Faculty Bibliography

Eosinophilic pneumonia is characterized by cough, lung infiltrates on imaging, and by the presence of eosinophils in the alveoli and pulmonary interstitium. Azacitidine, a pyramidine nucleoside analog of cytidine, is FDA approved for the treatment of various myelodysplastic syndromes. We present a case of a 76-year-old man with recently diagnosed myelodysplastic syndrome, who developed eosinophilic pneumonia after initiating therapy with azacitidine. There was clinical and radiographic improvement with cessation of the drug and treatment with prednisone. Diagnosis of drug-induced eosinophilic pneumonia is established by having a temporal relationship between onset of symptoms and initiation of therapy, bronchoalveolar lavage or lung biopsy evidence of pulmonary eosinophilia, no other explanation for the disease, and improvement upon cessation of the offending agent. Our case illustrates the need for a high index of suspicion to identify adverse pulmonary reactions associated with newly developed medications.

PURPOSE/OBJECTIVE:Chronic lung diseases are typically associated with impaired quality of life, stress, and anxiety. Written disclosure therapy (WDT) reduces stress in patients with a variety of chronic illnesses. We sought to determine whether WDT benefits patients with chronic lung disease. METHODS:A prospective, randomized, controlled trial was performed to evaluate the effect of using WDT in patients (N = 66) participating in a pulmonary rehabilitation program. Patients were randomly assigned to write about a particularly traumatic life event (WDT group) or to write about an emotionally neutral subject (control group). Exercise capacity, dyspnea and quality of life, and values of spirometry were recorded at baseline, at the end of the program, and at 6 months. RESULTS:The 6-minute walk distance (6MWD) significantly improved in both groups at 2 months, from 278 to 327 m in WDT and from 269 to 314 m in control groups (P < .01 in both groups). There was no difference in improvement in 6MWD between groups (P = .88). At 6 months, the gains made in 6MWD were no longer present. Dyspnea severity, as well as most of the other domains of the Chronic Respiratory Disease Questionnaire and the St. George's Respiratory Questionnaire, showed improvement within each group, but not between WDT and control groups. CONCLUSION/CONCLUSIONS:WDT did not add any additional benefit in patients with chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis when included as a component of pulmonary rehabilitation. These results are in contrast to previously seen benefits in patients with asthma.

Patients with bronchiectasis experience tenacious mucus, recurrent infectious exacerbations, and progressive worsening of symptoms and obstruction over time. Treatment is aimed at trying to break the cycle of infection and progressive airway destruction. Antibacterial treatment is targeted towards likely organisms or tailored to the results of sputum culture. Inhaled antibacterial therapy may offer the advantage of increased local concentration of medication, while minimizing systemic adverse effects; however, to date, studies have been equivocal in this disorder. Macrolides, in addition to their antibacterial properties, have unique anti-inflammatory properties, which may make them useful in this disorder. Other mucoactive and anti-inflammatory agents, such as inhaled corticosteroids, mannitol and hypertonic saline, may also prove useful in this disease, but further studies are needed.

PURPOSE OF REVIEW/OBJECTIVE:Bronchiectasis is an under-appreciated cause of chronic lung disease in the USA. We highlight developments in diagnosis and treatment of this debilitating disease. RECENT FINDINGS/RESULTS:A possible link between gastroesophageal reflux and development of nontuberculous mycobacterial lung disease was highlighted. Reflux is more common in patients with nontuberculous mycobacterial lung disease, and among those with established bronchiectasis more extensive disease was observed in those patients who also had reflux. Long-term mortality in bronchiectasis was significantly associated with age, lower body mass index, dyspnea, lack of vaccination, hypoxemia, hypercapnia, and other functional parameters. In a large, randomized clinical trial, addition of inhaled tobramycin to ciprofloxacin for acute exacerbations of Pseudomonas infection produced microbiologic improvement correlating with clinical outcomes but not overall improvement. A review noted that five macrolide trials reported reduced sputum volume, improved lung function, and better symptom control. Finally, articles suggested benefit from inhaled hyperosmolar agents (e.g. hypertonic saline and inhaled mannitol). SUMMARY/CONCLUSIONS:The possible link between gastroesophageal reflux and nontuberculous mycobacterial lung disease, and the microbiology and resistance patterns of bacteria observed in these patients were clarified. A large study of inhaled tobramycin for exacerbations was inconclusive, but macrolide therapy and hyperosmolar agents hold promise.

Pulmonary hyalinizing granulomata are rare, noninfectious, fibrosing lesions of the lung, which can mimic metastatic disease radiographically. Their etiology is unknown, but they may be caused by an exaggerated immune response. We report the radiology, long clinical course, and pathology of a patient with pulmonary hyalinizing granuloma who presented with initially asymptomatic pulmonary nodules. Over a 10-year period, the patient developed multiple insidious autoimmune phenomena, including lupus anticoagulant, neuromyotonia, demyelinating sensorimotor polyneuropathy, and eventually, Morvan's syndrome. Such an association has not been previously published to our knowledge.