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Resumen Objetivo El objetivo del estudio fue conocer la tendencia de las variables relacionadas con la tuberculosis (TB) en Espana a partir del registro del Programa Integrado de Investigacion en Tuberculosis (PII-TB) de la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) y evaluar el PII-TB mediante indicadores relacionados con sus objetivos cientificos. Metodo Estudio transversal multicentrico de base poblacional de casos nuevos de TB registrados prospectivamente por el PII-TB entre 2006 y 2016. La tendencia temporal de variables cuantitativas se realizo mediante un modelo de regresion lineal y las cualitativas mediante la prueba de χ2 de tendencia lineal. Resultados Se analizaron 6.892 casos de TB con una mediana anual de 531. La tendencia general fue significativamente decreciente en mujeres, inmigrantes, privados de libertad y en tratados inicialmente con 3 farmacos. Se incrementaron significativamente la tendencia de grupos de 40 -50 anos y > 50 anos, primera atencion por especialista de zona, hospitalizacion, retraso diagnostico, localizacion diseminada y extrapulmonar unica, cultivo (+), realizacion de antibiogramas, resistencia a farmacos, tratamiento directamente observado, prolongacion del tratamiento y muerte por otra causa. Los objetivos cientificos del PII-TB que incrementaron significativamente fueron las publicaciones alcanzando un maximo de 8 en 2016 y con un factor de impacto total de 49,664, y tambien mejoraron los proyectos iniciados anualmente, presentaciones en congresos y las tesis o tesinas. Conclusiones El PII-TB proporciona informacion relevante sobre la TB y sus factores asociados en Espana. Se ha formado un amplio equipo de investigadores y se han detectado aspectos cientificos positivos y otros mejorables.

Objective The objective of the study was to determine the trend of variables related to tuberculosis (TB) from the Integrated Tuberculosis Research Program (PII-TB) registry of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), and to evaluate the PII-TB according to indicators related to its scientific objectives. Method Cross-sectional, population-based, multicenter study of new TB cases prospectively registered in the PII-TB between 2006 and 2016. The time trend of quantitative variables was calculated using a lineal regression model, and qualitative variables using the χy test for lineal trend. Results A total of 6,892 cases with an annual median of 531 were analyzed. Overall, a significant down-ward trend was observed in women, immigrants, prisoners, and patients initially treated with 3 drugs. Significant upward trends were observed in patients aged 40−50 and >50 years, first visit conducted by a specialist, hospitalization, diagnostic delay, disseminated disease and single extrapulmonary location, culture(+), drug susceptibility testing performed, drug resistance, directly observed treatment, prolonged treatment, and death from another cause. The scientific objectives of the PII-TB that showed a significant upward trend were publications, which reached a maximum of 8 in 2016 with a total impact factor of 49.664, numbers of projects initiated annually, presentations at conferences, and theses. Conclusions PII-TB provides relevant information on TB and its associated factors in Spain. A large team of researchers has been created; some scientific aspects of the registry were positive, while others could have been improved.

a b s t r a c t Introduction: The magnitude of current resistance to antituberculosis drugs in Spain is unknown. The objective of this study is to describe resistance to first-line antituberculosis drugs and determine the associated factors. Methods: Prospective multicenter study of adult tuberculosis patients with positive Mycobacterium tuber- culosis culture and antibiogram including first-line drugs in 32 hospitals and one out-patient center of the Spanish Health System between 2010 and 2011. Results: A total of 519 patients, 342 Spanish nationals and 177 (34.1%) foreigners were studied. Drug resistance was found in 48 (9.2%), of which 35 (6.7%) were isoniazid-resistant. There were 10 (1.9%) multiresistant cases and no strain was extremely resistant. Initial isoniazid resistance was detected in 28 of the 487 (5.7%) antituberulosis-naive patients, most of whom were foreigners (p

