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Introduction. Staphylococcus (S.) aureus is one of the most omnipresent and dangerous human pathogens, whose main characteristic is the production of the enzyme coagulase. This characteristic serves to identify and assess the pathogenicity of the bacteria. In addition to skin infections, endocarditis, osteomyelitis, and infectious arthritis, it is a common cause of pneumonia both in children and adults. Case report. We described a case of a 65-year-old woman with a dry cough and malaise with patchy areas of consolidation on the chest X-ray and “ground-glass” opacity with bronchial wall thickening and unilateral mediastinal lymphadenopathy on chest computed tomography imaging. Methicillin-resistant S. aureus was isolated from the bronchoalveolar aspirate taken during bronchoscopy. The woman was empirically treated with azithromycin, and later, based on the antibiogram findings, azithromycin was replaced with meropenem, after which her health improved. Conclusion. We presented a rare case of pneumonia with unconvincing symptomatology and laboratory and radiological findings. Paying more attention to such cases in the future is crucial, especially to the use of antibiotics to which staphylococci are increasingly developing resistance.

Introduction. Li-Fraumeni syndrome (LFS) is a hereditary familial predisposition to a wide range of certain, often rare malignant diseases. Patients also have an increased risk of developing secondary and even tertiary malignancies throughout their lifetime. The most common malignancies are soft-tissue and bone sarcomas, breast cancer, brain tumors, adrenocortical carcinoma, and acute leukemia. The syndrome is inherited as an autosomal dominant disorder. In most families with LFS, germline mutations of the tumor protein have been identified on the TP53 gene. To our knowledge, this is the second case report of LFS that has been reported in our country so far. Case report. We present five members of the same family with malignant diseases typical for LFS. A woman at the age of 21 had recurrent astrocytoma and mediastinal liposarcoma. Her older sister had rhabdomyosarcoma and liver cancer and died at the age of 18. The mother of their father was diagnosed with breast cancer at the age of 45, and she died at the age of 52. The father’s sister had osteosarcoma and died before the age of 40. The father was diagnosed with lung adenocarcinoma at the age of 49, two years after the death of his second daughter. Genetic analysis identified a pathogenic, heterozygous germline mutation of the TP53 gene. He also has a third, 8-year-old daughter for whom he denied testing for LFS. Conclusion. Genetic analysis for LFS of all family members is required in patients with rare and multiple malignancies but also frequent and early onset malignancies in the family. Screening for the detection of early cancer manifestation is the key to prolonged survival in people with LFS.

Background/Aim. Acute pulmonary embolism (APE) may have different clinical manifestations. Also, its outcome can range from complete recovery to early death. Major bleeding (MB) as a due of the therapy also contributes to the overall adverse outcome. So far, it is unknown what the best predictors are for short-term mortality and MB among the several commonly used biomarkers. The aim of this study was to evaluate the significance of Creactive protein (CRP) and other biomarkers for the prediction of adverse clinical outcomes. Methods. This clinical, observational, retrospective-prospective study included 219 consecutive adult patients treated for APE. Results. Among 219 patients, 22 (10%) died within the first month after diagnosis. Twenty seven patients (12.3%) had at least one episode of MB. Composite end-point [netadverse clinical outcome (NACO)] was estimated in 47 (21.5%) of patients. The average values of all biomarkers were higher in the group of patient who died, and differences were statistically significant. Similar results were obtained for composite end-point. In terms of MB, none of biomarkers did not have significance, but CRP had a slight tendency toward significance. Results from univariate logistic regression model showed that troponin was statistically significant predictor of 30-day mortality. However, after adjusting for other variables, in multivariate logistic regression model troponin failed to be significant independent predictor of 30-day mortality. Unlike troponin, CRP and brain natriuretic peptide (BNP) were significant in all models – uni and multivariate (they were independent predictors of 30-day mortality). Conclusion. CRP has a good predictive value for 30-day mortality and NACO, and potential for MB in patients treated for APE.

