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R Speich

Publications and source records attributed to R Speich.

At least 37 records · Page 2Linked to original sources
PubMed2000

Giant cell arteritis "causing" AA-amyloidosis with rapid renal failure.

Giant cell arteritis (GCA) is a systemic vasculitic disease, which in very rare cases causes inflammatory complications such as secondary amyloidosis. We describe a well-documented case, with a clinically mild course, of biopsyproven giant cell arteritis as the only apparent cause of systemic AA-Amyloidosis. The deterioration in renal function due to amyloid deposition occurred rapidly and only a few months after manifestation of giant cell arteritis and was not reversible by steroid treatment. The renal arteries were normal and there was no glomerulonephritis due to giant cell arteritis. This unique case demonstrates that giant cell arteritis with a mild clinical course is closely associated with early-onset severe secondary amyloidosis.

Acute Kidney Injury↗
PubMed2000

[Indications for lung transplantation in advanced cystic fibrosis].

Lung transplantation has become a valid therapeutic option for cystic fibrosis patients with end-stage lung disease. The indication for transplantation does not rely on strict criteria only but must be evaluated case by case. In particular, the dynamics of the clinical course need to be considered with regard to impaired physical performance, recurrent infections, decline in pulmonary function and weight loss. Important risk factors are a poor nutritional status, osteoporosis, liver involvement, previous pleurodesis and the occurrence of multiresistant bacteria. Management and assessment of cystic fibrosis patients for lung transplantation is complex. Therefore patients should be referred to specialised centres at an early stage.

Bacterial Infections↗
PubMed2000

[Special problems after lung transplantation: walking a tightrope between infection and graft rejection].

Between November 1992 and September 1999 84 lungs have been transplanted at University Hospital Zurich. Currently the 1-year survival rate is up to 85%. However, long-term success is limited by the development of chronic rejection in the form of bronchiolitis obliterans. The risk factors are repeated episodes of acute rejection and infections, due to cytomegalovirus in particular. Both can occur in asymptomatic patients and are sometimes detected only by transbronchial lung biopsy. At the Zurich Lung Transplant Centre biopsies are performed as surveillance biopsies in asymptomatic patients in the first 6 months after transplantation, for clinical indications and as follow-up biopsies after a pathological result. Open lung biopsies are performed for special indications only. We evaluated 408 transbronchial biopsies taken between November 1992 and September 1999. Relevant findings were present in 46% of biopsies in symptomatic patients. Relevant acute rejection episodes were diagnosed in 15% of surveillance biopsies. Overall, 72% of acute rejection episodes requiring therapy and 33% of biopsies detecting cytomegalovirus were found in surveillance biopsies. 7 of 11 late (> 45 days postoperative) and 1 of 5 early (< or = 45 days postoperative) open lung biopsies revealed new diagnoses. Transbronchial biopsy after lung transplantation is at present the gold standard for diagnosis of acute rejection and cytomegalovirus pneumonia of the lung.

Adult↗
PubMed2000

[The value of bronchoalveolar lavage in the clarifying of HIV-associated lung diseases].

BACKGROUND AND OBJECTIVE: Examination of sputum is the first diagnostic step in the evaluation of HIV-infected patients with pulmonary complications. We were interested in the indications and the diagnostic value of subsequent bronchoscopy and bronchoalveolar lavage (BAL) and especially the importance of so-called atypical bacteria. PATIENTS AND METHODS: We analysed 59 consecutive BALs performed in HIV positive patients with pulmonary symptoms (48 men, 11 women, age 22-70 years, 36 in stage C). Culture for Legionella pneumophila and PCR analysis for Mycoplasma pneumoniae and Chlamydia pneumoniae were done in all cases. RESULTS: In 50 patients (85%) there was a clear indication for performing a BAL because either an infectious agent could no be detected on sputum examination (n = 36), or the patient's sputum production was insufficient (n = 14). In 30 (60%) of these cases bronchoscopy and BAL were able to establish a diagnosis. The most frequent agent was Pneumocystis carinii (n = 12). In contrast, BAL was able to establish coinfection in patients with positive sputum samples in one case only. So-called atypical bacteria were not found. CONCLUSION: In patients with a clear indication, especially a non-diagnostic sputum examination, BAL plays an important role in the work-up of HIV-associated pulmonary disease. The search for so-called atypical bacteria yields unsatisfactory results.

