New developments in diagnosis and management of lung cancer.
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Biomarkers, Tumor↗
Biomedical subjects
K T Luh
Publications and source records attributed to K T Luh.
Tuberculosis antigen A60 serodiagnosis in tuberculous infection: application in extrapulmonary and smear-negative pulmonary tuberculosis.
An ELISA diagnostic test for tuberculosis antigen A60 (TBA60) IgG/IgM was used in a tertiary referral hospital in Taiwan. From June 1992 to December 1993, serum samples obtained from 907 patients were analyzed for TBA60 IgG and IgM titres. The final diagnosis of these patients was confirmed by microbiological study and clinical follow up for 18-24 months. Among 147 patients with active pulmonary tuberculosis, IgG was positive in 112 (76.2%), IgM was positive in 14 (9.52%). Among 90 patients with active extrapulmonary tuberculosis, IgG was positive in 53 (58.9%), IgM was positive in 9 (10%). Among 153 patients with inactive tuberculosis, IgG was positive in 28 (18.3%), IgM was positive in 1 (1.6%). Among 517 patients with nontuberculous disease, IgG was positive in 50 (9.7%), IgM was positive in 3 (0.6%). In this study population with 26% (237/907) active tuberculous infection rate, the TBA60 ELISA IgG had a diagnostic sensitivity of 69.6% and a specificity of 92.1%. These results indicate a positive predictive value of 67.9% and a negative predictive value of 89.2%. The sensitivity of IgM was 10.5% and specificity, 99.4%. The serum IgG tire had good correlation with the extent of pulmonary TB had a higher percentage of IgG seropositivity (83.9%) than those with smear-negative pulmonary TB (70.6%) and extrapulmonary TB (58.9%). In 50 cases with active tuberculosis, follow-up examinations were carried out one month after treatment. In 18 cases with initially negative IgG and IgM titres, 13 showed elevation of serum IgG titres into positive level, one had positive seroconversion of IgM which was the only serological marker indicating active infection. Therefore, 77.8% (14/18) gained diagnostic benefit from follow-up serological examination. It was concluded that TBA60 IgG and IgM ELISA is a useful test when diagnosing tuberculosis. This test also assists in the clinical judgement of tuberculosis when used as an adjunct to symptoms and sputum smear, and for monitoring therapeutic response at the commencement of treatment.
Adolescent↗
Clinical and microbiological characteristics of Flavobacterium indologenes infections associated with indwelling devices.
Clinical infections caused by Flavobacterium indologenes have never been documented. Thirteen isolates derived from seven patients with indwelling device-associated F. indologenes infections were identified from 1 April through 30 November 1995. The antimicrobial susceptibilities to 20 antimicrobial agents of the isolates, the cellular fatty acid chromatograms for the isolates, and the random amplified polymorphic DNA (RAPD) patterns generated by arbitrarily primed PCR of the isolates were studied. The antibiotypes and RAPD patterns differed among the isolates recovered from different patients. However, both antibiotypes and RAPD patterns were identical among the five isolates from one patient with multiple episodes of central venous catheter-associated bacteremia within a 1.5-month period and between the two isolates from another patient suffering from two episodes of catheter-related bacteriuria at an interval of 14 days. It is documented that the recurrent infections in each of these two patients were caused by a single F. indologenes clone, respectively. Identical antibiotypes and RAPD patterns were also demonstrated between two isolates from a patient with ventilator-associated pneumonia, one recovered from an endotracheal aspirate and the other derived from a blood specimen 10 days later, indicating the invasive nature of F. indologenes. Two cellular fatty acid chromatograms were identified among these isolates. All of the isolates showed in vitro resistance to cephalothin, cefotaxime, ceftriaxone, moxalactam, aztreonam, aminoglycosides, erythromycin, clindamycin, vancomycin, and teicoplanin. F. indologenes should be included as an etiologic agent of infections associated with the use of indwelling devices.
Adult↗
Aspergillus laryngotracheobronchitis presenting as stridor in a patient with peripheral T cell lymphoma.
Invasive aspergillosis is a serious opportunistic infection in immunocompromised patients. The case history is described of a 44 year old patient with peripheral T cell lymphoma who developed hoarseness and stridor after chemotherapy. Aspergillus fumigatus was isolated repeatedly from the sputum. Bronchoscopic examination showed symmetrical creamy-white exophytic lesions involving both vocal cords and the supraglottic area. There was diffuse tracheobronchitis with multiple raised cream-coloured plaques in the trachea which histologically consisted of numerous septate branching hyphae consistent with Aspergillus species. The lesions responded to systemic treatment with amphotericin B.