Introduccion La magnitud de la resistencia actual a farmacos antituberculosos en Espana es desconocida. El objetivo del estudio es describir la resistencia a farmacos antituberculosos de primera linea y determinar sus factores asociados. Metodos Estudio prospectivo multicentrico de pacientes tuberculosos adultos con aislamiento de Mycobacterium tuberculosis y antibiograma de farmacos de primera linea en 32 hospitales y un centro extrahospitalario del sistema sanitario nacional durante los anos 2010 y 2011. Resultados Se estudio a 519 pacientes, 342 espanoles y 177 (34,1%) extranjeros, 48 de ellos (9,2%) con resistencia a cualquier farmaco, de los que 35 (6,7%) eran resistentes a isoniacida. Hubo 10 casos multirresistentes (1,9%) y ninguno extremadamente resistente. Se detecto resistencia inicial a isoniacida en 28 de los 487 (5,7%) pacientes sin antecedentes de tratamiento antituberculoso previo, afectando mas a los extranjeros (p < 0,01), y resistencia adquirida en 7 (22,6%) casos previamente tratados. La multirresistencia fue inicial en 6 casos (1,2%) y adquirida en otros 4 (12,9%). Los factores asociados a tener resistencia inicial a isoniacida fueron ser inmigrante y la convivencia en grupo (OR = 2,3; IC del 95%, 0,98-5,67, y OR = 2,2; IC del 95%, 1,05-7,07, respectivamente). El factor asociado a la existencia de resistencia adquirida a isoniacida fue la edad inferior a 50 anos (p = 0,03). Conclusiones La tasa de resistencia inicial a isoniacida es superior a la estimada, probablemente debida al aumento de la inmigracion durante los ultimos anos, lo que aconseja su vigilancia nacional sistematica. Los individuos inmigrantes y los que conviven en grupo tienen mayor riesgo de tener resistencia a isoniacida

OBJECTIVES: To determine predictive factors for changes in standard anti-tuberculosis chemotherapy at the time of diagnosis. METHODS: A prospective study was performed among tuberculosis (TB) patients treated at specialised centres during 2008-2009. Treatment outcome was monitored per standard guidelines. Treatment was considered successful if the patient was cured or completed treatment. Factors associated with treatment modification were analysed at the bivariate and multivariate levels using logistic regression. RESULTS: A total of 427 patients were included in the study. The initial standard treatment regimen was retained for 249 patients (58.3%), extended to 9 months for 36 (8.4%) and changed for 142 (33.3%). Factors associated with a change of regimen at the multivariate level were female sex, age ≥ 50 years, human immunodeficiency virus infection, comorbidities, alcoholism, hospitalisation and culture-positive sputum. Drug resistance and toxicity were analysed independently. Treatment outcome was successful in 97.2% of cases without a regimen change and in 87.3% of those with a changed regimen (P < 0.001). CONCLUSION: Factors associated with changes in the initial anti-tuberculosis regimen should be considered for rigorous follow-up. Results obtained through individualised treatment provided by specialists were good despite the complexity of the cases treated.

Resumen Debe sospecharse tuberculosis pulmonar en pacientes con sintomas respiratorios durante mas de 2–3 semanas. La inmunodepresion puede modificar la presentacion clinica y radiologica. La radiografia de torax presenta manifestaciones muy sugerentes de tuberculosis, aunque en ocasiones atipicas. Las pruebas radiologicas complejas (tomografia computarizada, resonancia magnetica) son mas utiles en la tuberculosis extrapulmonar. En el diagnostico, siempre que sea posible, se utilizaran al menos 3 muestras seriadas representativas de la localizacion clinica. La baciloscopia y el cultivo con medios liquidos deben realizarse en todos los casos. Las tecnicas de amplificacion genetica son coadyuvantes en la sospecha moderada o alta de tuberculosis. En los casos nuevos de tuberculosis, se recomienda administrar isoniacida, rifampicina, etambutol y piracinamida (HREZ) durante 2 meses e isoniacida mas rifampicina durante 4 meses mas, con las excepciones de los casos de meningitis, en que se alargara hasta 12 meses, y de la tuberculosis espinal con afeccion neurologica y la silicosis, hasta 9 meses. Se recomiendan las formulaciones combinadas. En pacientes con infeccion por el VIH deben realizarse los ajustes necesarios con el tratamiento antirretroviral. Debe realizarse antibiograma para farmacos de primera linea a todos los aislamientos iniciales de pacientes nuevos. El control del tratamiento es una de las actividades mas importantes en el abordaje de la tuberculosis. En la infeccion tuberculosa la prueba de tuberculina (PT) es positiva cuando es ≥5 mm y los metodos de deteccion de produccion de interferon gamma (IGRA) se recomiendan en combinacion con la prueba de la tuberculina. La pauta estandar de tratamiento de la infeccion es de 6 meses con isoniacida. En la tuberculosis pulmonar se aplicara aislamiento respiratorio durante 3 semanas o hasta obtener 3 muestras con baciloscopia negativa.

Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest X-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when >or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained.