Bacground/Aim. Obstructive sleep apnea (OSA) involves repeated episodes of cessation of breathing that occur due to a decrease in pharyngeal muscle tone. This disorder is more common in men and represents a significant risk factor for serious cardiovascular and cerebrovascular events. The gold standard in the diagnosis of this disorder represents a polysomnography (PSG), which is technically a complex and multidisciplinary method. Respiratory polygraphy (RP) may constitute an adequate replacement for most uncomplicated cases of obstructive sleep apnea. The aim of the study was to examine the efficacy of using respiratory polygraphies in diagnosing of obstructive sleep apnea. Methods. On all the patients with suspected obstructive sleep apnea, RP and a retrospective analysis of the obtained results were performed. Results. By completing our examination, we proved that there was a positive correlation between the results obtained by using RP and the predictors of obstructive sleep apnea such as the Epworth sleepiness scale (EPWORTH) score, neck circumference and body mass index. Conclusion. Respiratory polygraphy represents a cheaper and simpler replacement for PSG, especially with uncomplicated obstructive breathing disorders during sleep.

Introduction. Deep vein thrombosis and pulmonary embolism, known as venous thromboembolism, constitute a major global burden of disease. Both entities share the same risk factors. Psoriasis is a common, chronic skin disease. It also presents multisystemic inflammation, mainly affecting skin and joints, but it is also associated with the significant cardiovascular and metabolic states and comorbidities, on the so-called “psoriatic march”. Case report. We presented a 78-year-old female patient, with psoriasis associated with pulmonary embolism which is accidentally discovered. We did not find any other predisposing factor of this disease (primary or secondary thrombophilia), except hyperhomocysteinemia. The patient was treated with low molecular weight heparin (enoxaparin), followed by the administration of an oral vitamin K antagonist (warfarin sodium) in the weight adjusted regimens. Additionally, we recommended vitamin B complex, including folate. Supposed link between hyperhomocysteinemia and psoriasis was the decreased serum folate level as the result of increased vitamin utilization in the skin because of increased DNA synthesis. Conclusion. The reported case reflects existing literary knowledge about the increased risk of VTE and arterial thromboembolic events in the psoriatic patients. The highest risk appears in the patients with a severe disease and may be a consequence of systemic inflammation and hyperhomocysteinemia.

Background/Aim. As lung cancer is considered the greatest contributor to death among all cancer types any help might be valuable in the assessment of treatment effects. The aim of this study was for assess the quality of life (QoL) in patients with non-small cell lung cancer (NSCLC) treated with gemcitabine- cisplatin regimen as the first line of chemotherapy. Methods. The QoL was assessed using certified Serbian translations of the European Organization for Research and Treatment of Cancer Quality Life Questionnaire Core 30 (EORTC QLQ-C30) and Lung Cancer Module (QLQ-LC13) - version 3. The questionnaire was used before starting treatment and after the completion of the 2nd and the 4th cycle of chemotherapy. The questionnaire scales and single items were compared in order to assess the impact of treatment on the QoL. Results. A total of 60 patients started and 51 completed all questionnaires. There were no changes in the global health status score between the baseline, the 2nd and the 4th cycle of chemotherapy (42.78 ± 15.76, 45.56 ± 17.59, 48.20 ± 19.24, respectively; p = 0.1). Social function score, symptom scores: nausea and vomiting, pain, appetite loss, constipation, diarrhea and financial difficulties score differed significantly among chemotherapy cycles, indicating improved or worsened the QoL. In the lung cancer symptom score a significant difference between measurements was observed in cough, alopecia, chest pain and in using analgesics. Conclusion. Monitoring of changes in the QoL among patients with locally advanced and metastatic NSCLC showed that chemotherapy did not decrease the global health status but led to significant changes in the social and financial functioning of patients. Some symptoms associated with the disease reduced in the intensity but some new occurred as a result of chemotherapy. Using questionnaires to assess the QoL helped in easier identification of adverse effects and specific problems for adequate treatment.