Adult↗
Infected left atrial myxoma caused by Gemella morbillorum.
Gemella morbillorum was isolated from the blood of a 38-year-old woman with a 4-week history of fever. An echocardiogram showed a left atrial tumor. The patient was successfully treated by antibiotic therapy and early surgical excision of the tumor. Histological examination of the excised tumor revealed a typical myxoma with infiltrates of neutrophils and remnants of bacteria. To the best of our knowledge, this is the first reported case of infected left atrial myxoma caused by G. morbillorum.
Adult↗
Nosocomial candidemia in a university hospital in Taiwan.
The incidence of nosocomial candidemia increased 27-fold over the past 13 years at National Taiwan University Hospital. In order to investigate its predisposing factors, clinical manifestations and prognostic determinants, a prospective observational study of nosocomial candidemia was undertaken at the hospital. From 1 May 1994 to 30 April 1995, 118 consecutive adult patients with 120 Candida spp blood isolates were analyzed. Clinical presentations included fever (100%) with a median duration of 3 days, diarrhea within 7 days of candidemia (27.9%) and macronodular skin emboli (7.6%). Laboratory studies showed worsening azotemia (35.6%), elevation of aminotransferase (28.3%), leukocytosis (27.1%) and thrombocytopenia (23.3%). Use of multiple antibiotics, retained vascular catheters and parenteral nutritional support were the three most common predisposing factors for candidemia. C. albicans was the most common isolate (50%), followed by C. tropicalis (20%), C. glabrata (14%), C. parapsilosis (9.2%). C. guilliermondii (2.5%), and C. Krusei (1.7%). C. tropicalis was more frequently the cause of candidemia in patients with leukemia and neutropenia, while C. glabrata was more commonly seen in patients receiving fluconazole prophylaxis. A severity scoring system adopted from prospective bacteremia studies proved to be highly predictive of mortality in candidemic patients. The overall case fatality rate was 70/118 (59.3%), and 51/70 (72.9%) were attributable to candidemia. In a multivariate analysis, the prognostic factors adversely influencing outcome were: higher severity scores, no removal of the catheter, persistent candidemia and lack of antifungal therapy.
Adult↗
Microbial threats in Taiwan.
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Acquired Immunodeficiency Syndrome↗
Clinical features of tuberculosis associated with HIV infection in Taiwan.
To understand the clinical characteristics and outcome of tuberculosis (TB) in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan, we reviewed the medical records of 118 adult AIDS patients who were hospitalized at National Taiwan University Hospital between January 1988 and September 1995. Among them, 29 (24.6%) had TB. The mean age of the AIDS patients with TB was 37 years (range, 25-66 yr). Most patients were in the advanced stages of AIDS when human immunodeficiency virus (HIV) infection and/or TB were first diagnosed. The mean CD4+ lymphocyte count was 0.037 x 10(9)/L (range, 0-0.152 x 10(9)/L) at the time TB was diagnosed. There was no statistically significant difference in the mean CD4+ lymphocyte count between patients with isolated pulmonary TB and those with extrapulmonary involvement. Twenty-two patients (75.8%) had extrapulmonary TB with the most common site being the lymph nodes (72.7%). Clinical symptoms were nonspecific, and the chest physical examination was not helpful in the diagnosis. Acid-fast bacilli were detected in sputum smears from eight patients (36.4%). A primary tuberculosis pattern (hilar adenopathy, pleural effusion, middle or lower lobe infiltrates) in the chest radiographs was the most common radiologic finding (36.4%) in patients with pulmonary TB. The reactivation pattern (predominant upper-lobe infiltrates with or without cavitation) could only be found in cases of pulmonary TB without extrapulmonary involvement. Atypical patterns (diffuse interstitial infiltrates mimicking Pneumocystis carinii pneumonia or other patterns) and normal chest radiographs were noted in nearly one-third of the patients with pulmonary TB. A good response to antituberculosis drugs and a favorable outcome were demonstrated in the patients, except for two with drug-resistant Mycobacterium tuberculosis infection. Early identification of TB in HIV-infected patients requires clinical awareness of the unusual clinical presentations, especially among patients in the advanced stages of AIDS.
AIDS-Related Opportunistic Infections↗
Influence of beta-lactamase inhibitors on the activity of oxacillin against methicillin-resistant Staphylococcus aureus.