Unfortunately, advances in the management of tuberculosis (TB) occur all too slowly. It has, however, been quite a few years since the last guidelines on the diagnosis and treatment of TB were published by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). During the intervening period, not only have advances been made in the treatment and, above all, the diagnosis of TB, but the demographic profile of Spain has also changed significantly as a result of increased immigration. Today, 10% of the country’s population is foreign born and 30% of TB cases involve immigrant patients. In this context, we considered it both timely and essential to update the society’s guidelines and adapt the recommendations to take into account these changes in the composition of Spanish society.. To simplify access to the information, we decided to combine all the society’s recommendations on the diagnosis and treatment of TB in a single practice guideline based on the scientific evidence currently available. Recommendations are graded as A, B, C, or D. A grade A classification indicates that the supporting scientific evidence is good or very good (level 1 trials); grade B indicates that the evidence is reasonably good (level 2 trials); grade C that the supporting evidence is scant (individual case reports and case series); and grade D that the recommendation is based on expert opinion or consensus. We would like to thank SEPAR’s Scientific Committee for their confidence in the ability of this group of experts to compile the new TB guidelines, and we hope that the resulting document will be of use in improving the management of TB. DIAGNOSIS OF TUBERCULOUS INFECTION

Objetivo: Estudiar la utilidad de la medida de la presion transcutanea de anhidrido carbonico (PtcCO2) en pacientes con enfermedad respiratoria hospitalizados. Pacientes y metodos: Utilizamos el analizador de PtcCO2 SenTec®, que tambien determina la saturacion transcutanea de oxigeno (SpO2), mediante un sensor colocado en el lobulo de la oreja a una temperatura de 42 °C. Se compararon los valores gasometricos ­--presion arterial de anhidrido carbonico (PaCO2) y saturacion arterial de oxigeno (SaO2)--­ con los transcutaneos, analizando la correlacion, recta de regresion y la concordancia entre ambos metodos. Resultados: Se incluyo a 30 pacientes (20 varones y 10 mujeres) con diversas enfermedades respiratorias, con una media (± desviacion estandar [DE]) de edad de 71 ± 13 anos. La mediana de la PtcCO2 era de 43,25 mmHg, y la de la PaCO2 de 42,6 mmHg, sin existir diferencias entre ellas. La correlacion era significativa (? = 0,979; p < 0,0001), siendo la PtcCO2 = -­2,475 + 1,058 PaCO2. La media de las diferencias fue de 0,16 mmHg (intervalo de confianza del 95%, de ­-0,74 a 1,06); la media de las diferencias menos 1,96 DE fue de ­-4,64 mmHg, y mas 1,96 DE, de 4,96 mmHg. En cuanto a la SaO2, la mediana era del 94%, y la de la SpO2 del 95%, con diferencias entre ambas (p < 0,004). La correlacion fue significativa (? = 0,822; p < 0,0001), con SpO2 = 4,427 + 0,97 SaO2. La media de la concordancia era del 1,14% (intervalo de confianza del 95%, 0,381-1,899%); la media menos 1,96 DE era del ­-2,93%, y mas 1,96 DE, del 5,21%. Conclusiones: La determinacion transcutanea de anhidrido carbonico y de la SaO2 es de utilidad en pacientes con enfermedad respiratoria hospitalizados, dada su buena correlacion y concordancia, aunque la SpO2 tiende a sobrevalorar la SaO2.

OBJECTIVE: To evaluate the usefulness of transcutaneous carbon dioxide pressure (TcPCO2) monitoring in patients hospitalized for respiratory disease. PATIENTS AND METHODS: We used a SenTec TcPCO2 monitor that also determines transcutaneous oxygen saturation (SpO2) by means of a sensor placed behind the ear lobe at a temperature of 42oC. We compared arterial blood gas measurements—PaCO2 and arterial oxygen saturation (SaO2)—with transcutaneous measurements and analyzed the correlation, regression line, and agreement between the 2 methods. RESULTS: Thirty patients (20 men and 10 women) with various respiratory diseases and a mean (SD) age of 71 (13) years were included in the study. The median TcPCO2 was 43.25 mm Hg and the median PaCO2 was 42.6 mm Hg with no significant differences between the 2 measurements. The correlation was significant (ρ=0.979; P

La etiologia de este amplio grupo (masde 150 procesos) de enfermedades es, en la mayoria delos casos, desconocida, ya que solo en el 35% de ellases posible identificar el agente causal. La clasificacionde estas enfermedades se ha visto sujeta a numerosasrevisiones, aceptandose en la actualidad la elaboradapor consenso entre la American Thoracic Society (ATS)y la European Respiratory Society (ERS)

