The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules (PN) to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, hamartoma, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging.

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Background : The aim of this study was to evaluate treatment outcomes in patients with thoracic actinomycosis and identify patient characteristics associated with unfavorable responses to antibiotic therapy. Methods : A retrospective analysis was performed on 40 patients with pathologically confirmed thoracic actinomycosis. Results : Initial surgical treatment was performed on 17 patients to control severe symptoms such as hemoptysis or rule out lung cancer. Sixteen (94%) patients were successfully treated, including three patients who did not receive postoperative antibiotics, and one patient died of a postoperative complication. The median duration of oral antibiotic therapy after surgery was 3 months. After the diagnosis of actinomycosis, 23 patients began antibiotic therapy. The median duration of oral antibiotic therapy was 5 months. Favorable treatment outcomes were achieved in 18 of these 23 patients (78%), while five (22%) showed unfavorable responses to antibiotic therapy. Surgery was successfully performed in these five patients. The patients with unfavorable responses to antibiotic therapy had a longer duration of symptoms prior to treatment (median, 10 months) as compared to patients with favorable responses (median, 2 months; P = 0.012). Conclusions : Medical treatment failure is possible in patients with thoracic actinomycosis, and close monitoring is necessary in those who begin antibiotic therapy. In addition, surgical resection may be a valid option for patients who do not respond to antibiotic therapy, with the consideration of the age and comorbid conditions.

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Objective : To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. Methods : During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. Results : During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine . Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO ₂ /FiO ₂ ratio <300 and the absence of pharmacological prevention of venous thromboembolism. Conclusion : Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO ₂ /FiO ₂ < 300 and the absence of pharmacological prevention of venous thromboembolism.

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Background : The principal aim of the present study was to determine whether Acinetobacter spp. pneumonia differs from hospital-acquired pneumonias (HAPs) caused by other agents with respect to therapeutic success and survival rate. METHODS : This study includes 140 adult patients diagnosed with HAPs caused by identified etiologic agents between March 2005 and February 2006. These patients were divided into two groups according to the agent responsible for their infection (Acinetobacter spp. [n = 63] or non-Acinetobacter spp. [n = 77]). The groups were compared in terms of risk factors, therapeutic success and six-week survival rates. Results : Previous antibiotic use and the risk of aspiration were independent factors responsible for the development of Acinetobacter spp. pneumonia. Hypoalbuminemia, steroid use and the use of a mechanical ventilator were determined to be mortality-associated independent risk factors for Acinetobacter spp. pneumonia. The clinical success rate at the end of therapy was 41.6% and, at the sixth week, the survival rate was 35% among patients in whom Acinetobacter spp. was the causative agent. Conversely, in the control group, these values were 43 and 32%, respectively ( P > 0.05). We found that the use of the appropriate antibiotics for the treatment of Acinetobacter spp. pneumonia was an important factor in survival ( P < 0.001). Conclusion : The outcomes of Acinetobacter spp. pneumonia do not differ from HAPs associated with non-Acinetobacter spp. in terms of therapeutic success and survival rates.

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Background : Pulmonary hypertension (PH) occurs in many patients with interstitial lung disease, including sarcoidosis. We explored the frequency, clinical characteristics and outcomes of PH in Arab patients diagnosed with pulmonary sarcoidosis. Methods : A retrospective study in three tertiary hospitals was performed on 96 patients who underwent Doppler echocardiography. Demographic and clinical characteristics, physiological studies and computed tomography (CT) results were collected, and compared between patients with and without PH. Results : Twenty (20.8%) patients were found to have PH. Patients with PH were more likely to be symptomatic (cough, P = 0.008; dyspnea, P = 0.04), to have an advanced radiographic stage (P = 0.001), and to be receiving systemic therapy (P = 0.001), compared to those without PH. Physiological data including pulmonary function test parameters, arterial blood gas levels and oxygen saturation at rest and after exercise were all significantly lower in patients with PH compared to those without PH. Comparison of CT patterns between patients with and without PH showed significant differences in the frequencies of ground-glass opacity (61.5 vs. 28.8%, P = 0.032) and fibrosis (76.9 vs. 44.2%, P = 0.035). In total, four patients died during the study period, including three with evidence of PH. Conclusions : The frequency of PH in the present study was 20.8%. Clinical, physiologic and radiographic characteristics appeared to differentiate patients with PH from those without PH. The presence of PH contributed to poor outcomes in patients with pulmonary sarcoidosis.

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Objective : The aim of this study was to compare the results of virtual bronchoscopy (VB) images in defining tracheobronchial pathologies with those of fiber-optic bronchoscopy (FOB) in patients with clinical indication for bronchoscopy. Methods : Twenty-two patients with bronchoscopy indication were evaluated with FOB and VB. The VB results were evaluated blindly, independent of the FOB results. Results : In 19 of the 22 patients, tracheobronchial abnormalities were present on FOB, whereas 3 patients had normal findings on FOB. In 17 of 19 patients, VB demonstrated the FOB diagnosis of tracheobronchial abnormality. While FOB detected 11 endoluminal lesions, VB detected 6. While FOB detected 20 obstructive lesions, VB detected 26. In evaluating external compression, FOB detected 2 lesions and VB detected 15. Conclusions : VB is a non-invasive, uncomplicated, and reproducible examination method in patients with an indication for thorax examination. Virtual bronchoscopy could find a clinically broader field of application in the future.

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Burkholderia pseudomallei is the causative agent of melioidosis. It is endemic in South East Asian countries and North Australia. Sporadic cases of melioidosis have been reported from several parts of South India. Melioidosis may manifest as chronic pneumonia mimicking tuberculosis and generally be seen as a single entity. We report the first case of melioidosis and pulmonary tuberculosis co-infection in a diabetic patient. The causative agents were identified using standard methods and the patient recovered after completion of the recommended antibiotic therapy. Melioidosis is an emerging infectious disease in India. Though melioidosis and tuberculosis present with similar clinical picture, co-infections are rare. Hence, increased awareness among clinicians and microbiologists can help in diagnosing the disease even when there is no clinical suspicion.

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A thyroid storm is a life-threatening exacerbation of thyrotoxicosis, and is usually characterized by hyperthermia, tachycardia, severe agitation and altered mental status. A thyroid storm may be triggered by many causes, including systemic pulmonary infections. Delay in prompt diagnosis leads to high mortality. We present the first case of H1N1 infection triggering a thyroid storm. The delay in diagnosis because of preoccupancy with the H1N1 pandemic may have contributed to the poor outcome. When assessing cases with H1N1 infection, physicians should be more vigilant in order not to miss other important diagnoses.

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