Introduction/Aim. The disturbances in hemostasis are often in open surgical repair (OR) and endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA). These changes may influence the perioperative and early postoperative period inducing serious complications. The aim of this study was to compare the impact of OR and EVAR of AAA on clot quality assessed by rotational thromboelastometry (ROTEM®) tests. Methods. The study included 40 patients who underwent elective AAA surgery and were devided into two groups (the OR and the EVAR group - 20 patients in each group). The ROTEM ® test was performed in 4 points: point 1 - 10 min before starting anesthesia in both groups; point 2 - 10 min after aortic clapming in the OR group and 10 min after the stent-graft trunk release in the EVAR group; point 3 - 10 min after the releasing of aortic clamp in the OR group and 10 min after stentgraft placement and releasing the femoral clamp in the EVAR group; point 4 - one hour after the procedure in both groups. Three ROTEM® tests were performed as: extrinsically activated assay with tissue factor (EXTEM), intrinsically activated test using kaolin (INTEM), and extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (FIBTEM). All tests included the assessment of the maximum clot firmness (MCF) and the platelet component of clot strength was presented as maximal clot elasticity (MCE). Results. No significant difference in age, gender and diameter of AAA between groups was found. The time required for the procedure was significantly longer and loss of blood was greater in the OR group than in the EVAR group (p < 0.001). The significant deviation of MCF values in EXTEM test was found mainly in the point 3 (p ≤ 0.004) with significant difference between groups (p < 0.001). A significant difference of MCF values in INTEM test between groups was found in the points 3 and 4 (p < 0.001), which were dose-dependent by heparin sulfate. The MCF values in FIBTEM test were more prominent in the OR group than in the EVAR group without significant difference. The significant changes of MCF values in the FIBTEM test were found during time in both groups (p < 0.001). The values of MCE were lower in both groups, but without significant changes and difference between groups (p = 0.105). Conclusion. The disorders of hemostatic parameters assessed by ROTEM® tests are present in both the OR and the EVAR groups being more prominent in OR of AAA. Vigilant monitoring of hemostatic parameters evaluated by ROTEM® tests could help in administration of the adequate and target therapy in patients who underwent EVAR or OR of AAA.

Introduction. Pulmonary alveolar proteinosis is an uncommon disease characterized by the accumulation of surfactant proteins and phospholipids within the alveolar spaces. Acquired disease can be idiopathic (primary) and secondary. The prevalence of acquired pulmonary alveolar proteinosis is about 0.37 per 100,000 persons. Common symptoms are dyspnea and cough. Chest X-ray shows bilateral perihilar infiltrates. Open-lung biopsy is the gold standard for the diagnosis. Treatment includes whole-lung lavage, application of granulocyte-macrophage colonystimulating factor and lung transplantation. Case report. We reported a 51 year-old man with primary form of the disease. It was the second case of this extremely rare disease in the past 30 years in our clinic. The symptoms were longlasting dry cough, fever and physical deterioration. Chest Xray revealed bilateral pulmonary infiltrates; computed tomography showed patchy ground-glass opacification with interlobular thickening. The diagnosis was established by open lung biopsy. Additional tests were performed to exclude secondary form of the disease. Conclusion. We presented a rare clinical entity with typical clinical features and clinical and radiological course of the disease, in order to improve differential diagnostic approach to patients with bilateral lung infiltrations. In patients with pulmonary alveolar proteinosis timely diagnosis and adequate treatment can improve a prognosis.

Introduction. Nitrofurantoin, a furan derivative, introduced in the fifties has widely been used as an effective agent for the treatment and prevention of urinary tract infections (UTI). Spectrum of adverse reactions to nitrofurantoin is wide, ranging from eosinophilic interstitial lung disease, acute hepatitis and granulomatous reaction, to the chronic active hepatitis, a very rare adverse effect, that can lead to cirrhosis and death. Case report. We presented a 55-year-old female patient with eosinophilic interstitial lung disease, severe chronic active hepatitis and several other immune- mediated multisystemic manifestations of prolonged exposure to nitrofurantoin because of the recurrent UTI caused by Escherichia coli. We estimated typical radiographic and laboratory disturbances, also restrictive ventilatory changes, severe reduction of carbon monoxide diffusion capacity and abnormal liver function tests. Lymphocytic-eosinophylic alveolitis was consistent with druginduced reaction. Hepatitis was confirmed by liver biopsy. After withdrawal of nitrofurantoin and application of high dose of glicocorticosteroids, prompt clinical and laboratory recovery was achieved. Conclusion. Adverse drug reactions should be considered in patients with concomitant lung and liver disease. The mainstay of treatment is drug withdrawal and the use of immunosuppressive drugs in severe cases. Consideration should be given to monitor lung and liver function tests during long term nitrofurantoin therapy.