Marco de referencia La tuberculosis pulmonar con baciloscopia de esputo negativa plantea dificultades diagnosticas cuando no se dispone de medios liquidos de cultivo debido al lento crecimiento del Mycobacterium tuberculosis en los medios tradicionales de cultivo y a la necesidad de utilizar exploraciones invasivas. Objetivo Evaluar los hallazgos de la tomografia computarizada de alta resolucion (HRCT) en pacientes con tuberculosis pulmonar y baciloscopia de esputo negativa. Metodo Se estudiaron prospectivamente 28 pacientes (12 con tuberculosis activa y 16 inactiva) mediante HRCT, valorando los siguientes hallazgos: nodulos centrolobulillares, estructuras lineales ramificadas multiples, macronodulos, cavitacion, consolidacion, engrosamiento de septos interlobulillares, vidrio esmerilado, bronquiectasias, enfisema, distorsion broncovascular, cambios fibroticos, adenopatias mediastinicas calcificadas, calcificacion parenquimatosa, engrosamiento pleural y derrame pleural. Resultados Los hallazgos que se asociaron significativamente a enfermedad activa fueron: consolidacion (67%), macronodulos (67%) y nodulos centrolobulillares (67%). La presencia de nodulos centrolobulillares y/o consolidacion tuvo una sensibilidad del 83% y especificidad del 87%. Los hallazgos que se asociaron significativamente a enfermedad inactiva fueron bronquiectasias (87%) y distorsion broncovascular (62%). Conclusion Nuestros resultados apoyan el valor de la HRCT en pacientes con tuberculosis pulmonar y baciloscopia de esputo negativa, ya que el hallazgo de nodulos centrolobulillares y/o consolidacion tiene una buena sensibilidad y especificidad para diagnosticar enfermedad pulmonar activa.

Twenty-eight (11.6%) out of 241 Spanish patients enrolled in an international phase III clinical trial of mild to moderate community-acquired pneumonia (CAP) comparing gemifloxacin vs. trovafloxacin were diagnosed of Legionnaires' disease. A definite diagnosis was established by seroconversion in 13 patients of whom only 2 had a positive Legionella urinary antigen. The remaining 15 patients were possible Legionella infections based on a single elevated IgG titer (> or = 1:512). All patients had a radiologically confirmed diagnosis of pneumonia, 5 (19%) patients were older than 65, comorbidity was present in 9 (33%), and 10 (36%) had to be hospitalized. Fifteen patients were treated with oral gemifloxacin (320 mg/day) and 13 with oral trovafloxacin (200 mg/day). Overall, clinical success occurred in 25 (89.3%) patients after 7 days of treatment and only 1 patient needed a 14-day treatment. There were only one adverse event withdrawal and one clinical failure, and no patients died. In light of the favorable clinical outcome, the use of newer fluoroquinolones seems adequate for the treatment of suspected or proven Legionella pneumonia.

In order to assess factors associated with spontaneous pneumothorax (SP), mainly climatic changes, a prospective study was undertaken of 62 SP episodes among patients admitted to our hospital during a two-year period, from January 1994 to January 1996. Atmospheric pressure (AP) changes were analyzed, with daily recording of the number of unusual changes in AP (increases above 95th percentile and decreases below 5th percentile) and how many of these changes were followed by some episode of spontaneous pneumothorax during the following five days. To measure the degree of this association between the emergence of pneumothorax and exposure to unusual changes I AP, the relative risk (RR) was calculated. A total of 77 unusual AP changes were observed, 17 of which concurred with the emergence of 8 episodes of SP during the following five days, with a RR of 2.7 (1.6-4.4). Although the etiology of SP is unknown and probably of multifactorial origin, these data suggest that unusual changes in AP may play a relevant role in triggering this condition.

El sarcoma intimal de la arteria pulmonar es un tumor infrecuente que habitualmente se diagnostica en el acto quirurgico o la autopsia. Por lo general crece regionalmente, con poca capacidad de metastatizar. El diagnostico es dificil y con frecuencia se retrasa debido a la naturaleza inespecifica de los sintomas. Su baja frecuencia y el crecimiento insidioso hacen que a menudo se confunda con una tromboembolia pulmonar, y por ello se trata inadecuadamente con anticoagulacion prolongada o trombolisis. El pronostico es malo, con una media de supervivencia de 12 meses desde el inicio de los sintomas. Presentamos el caso de una paciente a quien se diagnostico preoperatoriamente un sarcoma intimal de la arteria pulmonar que se sometio a reseccion quirugica, sin que se evidenciase recurrencia en el seguimiento a largo plazo. Tambien se realiza una revision de la bibliografia.

Intimal sarcoma of the pulmonary artery is a rare tumor that is usually diagnosed during surgery or autopsy. Such tumors are characterized by local growth, with only slight ability to metastasize. Diagnosis is difficult and often delayed owing to the nonspecific nature of the symptoms. Since intimal sarcoma of the pulmonary artery is so rare and insidious it is often confused with pulmonary thromboembolism and is therefore treated inappropriately with prolonged anticoagulation or thrombolysis. With a mean survival of 12 months from the onset of symptoms, the prognosis is poor. We present the case of a woman who was preoperatively diagnosed with intimal sarcoma of the pulmonary artery and who underwent surgical resection with no apparent recurrence at long term follow-up. A review of the literature is also included.