We studied the in vitro susceptibility to oxacillin of 46 isolates of methicillin-resistant Staphylococcus aureus (MRSA) isolates with a minimum inhibitory concentration (MIC) > 8 micrograms/ml of oxacillin, with and without adding clavulanic acid, sulbactam, or tazobactam in three different concentrations (2, 4, and 8 micrograms/ml). All 46 strains were found by the rapid chromogenic cephalosporin method to be beta-lactamase producers. For those strains with low-level resistance (MIC of 16 or 32 micrograms/ml), the MICs of oxacillin decreased four- to 32-fold and two- to 32-fold after adding sulbactam and tazobactam, respectively. For those with high-level resistance (MIC of > or = 64 micrograms/ml), the MICs either did not change or decreased only two-fold after we added one of three beta-lactamase inhibitors. The results suggest that beta-lactamase production probably plays a role in resistance to oxacillin in those MRSA strains of low-level oxacillin resistance.
Anti-Bacterial Agents↗
In vitro activities of antimicrobial agents, alone and in combination, against Acinetobacter baumannii isolated from blood.
In vitro activities of 15 antimicrobial agents against 90 strains of Acinetobacter baumannii isolated from blood cultures from hospitalized patients were determined using the agar dilution method. Imipenem, ofloxacin, and ciprofloxacin had the best antimicrobial activity with minimum inhibitory concentrations (MIC50s) of 0.25 mu g/ml and MIC90s of 0.5-1 mu g/ml. beta-lactam antibiotics other than imipenem had poor activity, with MIC50s ranging from 8 to 64 mu g/ml and MIC90s from 32 to > or = 256 mu g/ml. The checkerboard titration method was used to study the effects of combination of two antimicrobial agents. Combinations of ceftazidime, aztreonam, imipenem, or ciprofloxacin with amikacin showed either synergistic effects or partial synergistic effects for 40.9%-86.4% of 22 tested strains. The best in vitro activity was observed with the combination of imipenem and amikacin. No antagonistic effects were observed with the combination of imipenem and amikacin. Synergistic effects were confirmed by time-kill curve studies. In conclusion, imipenem, ofloxacin, and ciprofloxacin were the three most active agents against human blood isolates of A. baumannii. The combination of a beta-lactam or ciprofloxacin with amikacin was synergistic for some of the isolates.
Acinetobacter↗
Macrolides resistance of common bacteria isolated from Taiwan.
To determine the susceptibility to macrolides of common pathogenic bacteria isolated from Taiwan, the in vitro activities of erythromycin, roxithromycin, azithromycin, clarithromycin, and dirithromycin were tested against 492 clinical isolates of eight different bacteria, collected from the National Taiwan University Hospital. The results showed high minimum inhibitory concentrations (MICs) against most of the tested bacteria. The MIC90s for Staphylococcus aureus (both methicillin-resistant and -sensitive strains), coagulase-negative staphylococci (both methicillin-resistant and -sensitive strains), Streptococcus pyogenes, Streptococcus pneumoniae, enterococci, peptostreptococci, and Bacteroides fragilis were all > or = 256 micrograms/ml. The MIC50s for methicillin-resistant strains of S. aureus and coagulase-negative staphylococci, and enterococci were > or = 256 micrograms/ml. For S. pneumoniae, peptostreptococci, and B. fragilis, the MIC50s were > 8 micrograms/ml. The resistance rates to macrolides were 80% or more in methicillin-resistant staphylococci and about 30% in methicillin-sensitive staphylococci. Around 55% of S. pneumoniae strains and 37 approximately 42% of S. pyogenes strains were resistant to macrolides. Cross-resistance to different macrolides was clearly demonstrated in most of the resistant strains.
Anti-Bacterial Agents↗
Clinical spectrum of tuberculosis in older patients.