Background. The Mounier-Kuhn syndrome (MKS) or tracheobronchomegaly (TBM) is a rare condition of unknown frequency, up to now about 100 cases have been reported. It presents by marked dilatation of the trachea and major bronchi, recurrent respiratory infections and consecutive bronchiectasis and scars in lung parenchyme. Sometimes enlargement of transversal colon may be present. Diagnosis is usually made radiologically. Cases report. We reviewed two patients 77 and 72 years old with typical clinical presentation and enlarged upper airways, in whom diagnosis of MKS was established by chest multislice computed tomography (MSCT). Transversal diameter of trachea was 30 mm in the first patient and 33 mm in the other one. Complications of syndrome (tracheal diverticulosis in the first patient, and pulmonary fibrosis, bulous emphysema and bronchiectasis in both patients) also were seen. Lung function tests showed mixed ventilation disorder, and disturbance of respiratory gases values in arterial blood samples. Conclusion. The Mounier-Kuhn syndrome is rare disorder, although diagnosis is often missed. Clinical presentation is similar to chronic obstructive pulmonary disease or bronchiectasis. Computed tomography is gold standard for diagnosis. Therapy is presumely supportive.

Beckground/Aim. K-ras oncogene is mutated in about 20% of lung cancer. The purpose of this study was to investigate the predictive significance for therapeutic response of K-ras mutations in advanced non-small cell lung cancer (NSCLC) patients. Methods. Bronchial aspirate samples were assessed prior to platinum-based chemotherapy start in 39 patients with stage IIIb or IV NSCLC. K-ras mutations at codons 12 and 13 were analyzed by single strand conformation polymorphisam (SSCP) and allele specific oligonucleozide hybridisation of polymerase chain reaction (PCR) of the patient's DNA present in bronchial aspirate. After two cycles of chemotherapy the patients were subjected to response evaluation. Results. Of 39 patients 10 (25.5%) demonstrated K-ras mutations, while 29 (74.4%) patients had not. There were no significant differences between these two groups of patients with respect to baseline patient characteristics. Partial response to the therapy had 16 (41%), no changes 14 (36%), and progressive disease 9 (23%) patients. There was a tendency to higher response rate for patients without K-ras mutations versus those with mutations, but not statistically significant (p = 0.14). Conclusion. There was no significant predictive value for therapeutic response of K-ras mutations for advanced non-small cell lung cancer.

Background/Aim. Systemic connective tissue diseases (SCTD) are chronic inflammatory autoimmune disorders of unknown cause that can involve different organs and systems. Their course and prognosis are different. All of them can, more or less, involve the respiratory system. The aim of this study was to find out the frequency of respiratory symptoms, lung function disorders, radiography and high-resolution computerized tomography (HRCT) abnormalities, and their correlation with the duration of the disease and the applied treatment. Methods. In 47 non-randomized consecutive patients standard chest radiography, HRCT, and lung function tests were done. Results. Hypoxemia was present in nine of the patients with respiratory symptoms (20%). In all of them chest radiography was normal. In five of these patients lung fibrosis was established using HRCT. Half of all the patients with SCTD had symptoms of lung involvement. Lung function tests disorders of various degrees were found in 40% of the patients. The outcome and the degree of lung function disorders were neither in correlation with the duration of SCTD nor with therapy used (p > 0.05 Spearmans Ro). Conclusion. Pulmonary fibrosis occurs in about 10% of the patients with SCTD, and possibly not due to the applied treatment regimens. Hypoxemia could be a sing of existing pulmonary fibrosis in the absence of disorders on standard chest radiography.