La leishmaniasis visceral no es inusual en pacientes con sindrome de inmunodeficiencia adquirida (sida), pero su afectacion pulmonar es infrecuente. La leishmaniasis pulmonary a menudo se presenta como neumonitis intersticial. Describimos un caso en el cual el hallazgo de amastigotes en la biopsia transbronquial permitio el diagnostico de leishmaniasis pulmonar. Sin embargo, los hallazgos radiologicos y del lavado broncoalveolar eran compatibles con una bronquiolitis obliterante que podria deberse al virus del sida. Ademas, la biopsia transbronquial permitio diagnosticar un adenoma bronquioloalveolar con la presencia radiologica de multiples nodulos.

El objetivo de este estudio ha sido analizar las situaciones que dificultan la aplicacion de las indicaciones de la quimioprofilaxis antituberculosa. Se estudiaron 128 enfermos (106 VIH– y 22 VIH+) diagnosticados consecutivamente de tuberculosis (TB). Los pacientes fueron entrevistados personalmente mediante un cuestionario para identificar los diferentes grupos de riesgo y determinar las actuaciones que se habian realizado para prevenir la TB. En el grupo VIH–, 63 individuos (57,8%) tuvieron al menos un factor de riesgo; los mas frecuentes fueron: contacto con enfermos tuberculosos (31,1%), TB anterior (15,1%), perdida rapida de peso o desnutricion cronica (13,2%) y residencia en instituciones cerradas (5,6%). En 51 de ellos (48,1%) habia indicacion de valoracion para quimioprofilaxis y de estos, 43 (84,3%) habian realizado alguna visita medica en los ultimos 5 anos. Sin embargo, solo en 10 de los enfermos visitados (23,3%) se indico la prueba de la tuberculina y en cuatro (9,3%) se prescribio isoniazida. En el grupo VIH+, 13 de los 18 individuos con indicacion de valorar quimioprofilaxis (72,2%) habian sido visitados, en 12 (97,7%) se realizo la prueba de la tuberculina y en cuatro (30,7%) se indico isoniazida. Ninguno de los pacientes de ambos grupos en que se indico un curso completo de quimioprofilaxis tomo isoniazida durante un tiempo suficiente. La mayoria de los pacientes VIH– con indicacion de valorar quimioprofilaxis habia realizado alguna visita medica en los 5 anos previos a su enfermedad; sin embargo, menos de la cuarta parte fueron valorados en este sentido. Esta situacion probablemente es consecuencia de la dispersion asistencial existente en nuestro pais en materia de control de la tuberculosis. Por contra, en casi todos los pacientes VIH+ visitados se comprobo su estado tuberculinico, debido a que se beneficiaron de una asistencia protocolizada.

La neumonia eosinofila cronica (NEC) se caracteriza por sindrome clinico inespecifico, patrones radiologicos intersticial y acinar perifericos e infiltracion pulmonar por eosinofilos, acompanada o no de eosinofilia periferica, asi como por su respuesta espectacular al tratamiento con esteroides. Estudiamos 4 pacientes diagnosticados de NEC, uno ex juvantibus y los otros tres mediante lavado broncoalveolar (LBA). Ninguno padecio asma y solo uno de ellos tenia eosinofilia periferica. Todos siguieron tratamiento esteroide prolongado sin recidivas. Dos pacientes tuvieron una evolucion torpida sin que pudiera demostrarse en ellos su asociacion a bronquiolitis obliterante con o sin neumonia organizativa. Destacamos la inocuidad y rentabilidad del LBA en el diagnostico de la NEC.

Visceral leishmaniasis is not unusual in patients with acquired immunodeficiency syndrome (AIDS), but lung infiltration is uncommon. Leishmaniasis involving the lung often manifests as interstitial pneumonitis. We report a case in which the discovery of amastigotes in the transbronchial biopsy led to a diagnosis of leishmaniasis. However, the findings from x-rays and study of the bronchoalveolar lavage fluid were consistent with bronchiolitis obliterans, possibly caused by the AIDS virus. In addition, the transbronchial biopsy findings were consistent with a diagnosis of bronchioloalveolar adenoma with radiographic evidence of multiple nodules.

