其二是压缩肺(lung entrapment),主要由于全身性疾病、感染或恶性肿瘤侵及胸膜使胸膜毛细血管通透性增加,渗出性积液增加阻碍肺复张[2]。陷闭肺和压缩肺并非完全独立的两个疾病状态,常有相互重叠和演变,例如压缩肺使乳酸脱氢酶(lactate dehydrogenase,LDH)和积液中细胞逐渐增多,纤维蛋白性胸膜炎发展为纤维膜,后期LDH和细胞数下降则表现为持续性胸腔积液,影响肺复张[3-4]。     

Unexpandable lung from pleural disease

Unexpandable lung is a common complication of malignant pleural effusions and inflammatory pleural diseases, such as pleural infection (e.g. empyema and complicated parapneumonic effusion) and noninfectious fibrinous pleuritis. Unexpandable lung due to pleural disease may be because of an active pleural process, and is referred to as malignant or inflammatory lung entrapment. An unexpandable lung may also be encountered in the setting of remote pleural inflammation resulting in a mature fibrous membrane overlying the visceral pleura preventing full expansion of the lung. This condition is termed trapped lung and may be understood as a form of defective healing of the pleural space. Trapped lung typically presents as a chronic, stable pleural effusion without evidence of active pleural disease. An unexpandable lung most often manifests itself as an inability of fully expanding the lung with pleural space drainage. Patients will either develop chest pain preventing complete drainage of the pleural space or develop a post‐procedure pneumothorax. Pleural manometry and radiological imaging are useful in the assessment of an unexpandable lung. Pleural manometry can demonstrate abnormal lung expansion during drainage and imaging will demonstrate abnormal visceral pleural thickening found in trapped lung or malignant and inflammatory lung entrapment.     

Surgical diagnosis of pleural disease

Videothoracoscopy is a minimally invasive techinique providing a direct view of the pleural cavity. It enables complete exploration of the cavity with biopsies of pathological zones. The indication, based on clinical or radiographic findings, is retained when less invasive methods have been unable to establish the diagnosis and a specific pleural disease (tumor or other) is suspected. Depending on the observations at videothoracoscopy and the suspected disease, deep biopsies to the subpleural fat can be made with a forceps if nodules have been identified. If the pleura is uniformly thin, a small flap can be detached for the biopsy. Several pleura sites are biopsied and a direct pathology examination can be performed on certain specimens. Videothoracoscopy enables careful hemostasis of biopsied zones and symphysis (generally with talc) if needed. The perioperative mortality is low (<0.5%) with good sensitivity greater than 90% and excellent specificity at 100%. The presence of complete pleural symphysis counterindicates videothoracoscopy. In such patients, direct access via an intercostal incision is needed to obtain localized biopsies.