Abstract: Introduction: Secondary antiphospholipid syndrome (SAPS) is APS that occurs in the context of another medical condition. Although antiphospholipid antibodies (aPL) can occur in patients with viral, bacterial, or protozoal infections, they are rarely associated with thrombosis. Aim: To present an uncommon case of pneumonia and pleural effusion complicated with pulmonary thromboembolism in a patient with systemic lupus erythematosus (SLE), due to non-diagnosed secondary antiphospholipid syndrome. Case report: A 28 years old woman, never pregnant, with a family history of systemic lupus erythematosus, has been suffering from SLE from the age of 18. She had only articular and skin manifestations, without internal organ involvement. She has been taking Methotrexate (10 mg weekly) and Prednisone (5 mg daily) in the previous 10 years. She was presented at the Emergency department with the radiological finding of pleuropneumonia followed by temperature up to 39C, shortness of breath, cough, fatigue, and weakness. Results: She was treated initially with three antibiotics and thoracocentesis. She developed pulmonary thrombosis without deep venous thrombosis. Laboratory findings were: ESR = 37 mm/h, CRP = 2+, ANA = 1/80 peripheral, RF negative, anti-dsDNA = 147 (positive > 40), anti-Sm negative, anticardiolipin IgG antibody 158 GPL (up to 12), anticardiolipin IgM antibody 5.5 MPL (up to 10), anti-beta2-glycoprotein IgG and IgM were negative and lupus anti-coagulant was 88" (18"-55"). The patient underwent Heparin and Warfarin treatment, by checking INR to be in a 2.6 to 3.5 range. Prednisolone and Hydroxychloroquine were also started. Conclusion: All patients suspected with SLE should be evaluated for antiphospholipid antibodies (APL). However, APS diagnosis requires both clinical and laboratory features.

Introduction: Although pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of the pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. Case report: We present a previously healthy man who had no contagious or TB contact but developed massive tuberculous pleural effusion which eventually was unexpected tuberculous. He started with therapy per protocol and feeling well. The purpose of this case and review of literature was to remind the physicians that tuberculosis is not a sickening illness, but on the contrary, it is in the expansion. Discussion: When a patient presents with new pleural effusion, the diagnosis of tuberculous pleuritis should be considered. The patient is at great risk for developing pulmonary or extra pulmonary TB if the diagnosis is not made properly. Between 3% and 25% of patients with TB will have TB pleuritic or more in immunocompromised patients.The treatment for TB pleuritis is the same as that for pulmonary TB. Conclusion:The gold standard for the diagnosis of tuberculous pleural effusion remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli.

Pulmonary embolism (PE) and deep vein thrombosis (DVT) are associated with considerable morbidity and mortality, and for as much as twenty-five percent of PE patients the primary clinical appearance is unexpected death. Diagnosis of PE is based on clinical suspicious at first, but sometimes its diagnostics can be extremely difficult. Newly increased interest in an inherited thrombophilic states has been provoked by the discovery of several common inherited abnormalities, i.e. the prothrombin (PT) gene G20210A, Factor V Leiden (FVL) mutation (Arg506Gln), hyperhomocystenemia and homocysteiuria, Wein-Penzing defect, Sticky Platelet Syndrome (SPS), Quebec platelet disorder (QPD) and Sickle Cell Disease (SCD). PE incidence rates increase in recent years. The only explanation at this moment is increased awareness of PE, especially after any kind of surgery, immobile state or unexplained shorthness of breath.

Introduction: Localized interlobar effusions in congestive heart failure (phantom or vanishing lung tumor/s) are infrequent, but widely recognized entities. Case report: A 80-years-old woman affected by progressive dyspnea over the previous three months, with productive cough. She was treated hypertension and had a pace maker implanted due to bradycardia. Chest X ray has shown right side pneumonia with high positive inflammatory markers. After resolution of pneumonia, phantom tumor of the lung was revealed, which disappear with intensive loop diuretics. Conclusions: The diagnosis of the phantom tumor ought to be pondered as a possibility in any patient with congestive heart failure and lung mass. The patient at hand featured no prior history of congestive heart failure, hence indicating that phantom tumor may occur in non-chronic heart failure patients. Albeid the reliable diagnosis of the phantom tumor through the utilization of imaging modalities in patients without congestive heart failure can be rather challenging, such possibility must be considered in a patient with a lung mass in the major fissure of the lungs. Due to accelerated expansion of the geriatric population and subsequent spread of the congestive heart failure, a rise in the incidence of vanishing tumors of the lung may be anticipated.