Pulmonary tuberculosis with negative sputum bacilloscopy involves diagnostic difficulties when there are not available liquid culture media due to the slow growth of Mycobacterium tuberculosis in the traditional culture media, and also due to the need for carrying out invasive examinations.Evaluate the high resolution computerized tomography findings (HRCT) in patients with pulmonary tuberculosis and negative bacilloscopy of sputum.Prospectively 28 patients (12 with active tuberculosis and 16 with inactive tuberculosis) were evaluated through HRCT, assessing the following findings: centrolobular nodules, multiple branched linear structures, macronodules, cavitation, consolidation, enlargement of interlobular septums, ground-glass change, bronchiectases, emphysema, broncovascular distortion, fibrotic changes, calcified mediastinal adenopathies, parenchymous calcification, pleural enlargement, and pleural effusion.The findings that were associated significantly to the active disease were: consolidation (67%), macronodules (67%) and centrolobular nodules (67%). The presence of centrolobular nodules and/or consolidation had a sensitivity of 83% and a specificity of 87%. The findings significantly associated to inactive disease were bronchiectases (87%) and broncovascular distortion (62%).Our results support the value of HRCT in patients with pulmonary tuberculosis and negative sputum bacilloscopy, since the finding of centrolobular nodules and/or consolidation has good sensitivity and specificity for the diagnosis of active pulmonary disease.

In order to assess factors associated with spontaneous pneumothorax (SP), mainly climatic changes, a prospective study was undertaken of 62 SP episodes among patients admitted to our hospital during a two-year period, from January 1994 to January 1996. Atmospheric pressure (AP) changes were analyzed, with daily recording of the number of unusual changes in AP (increases above 95th percentile and decreases below 5th percentile) and how many of these changes were followed by some episode of spontaneous pneumothorax during the following five days. To measure the degree of this association between the emergence of pneumothorax and exposure to unusual changes I AP, the relative risk (RR) was calculated. A total of 77 unusual AP changes were observed, 17 of which concurred with the emergence of 8 episodes of SP during the following five days, with a RR of 2.7 (1.6-4.4). Although the etiology of SP is unknown and probably of multifactorial origin, these data suggest that unusual changes in AP may play a relevant role in triggering this condition.

El secuestro pulmonar es una zona de tejido pulmonar, separada del arbol traqueobronquial, que recibe el aporte sanguineo de una arteria sistemica. El diagnostico requiere la comprobacion de los vasos anomalos mediante arteriografia. Sin embargo, con la resonancia magnetica (RM) es posible demostrar tanto las alteraciones del parenquima pulmonar como la vascularizacion aberrante en diversos planos, por lo que se puede obviar la necesidad de angiografia. Se describe un caso de secuestro pulmonar intralobar diagnosticado por RM y confirmado despues mediante arteriografia y en la intervencion quirurgica. Se comenta la aportacion de la RM y la angiografia por RM, no solo en el diagnostico, sino tambien en la evaluacion prequirurgica del secuestro pulmonar. Destaca sobre todo que se trata de maniobras no invasivas que no requieren la utilizacion de medio de contraste.

Se presenta un caso de esclerosis tuberosa con retraso mental y epilepsia que fue diagnosticado a partir de su afectacion pulmonar. El hallazgo de las lesiones caracteristicas en el estudio cerebral mediante resonancia nuclear magnetica evito la necesidad de realizar otras tecnicas diagnosticas mas agresivas. Se hace una descripcion exhaustiva del proceso revisando la bibliografia existente y destacando la rareza de la afeccion pulmonar en la esclerosis tuberosa. Se valora asimismo el uso de tamoxifeno y progesterona para retrasar la evolucion progresivamente fatal de la enfermedad.

A 42-year-old man was admitted to the hospital with fever, abdominal pain and miliary radiological pattern. The amylase and lipase in serum, and the amylase in urine were increased. The tuberculin skin test was negative. The thoracic and abdominal CT scan showed costal affectation, multiple focal hepatic lesions and large necrosing peripancreatic lymphadenopathies. The transbronchial biopsy and the pancreatic punction demonstrated granulomatous necrotic lesions, and M. tuberculosis grew in the bronchial washing culture. The specific treatment normalized the pulmonary, costal and pancreatic lesions.

To assess the serological response to fractions of Mycobacterium tuberculosis sonicate antigen by Western blot analysis in patients with tuberculosis and contacts.We studied 71 individuals including 43 patients with active tuberculosis, 16 contacts and 12 healthy blood donors. For Western blot analysis, M. tuberculosis (H37Rv strain) sonicate antigen extract was fractionated by electrophoresis on polyacrylamide gel (SDS-PAGE).We obtained antibody responses directed against four antigenic fractions with molecular weights of 71, 65, 26-38 and 19 kDa. Sixty per cent of pleural tuberculosis and 52.4% of smear-positive pulmonary tuberculosis had whole responses against all four fractions; there were no partial responses in these groups. For patients with smear-negative pulmonary tuberculosis whole responses were 17.6% and partial responses 41.2%. All contacts whose tuberculin tests converted from negative to positive (three cases) reacted exclusively against the 19 kDa fraction.Western blot-positive results in patients with pleural and smear-positive pulmonary tuberculosis were characterised by a whole pattern against all four antigenic fractions, whereas patients with smear-negative pulmonary tuberculosis showed heterogeneous results. The exclusive response against the 19 kDa fraction observed in contacts with tuberculin conversion could help to identify candidates for preventive therapy.