AIDS-Related Opportunistic Infections↗
PubMed2000

Osteonecrosis after lung transplantation: cystic fibrosis as a potential risk factor.

BACKGROUND: Osteonecrosis is a known complication after transplantation of solid organs. The incidence of osteonecrosis after lung transplantation is not well documented. METHODS: We investigated the incidence of symptomatic osteonecrosis in lung transplant recipients, transplanted between November 1992 and June 1998 at our institution. For the detection of osteonecrosis, all patients complaining of musculoskeletal pain underwent magnetic resonance imaging. Demographic characteristics, time after transplantation, etiology of underlying lung disease, and the number of steroid pulses for rejection episodes were compared for patients with and without osteonecrosis. RESULTS: Of 63 transplant recipients, all 49 with a follow-up of >3 months were included for analysis. Of seven symptomatic transplant recipients, five cases of osteonecrosis (10%) were detected at a median duration of 216 days (range 44-600) after transplantation. Patients with osteonecrosis have been treated with the same immunosuppressive regimen and with an equal number of steroid pulses for acute rejection episodes (1.4+/-1.1 vs. 1.4+/-1.5, P=0.69), but were younger (26+/-8 vs. 40+/-11 years, P<0.01) than other transplant recipients. Symptomatic osteonecrosis was detected in four of 14 patients (29%) with cystic fibrosis (CF), compared with one osteonecrosis among 35 patients (3%) with other underlying diseases (P<0.02). Within the group of CF patients, specific clinical and demographic characteristics correlating with the risk for subsequent osteonecrosis could not be found. CONCLUSION: In lung transplant recipients, CF may be a risk factor for the development of symptomatic osteonecrosis.

Adolescent↗
PubMed2000

Interleukin-10 secretion by alveolar macrophages and monocytes in sarcoidosis.

BACKGROUND: Alveolitis and the production of proinflammatory cytokines are known features of sarcoidosis. Because of the usually spontaneous resolution of alveolitis despite local secretion of mediators causing inflammation and granuloma formation, we hypothesized that downmodulating mechanisms such as anti-inflammatory cytokines might be involved in this process. OBJECTIVE: Investigation of the secretion of the macrophage deactivating cytokines interleukin-10 (IL-10) and transforming growth factor-beta (TGF-beta) by alveolar macrophages in untreated sarcoidosis of the lung. METHODS: Fourteen consecutive and untreated patients with pulmonary sarcoidosis and 18 volunteers underwent bronchoscopy. Alveolar macrophages (AM) were obtained by bronchoalveolar lavage and the secretion of IL-10 and TGF-beta was studied. RESULTS: Spontaneous IL-10 production by AM was found in 6 of 14 patients and in 2 of 18 controls. The IL-10 level of lipopolysaccharide-stimulated AM was significantly higher in patients. Monocytes secreted significantly more IL-10 than AM, but there was no difference between sarcoid and control monocytes. No difference was found in the secretion of TGF-beta between patients and controls. CONCLUSION: Increased local secretion of IL-10 - but not TGF-beta - may represent a downmodulating mechanism involved in the spontaneous resolution of alveolitis in sarcoidosis.

Adult↗
PubMed1999

Extracorporeal photochemotherapy for Epstein-Barr virus-associated lymphoma after lung transplantation.

Posttransplantation lymphoproliferative disorder (PTLD) is a serious complication after transplantation of solid organs. Highest incidence rates have been reported for lung transplant recipients. With the current treatment strategy for early onset PTLD, a reduction of immunosuppressive drugs, mortality of lung transplant recipients with PTLD remains high, due to both, incomplete control of PTLD and transplant rejection. We present a lung transplant recipient with a history of acute rejection and Epstein Barr virus-associated posttransplantation malignant non-Hodgkin's lymphoma. Extracorporeal photochemotherapy, in combination with a moderate reduction of immunosuppressive therapy, resulted in complete disappearance of PTLD. After a first year of follow-up, no further rejection and no recurrence of PTLD have occurred. Treatment with ECP, with its beneficial effects on both, rejection after organ transplantation and malignant lymphoma, may be a particularly valuable approach for the treatment of PTLD in patients after lung transplantation, with its increased risk for transplant rejection.