OBJECTIVE: To investigate the clinical differences between old and young patients infected with Mycobacterium tuberculosis in a developing country. DESIGN: Retrospective chart and chest radiograph review. SETTING: A university-affiliated teaching hospital. PATIENTS: The medical records of patients with documented tuberculosis (TB) from January 1990 through December 1991 were analyzed. Clinical assessment included sex, age, diagnosis at first visit, past history, symptoms and signs, laboratory data, X-ray findings, bacteriological examinations, outcome, time elapsed from first visit to initiation of anti-TB therapy and the major determinants for starting anti-TB therapy. Statistical significances were analyzed by Student's t test and chi 2 tests. RESULTS: Among 205 patients with culture-proven TB, 57 were 65 years of age and older (range, 65 to 91; mean, 73) and 148 under 65 years of age (range, 16 to 64; mean, 41). There was a higher incidence of previous TB (26.3% vs. 16.2%) and diabetes mellitus (24.5% vs. 14.3%) in the elderly patients. Initial diagnosis of TB at first visit was less frequent in the elderly than in the young group (38.6% vs. 47.3%), although symptoms and signs at first visit were similar in each of the age groups. Radiographic presentation with mass lesions was more frequently encountered in elderly patients (10.5% vs. 2.1%, P < .05). Elapsed time from the first visit to suspicion of TB and the initiation of anti-TB therapy was frequently delayed in elderly patients (22 +/- 23 vs. 13 +/- 20 days, P < .05). The incidence of drug-resistance (39% vs. 16%, P < .05) and unfavorable response to anti-TB therapy (17.5% vs. 3.4%, P < .05) were significantly higher in the older patients. CONCLUSIONS: Although clinical presentation of TB in the elderly did not differ significantly from that in younger patients, this study showed that diagnosis and treatment were more often delayed in the elderly, and there was a higher incidence of treatment failure.
Adolescent↗
Direct determination of cryptococcal antigen in transthoracic needle aspirate for diagnosis of pulmonary cryptococcosis.
Pulmonary cryptococcosis causes significant morbidity and mortality in immunocompromised patients. Definitive diagnosis of pulmonary cryptococcosis is usually difficult. The use of direct determination of cryptococcal antigen in transthoracic needle aspirate to diagnose pulmonary cryptococcosis was investigated. Over a 2-year period, we studied a total of 41 patients with respiratory symptoms and pulmonary infiltrates of unknown etiology who were suspected of having pulmonary cryptococcosis. Twenty-two patients were immunocompetent patients and 19 patients were immunocompromised. A diagnosis of pulmonary cryptococcosis was based on cytological examination, culture for Cryptococcus neoformans, histopathologic examination, and clinical response to antifungal therapy. All patients underwent chest ultrasound and ultrasound-guided percutaneous transthoracic needle aspiration to obtain specimens for cryptococcal antigen determination. The presence of cryptococcal antigen was determined by the latex agglutination system (CALAS; Meridian Diagnostics, Cincinnati, Ohio). An antigen titer equal to or greater than 1:8 was considered positive. The specimens were also sent for cytological examination, fungal culture, and/or histopathologic examination. A final diagnosis of pulmonary cryptococcosis was made in eight patients. Direct determinations of cryptococcal antigen in lung aspirate were positive in all eight patients with pulmonary cryptococcosis (100% sensitivity, 97% specificity, a positive predictive value of 89%, and negative value of 100%), and there was only one false-positive in noncryptococcosis patients. The diagnostic accuracy was 97.5%. Serum cryptococcal antigen was positive in only three patients with pulmonary cryptococcosis (sensitivity, 37.5%). This study showed that direct measurement of cryptococcal antigen in lung aspirate can be a rapid and useful test for diagnosis of pulmonary cryptococcosis.
Adolescent↗
Transthoracic needle biopsy of thoracic tumours by a colour Doppler ultrasound puncture guiding device.
BACKGROUND: Ultrasound guided transthoracic needle aspiration biopsy has recently been used to obtain specimens for histological diagnosis of pulmonary and mediastinal tumours. Conventional real time, grey scale puncture guiding devices cannot differentiate vascular structures, and clear visualisation of the needle shaft or tip within a desired target is not always possible. This study describes a new built-in colour Doppler ultrasound puncture guiding device and assesses the relative safety of transthoracic needle aspiration biopsy of thoracic tumours by grey scale or colour Doppler ultrasound guidance. METHODS: Thirty patients with radiographic evidence of pulmonary (22 patients) or mediastinal tumours (eight patients) underwent ultrasonographic evaluation and transthoracic needle aspiration biopsy by using the colour Doppler ultrasound puncture guiding device (Aloka UST 5045P-3.5). These tumours were initially examined by grey scale ultrasound, and colour Doppler imaging was then used to evaluate the number of blood vessels surrounding and within the target tumour and the possibility of visualisation of the needle shaft or needle tip during the aspiration biopsy procedure. RESULTS: The colour Doppler ultrasound guiding device was far superior to the grey scale device for identification of the number of vessels surrounding or within the target tumour (83% v 20%) and for visualisation of the needle shaft or needle tip (80% v 17%). CONCLUSIONS: By using the colour Doppler ultrasound puncture device, vascular structures surrounding or within the target tumour can be verified. Visualisation of the needle shaft or tip is also better. Biopsy routes can be selected to avoid puncturing vessels. This approach should be particularly helpful for guiding biopsies of mediastinal tumours, where puncturing the heart or great vessels is a potential complication.