We aimed to evaluate the differences in pulmonary function, quality of life (CVRS) and dyspnea in patients with chronic obstructive pulmonary disese (COPD) and emphysema according to the body mass index (BMI). Moreover, we analyzed the relation between BMI, pulmonary function, CVRS and dyspnea.This was a prospective, 12-months study including 20 patients with COPD and emphysema. They were classified in group A (BMI21 kg/m(2) group B (BMI= 21 kg/m(2)). We performed pulmonary function tests and determined the levels of dyspnea and CVRS according to a scale of dyspnea and a CVRS questionnaire.Seven patients had a BMI21 kg/m(2) and it was=21 kg/m(2) in 13 patients. DLCO in group A patients was lower than in group B. After a multiple regression analysis, the FVC accounted for 52% of dyspnea variability. Both PEM and dyspnea were the parameters that better predicted the CVRS.Patients with COPD and emphysema with a VMI21 kg/m(2) have a lower DLCO than patients with a BMI= 21 kg/m(2). In our patients, dyspnea sensation depended on the FVC. In addition,the CVRS depended on dyspnea sensation and PEM.

Se presenta un paciente de 42 años que ingresa en nuestro hospital con fiebre, dolor abdominal y patrón radiológico miliar. Tenía un aumento de amilasemia y amilasuria y de la lipasa sérica. El mantoux era negativo. En el estudio de TAC había engrosamiento costal, lesiones hepáticas focales múltiples y adenopatías necrosadas en zona peripancreática. Las biopsias transbronquiales y la punción pancreática mostraron lesiones granulomatosas necrotizantes, cultivándose M. tuberculosis complex en el broncoaspirado. El tratamiento específico normalizó todas las alteraciones pulmonares, costales y pancreáticas.

Se estudiaron comparativamente entre febrero de 1987 y diciembre de 1989, 79 neumotorax espontaneos idiopaticos, 40 de ellos drenados con tubos de calibre 12 F y los restantes con 10 F. El drenaje con tubos de pequeno calibre fue efectivo con una media de utilizacion de 5,2 ± 3,9 dias, requiriendo en solo un caso tratamiento quirurgico por fuga aerea persistente. No se encontraron diferencias significativas entre ambos grupos en cuanto a tiempo de drenaje, complicaciones y recidivas tras un seguimiento minimo de doce meses. Por ello, recomendamos el uso de drenajes de pequeno calibre en los neumotorax espontaneos idiopaticos, especialmente los de calibre 10 F, menos traumaticos y de similar efectividad que los 12 F.

We report a case of bronchial atresia in the apical segment of right down lobule associated to subcarinal bronchogenic cyst in an eighteen years old patient who consults by long time bronchitis. The thorax X-ray shows an image suggested of mucoid impaction. The respiratory function tests are not essential for the diagnostic. The fiber bronchoscopy is normal and the diagnostic is established by mean image technics (thoracic HR-TC and MR).

To determine clinical features and outcome in hospitalized patients with acute lung injury secondary to diffuse pulmonary hemorrhage (DPH).Eight adult patients suffering DPH and acute lung injury were undergone to diagnosis procedure and following.Two cases of idiopathic pulmonary hemosiderosis, two cases of systemic lupus erythematous, two cases of Goodpasture's syndrome, one case of idiopathic rapidly progressive glomerulonephritis and one of periarteritis nodosa were diagnosed. Treatment was methylprednisolone in all cases; besides, three cases required ventilatory support, and one immunosuppressive therapy, plasmapheresis and hemodialysis. One patient died and three of them suffered relapse with satisfactory outcome.We remark the presence of acute lung injury as an initial feature of DPH in our experience and the importance of a prompt diagnosis of the underlying disease.

Spain has the highest rates in Europe of the acquired immune-deficiency syndrome (AIDS), and probably a high rate of dual human immunodeficiency virus (HIV)/tuberculosis infection.To determine the trends of tuberculosis mortality in Spain from 1970 to 1993, and to draw conclusions about the effects of the AIDS epidemic on these trends.Official population figures and data on deaths from tuberculosis were used to calculate specific tuberculosis mortality rates by age and sex (per 100000 population). Causes of death from tuberculosis were grouped according to the International Classification of Diseases.The crude death rate decreased from 10.28 to 1.84, with an annual mean decrease of 8.1% (95% confidence interval 7.5% to 8.7%). No changes in mortality from tuberculosis of the central nervous system (CNS) have been recorded since 1982, and none in mortality from other tuberculosis and in the age group 20-49 years since 1986. Mortality was higher among males and in the older age groups. The peak observed in the 1970s, due to the excess of deaths from CNS tuberculosis in children under the age of 5 years, has disappeared.Between 1970 and 1993, tuberculosis mortality in Spain decreased, although an excess of deaths occurred in young adults and from extra-pulmonary tuberculosis, coinciding with the AIDS epidemic.