Adolescent↗
PubMed1999

[Pseudomonas pneumonia--an important differential pulmonary infiltration diagnosis in AIDS].

Bacterial pneumonias are the most common pulmonary complication in HIV-infected patients. Up to now, H. influenzae and S. pneumoniae have been described as the most important germs. Within a period of 4 years we diagnosed 15 cases of pneumonia caused by P. aeruginosa. All patients were in HIV stage C3; 3F, 12M; median age 34 (24-54) years; median CD4 count 10 (0-130) microliters. Except for 3 nosocomial pneumonias, all others were community-acquired. Only 3 patients had neutropenia < 1000/microliter; 7 were intravenous drug abusers. Morphologically there were 6 cases of abscess pneumonia, in 3 of which pleural drainage was necessary because of pyopneumothorax. 4 patients showed bilateral infiltrates that could not be differentiated from those of P. carinii pneumonia. Our diagnosis was based on quantitative cultures of broncho-alveolar lavage fluid (9 cases, two of them with concurrent positive blood cultures/positive cultures of the pleural fluid), pleural puncture (one case), sputum in pneumonias responding only to antipseudomonas therapy (3 cases), and autopsy (2 cases). 8 patients died of pseudomonas pneumonia within 1-3 months despite therapy. 7 patients received pseudomonas-specific combination therapy, but all died after median 9 (4-15) months of the underlying illness. In 3 cases recurrent pseudomonas pneumonia could be documented bacteriologically. We conclude that in HIV-infected patients pneumonia caused by P. aeruginosa is a significant and severe pulmonary complication.

AIDS-Related Opportunistic Infections↗
PubMed1999

Efficacy and cost effectiveness of oral ganciclovir in the prevention of cytomegalovirus disease after lung transplantation.

BACKGROUND: Cytomegalovirus is the single most frequent pulmonary pathogen in lung transplant recipients who survive at least 2 weeks. Patients at increased risk are either seropositive or have received an allograft from a donor with latent infection. Morbidity and mortality caused by cytomegalovirus disease is still considerably high. METHODS: In an open, comparative study, we evaluated the efficacy, tolerance, and cost effectiveness of postoperative ganciclovir prophylaxis: intravenous dose of 2x5 mg/kg/day for 14 days, followed by either intravenous doses of 5 mg/kg]day (five patients), or oral doses of 3x 1000 mg (nine patients) up to 90 days. Oral ganciclovir was continued until prednisone was tapered below 15 mg/day. Prophylaxed groups were compared with a historical control (eight patients) in respect to cytomegalovirus disease, in-hospital stay, overall costs, and survival. Follow-up times and the net state of immunosuppressive therapy between groups were comparable. RESULTS: Six (75%) of the non-prophylaxed patients developed cytomegalovirus disease compared to none in the intravenous and one in the oral ganciclovir group (P=0.013). The non-prophylaxed patients had a longer cytomegalovirus-related in-hospital stay (P=0.018) and nonsignificantly higher cytomegalovirus-related costs. Bronchiolitis obliterans syndrome was less frequent with prophylaxis (P=0.039), and survival tended to be better (P=0.072). The only adverse effect was a subclavian vein thrombosis in the intravenous ganciclovir group. CONCLUSIONS: In lung transplant recipients, ganciclovir prophylaxis, either intravenous or oral, is safe, well tolerated, and effective in preventing cytomegalovirus disease. Moreover, ganciclovir prophylaxis seems likely to reduce the incidence of bronchiolitis obliterans syndrome. The oral formulation might be preferable because its convenience and possibly lower costs.

Administration, Oral↗
PubMed1999

The nitric oxide synthase cofactor tetrahydrobiopterin reduces allograft ischemia-reperfusion injury after lung transplantation.