Adult↗
Tumor angiogenesis correlates with histologic type and metastasis in non-small-cell lung cancer.
This study investigated the clinico-pathologic correlation of tumor angiogenesis in non-small-cell lung cancers. Formalin-fixed, paraffin-embedded surgical specimens of 55 consecutive patients with primary non-small-cell lung cancers were examined. Included were 26 squamous cell carcinomas and 29 adenocarcinomas. Twenty-five patients had stage I disease, eight patients had stage II disease, and 22 patients had stage IIIA or IIIB disease. Among them, 28 had nodal metastasis and 27 did not. The microvessel was demonstrated by immunocytochemical staining for factor VIII and platelet endothelial cell adhesion molecules (PECAM-1). The microvessels in the areas of highest neovascularization were counted under light microscopy in 200x field by two independent observers without knowledge of clinical information. At least three separate fields were counted for each specimen. The Mann-Whitney U test was used for statistical analysis. The microvessel counts in adenocarcinoma were significantly higher than in the squamous cell carcinoma (54.4 +/- 35.65 versus 26.16 +/- 20.46 in factor VIII staining and 80.52 +/- 48.42 versus 40.04 +/- 32.33 in PECAM-1 staining; p < 0.001). The microvessel counts in patients with Stages I-II disease were significantly lower than that of stages IIIA-IIIB disease (23.63 +/- 16.21 versus 65.36 +/- 31.92 in factor VIII staining and 41.85 +/- 36.76 versus 93.00 +/- 43.08 in PECAM-1; p < 0.001). Patients with nodal metastasis had higher microvessel density than those without nodal metastasis (56.67 +/- 35.55 versus 23.44 +/- 15.77 in factor VIII staining and 86.89 +/- 46.46 versus 36.30 +/- 25.83 in PECAM-1 staining; p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Adenocarcinoma↗
A pseudoepidemic of Mycobacterium chelonae infection caused by contamination of a fibreoptic bronchoscope suction channel.
An unusual increase in the frequency of isolation of Mycobacterium chelonae subspecies chelonae from specimens of bronchial washings was found between September and December 1992 in National Taiwan University Hospital. During this period, a total of 123 patients underwent fibreoptic bronchoscopy with an Olympus P20. Seventy six patients had bronchial washing for bacteriological study and cytological examination. Acid-fast bacilli were found in 21 patients, in 18 of whom Mycobacterium chelonae were isolated from bronchial washing cultures. Eight patients were treated as mycobacterial infected, because of the presence of unexplained pulmonary lesion, positive acid-fast stain and culture for Mycobacterium chelonae. Diagnosis of lung cancer was delayed in one patient because of the initial negative cytological study and positive bacterial culture. The fibreoptic bronchoscope was disinfected by automated washing machine (EW-20, Olympus) using 2.3% glutaraldehyde according to a standard protocol. From a survey to search for possible sources of contamination, they were identified at the suction channel of four different bronchoscopes. This episode proved to be a pseudoepidemic. The contamination was controlled by extensive suction and rinsing of the channel with 70% alcohol immediately after disinfection by the automated bronchoscope disinfection machine. This study shows that, despite using the disinfection machine, the suction channel could still be contaminated with Mycobacterium chelonae. This may cause diagnostic confusion and unnecessary antimycobacterial treatment.
Aged↗
Diagnosis of pulmonary arteriovenous malformation with color Doppler ultrasonography.
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Adult↗
"Fluid color" sign: a useful indicator for discrimination between pleural thickening and pleural effusion.
Color Doppler imaging has been applied traditionally in the evaluation of cardiovascular diseases. Recently it was observed that color signal may appear within the fluid collection in the pleural space during respiratory and cardiac cycles ("fluid color sign"). We performed this applicability of fluid color sign to the detection of pleural fluid capable of being removed to assess needle aspiration. From July 1992 to February 1994, we prospectively analyzed 76 patients who were suspected of having minimal pleural effusion on the basis of their chest radiographs. All patients were examined by color Doppler ultrasonography for the presence of fluid color sign, which was followed by needle aspiration to verify the presence of pleural effusion. Among the 65 patients with aspiratable fluid, 58 demonstrated positive fluid color sign (sensitivity 89.2%). None of the patients with solid pleural thickening showed fluid color sign (specificity 100%). With its relatively high sensitivity and specificity, the fluid color sign may be a useful diagnostic aid to real-time, gray scale ultrasonography for minimal or loculated effusion.
Adolescent↗