Faculty Bibliography

Antibiotic therapy against non-tuberculous mycobacteria (NTM) is prolonged and can be associated with toxicity. We sought to evaluate whether chest physical therapy (PT) was associated with clinical improvement in patients with NTM not receiving anti-mycobacterial pharmacotherapy. A retrospective review of 77 subjects that were followed from June 2006 to September 2014 was performed. Baseline time point was defined as the first positive sputum culture for NTM; symptoms, pulmonary function, and radiology reports were studied. Subjects were followed for up to 24 months and results analyzed at specified time points. Half of the subjects received chest PT at baseline. Cough improved at 12 (p = 0.001) and 24 months (p = 0.003) in the overall cohort when compared with baseline, despite lack of NTM antibiotic treatment. Cough decreased at 6 (p = 0.01), 9 (p = 0.02), 12 (p = 0.02) and 24 months (p = 0.002) in subjects that received chest PT. Sputum production also improved at 24 months in the overall cohort (p = 0.01). There was an increase in the percent change of total lung capacity in subjects that received chest PT (p = 0.005). Select patients with NTM may have clinical improvement with chest PT, without being subjected to prolonged antibiotic therapy. Future studies are warranted to prospectively evaluate outcomes in the setting of non-pharmacologic treatment and aid with the decision of antibiotic initiation.

INTRODUCTION Bacteremia as a direct result of bronchoscopy is a relatively uncommon event. We report a case of an empyema and streptococcus pneumoniae bacteremia following bronchoscopy. CASE PRESENTATION A 62 year female with a distant history of extrapulmonary sarcoidosis and new autoimmune serologies suggestive of Sjogren's presents with one month history of shortness of breath and cough. A CT chest revealed patchy bilateral opacities in the lung, as well as significant lymphadenopathy. The patient underwent a bronchoscopy with bronchoalveolar lavage and transbronchial biopsy of the right lower lobe. She also underwent a transbronchial needle aspiration of the subcarinal lymph node. The patient was discharged home on the same day without significant findings on her post-bronchoscopy chest x-ray. The bronchoscopy was diagnostic for non-caseating granulomas. Two days after the procedure, the patient developed fever, shortness of breath and chest pain. CT chest revealed a loculated right pleural effusion and a new right lower lobe infiltrate. A thoracentesis was performed which revealed a pH of less than 6.8. Cultures from the pleural fluid were consistent with streptococcus. Blood cultures were positive for streptococcus pneumoniae. The patient underwent a VATS, decortication and right lower lobe wedge resection. Pathology from the wedge resection was consistent with non-necrotizing granulomatous inflammation of the lung and empyema. The patient improved after surgery and antibiotics. Upper and lower respiratory tract cultures from sputum and bronchoscopy were all negative. DISCUSSION Yigla et al report a bacteremia rate as high as 6.5% following fiberoptic bronchoscopy. Bacteremia following bronchoscopy, however, remains the exception rather than the norm. Witte et al looked at 47 patients following transbronchial needle aspiration, and 22 patients following transbronchial biopsies. Blood cultures were drawn within 24 hours post procedure, and in no patients were blood cultures found to be positive. In 1977, Beyt et al reported a case of fatal pneumonitis and septicemia following fiberoptic bronchoscopy and endobronchial biopsy. Few cases such as this highlight the rare yet serious complication of septicemia following bronchoscopy. In our patient, it is possible that the empyema and bacteremia may have resulted from bacteriologic inoculation after contamination of the bronchoscope during insertion; however, bronchoscopically obtained cultures do not confirm this theory. Although bacteremia following bronchoscopy remains a rare event, clinicians should be aware of this potentially serious complication. CONCLUSION Although rare, bacteremia as a direct result of bronchoscopy can occur. Clinicians should be aware of this potentially serious complication

BACKGROUND AND OBJECTIVE: Patients with idiopathic pulmonary fibrosis (IPF) have a higher prevalence of coronary artery disease and this could have an impact on their outcomes. We investigated the predictive ability of coronary artery calcification, assessed by routine CT, which may predict the presence of coronary artery disease. METHODS: The study cohort consisted of patients with IPF and with left heart catheterization data plus CT scans from July 2003 to July 2008. Grades of coronary calcification on CT were compared with left heart catheterization determination of coronary artery disease. RESULTS: There were 57 patients in whom left heart catheterization review demonstrated significant coronary artery disease in 28.1% (16/57), mild disease in 40.3% (23/57) and none in 31.6% (18/57). The median time interval between the catheterization and the reviewed CT scan was 39 days. The sensitivity of moderate to severe calcification for significant coronary artery disease was 81%, while the specificity was 85%, with an associated odds ratio of 25.2 (4.64-166, P < 0.005). There was excellent agreement among three radiologists in the grading of coronary calcification. CONCLUSIONS: Coronary calcification, as assessed by routine CT of the chest, has very good performance characteristics in predicting underlying significant coronary artery disease in patients with IPF. The routine availability of this study enables the ready screening for coronary artery disease in IPF patients.