OBJECTIVE: Exogenous nitric oxide reduces ischemia-reperfusion injury after solid organ transplantation. Tetrahydrobiopterin, an essential cofactor for nitric oxide synthases, may restore impaired endothelium-dependent nitric oxide synthesis. We evaluated whether tetrahydrobiopterin administration to the recipient attenuates lung reperfusion injury after transplantation in swine. METHODS: Unilateral left lung transplantation was performed in 15 weight-matched pigs (24-31 kg). Donor lungs were flushed with 1.5 L cold (1 degrees C) low-potassium-dextran solution and preserved for 20 hours. Group I animals served as controls. Group II and III animals were treated with a bolus of tetrahydrobiopterin (20 mg/kg). In addition, in group III a continuous infusion of tetrahydrobiopterin (10 mg/kg per hour over 5 hours) was given. One hour after reperfusion, the recipient right lung was occluded. Cyclic guanosine monophosphate levels were measured in the pulmonary venous and central venous blood. Extravascular lung water index, hemodynamic variables, lipid peroxidation, and neutrophil migration to the allograft were assessed. RESULTS: In group III a significant reduction of extravascular lung water was noted in comparison with the controls (P =.0047). Lipid peroxidation in lung allograft tissue was significantly reduced in group II (P =.0021) and group III ( P =. 0077) in comparison with group I. Pulmonary venous levels of cyclic guanosine monophosphate increased up to 23 +/- 1 pmol/mL at 5 hours in group II and up to 40 +/- 1 pmol/mL in group III (group I, 4.1 +/- 0.5 pmol/mL [I vs III]; P <.001), whereas central venous levels of cyclic guanosine monophosphate were unchanged in all groups. CONCLUSION: Tetrahydrobiopterin administration during lung allograft reperfusion may reduce posttransplantation lung edema and oxygen-derived free radical injury in the graft. This effect is mediated by local enhancement of the nitric oxide/cyclic guanosine monophosphate pathway.

Animals↗
PubMed1999

Complications in the native lung after single lung transplantation.

OBJECTIVES: Single lung transplantation is a viable option for patients with end-stage pulmonary disease; despite encouraging results, we observed serious complications arising in the native lung. We retrospectively reviewed 36 single lung transplants to evaluate the incidence of complications arising in the native lung, their treatment and outcome. METHODS: Between 1991 and 1997, 35 patients received 36 single lung transplants for emphysema (16), pulmonary fibrosis (14), lymphangioleiomyomatosis (4), primary pulmonary hypertension (1) and bronchiolitis obliterans (1). The clinical records were reviewed and the complications related to the native lung were divided into early (up to 6 weeks after the transplant) and late complications. RESULTS: Nineteen complications occurred in 18 patients (50%), leading to death in nine (25%). Early complications (within 6 weeks from the transplant) were bacterial pneumonia (1), overinflation (3), retention of secretions with bronchial obstruction and atelectasis (1), hemothorax (1), pneumothorax (1) and invasive aspergillosis (3); one patient showed active tuberculosis at the time of transplantation. Two patients developed bacterial pneumonia and invasive aspergillosis leading to sepsis and death. The other complications were treated with separate lung ventilation (1), bronchoscopic clearance (1), chest tube drainage (1) and wedge resection and pleurodesis (mechanical) by VATS (1). One patient with hyperinflation of the native lung eventually required pneumonectomy and died of sepsis. The patient with active tuberculosis is alive and well after 9 months of medical treatment. Late complications were recurrent pneumothorax (4), progressive overinflation with functional deterioration (2), aspergillosis (1) and pulmonary nocardiosis (1). Recurrent pneumothorax was treated with chest tube drainage alone (1), thoracoscopic wedge resection and/or pleurodesis (2) and pneumonectomy (1); hyperinflation was treated with thoracoscopic lung volume reduction in both cases; both patients with late infectious complications died. CONCLUSIONS: After single lung transplantation, the native lung can be the source of serious problems. Early and late infectious complications generally result in a fatal outcome; the other complications can be successfully treated in most cases, even if surgery is required.

Adolescent↗
PubMed1999

[Lung transplantation in advanced pulmonary emphysema].

Over the last 15 years lung transplantation developed from an experimental technique to a valid therapy for patients with end-stage pulmonary emphysema. The main reason for this progress are better defined selection criteria, improved operative technique and organ preservation, optimized peri- and postoperative management, and a more precise immunosuppressive and anti-infective therapy. Indications, technique, treatment and results of lung transplantation in emphysema patients are discussed.

Aged↗
PubMed1998

[Red fingers].

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AIDS-Related Opportunistic Infections↗