Swyer-James syndrome, unilateral hyperlucent lung with air entrapment, generally occurs after severe infections during childhood. It is usually diagnosed by its characteristic chest radiographic image film or computed tomography, in patients who are almost asymptomatic. We report a case of Swyer-James syndrome, diagnosed from the study of severe pulmonary hypertension and with a fatal outcome.

To analyze the situations that make chemoprophylaxis for tuberculosis difficult. One hundred twenty-eight patients consecutive (106 HIV negative and 22 HIV positive) diagnosed of tuberculosis (TB) were studied. The patients were interviewed and a questionnaire was filled out in order to identify risk groups and determine what steps had been taken to prevent TB. In the HIV negative group, 63 (57.8%) had at least one risk factor. The most common were contact with persons with active TB (31.1%), former TB (15.1%), rapid weight loss or chronic malnutrition (13.2%) and residence in closed institutions (5.6%). Of the 51 (48.1%) for whom evaluation of chemoprophylaxis was indicated, 43 (84.3%) had been examined by a physician within the past five years; only 10 (23.3%) of them, however, had been checked for TB and isoniazide had been prescribed for only 4 (9.3%). In the HIV positive group, 13 (72.2%) of those for whom evaluation of chemoprophylaxis was indicated had been seen by a physician; 12 (97.7%) of them were given tuberculin tests checked for TB and isoniazide was prescribed for 4 (30.7%). None of the patients in either group who were prescribed a full course of prophylaxis actually took the drug enough. Most HIV negative patients for whom evaluation of chemoprophylaxis was indicated had been examined by a physician in the five years before disease was detected; less than a quarter of them were checked for TB, however. This situation is probably a consequence of the structure of health care in Spain as it affects TB control. Nearly all the HIV positive patients were checked for the disease, as they benefited from protocolized health care.

To identify the situations that influence in the delayed diagnosis of tuberculosis.We studied 109 patients (87 non HIV-infected and 22 HIV-infected) who were diagnosed of tuberculosis in one year consecutively, using a questionnaire to obtain time intervals in which the whole diagnostic delay (WD) was divided.WD was higher than 1 month in 90 % of non HIV-infected patients. The delay due to the health system (SD) was higher (71%1 month) than the delay due to patient (PD; 30%1 month) and there was a negative correlation between both (R-0.73). In HIV+ group, WD was lower (59.1%month) and, although PD was higher (40.9%1 month), the time that the system delayed the suspicion of the diagnosis was lower (5.5%1 month). In HIV-group there were the following significant differences: higher delay in the suspicion of diagnosis (DSD) (61.4% and 60.8%1 month) and shorter time to make the diagnosis (12.3% and 21.6%1 month) in sputum smear-positive patients and who had cavitary lesions; PD was higher (67.1%1 month) in patients with general symptoms and nearly none in patients with upper airways symptoms; and higher DSD in presence of nonspecific symptoms like cough or/and expectoration (68.6%1 month) or upper airways symptoms (100%1 month). As these clinical symptoms were consulted in primary care mainly, there was a higher SD (75.751 month) and DSD (58.1%1 month), and were increased when a promptly chest X-ray was not performed (87.1 and 68.7%1 month).Delayed diagnosis of tuberculosis is common. In non HIV-infected patients, it occurs mainly in the health system. Diagnostic delays contribute to raise advanced disease with more contagious potential.

Changes in cell immunity made manifest by decreases in blood levels of CD4 T cells is the main indicator of progressing HIV infection. The decrease in these lymphocytes, as well as in the CD4/CD8 index and increases in suppressant or cytotoxic CD8 cells can be detected in bronchoalveolar (BAL) lung samples. It is not clear whether the high incidence of respiratory system diseases in HIV patients stems from local or systemic immune changes. The aim of this study was to compare changes in the systemic cell immunity studied in samples of peripheral blood with changes detected in BAL samples from HIV patients with acute respiratory disease. We studied 42 patients in the advanced stages of AIDS (C3 by Centers for Disease Control classification) who were hospitalized for acute respiratory disease and who underwent diagnostic fiberoptic bronchoscopy and BAL. Cell counts and lymphocyte populations were analyzed by flow cytometry in samples of peripheral blood and BAL. The percentage of CD4 lymphocytes and the CD4/CD8 index were lower in BAL, particularly in patients with blood CD4 levels below 12% of the total T cell population, or at a level of 20 CD4 cells/microliters. Changes in cell immunity in patients with advanced HIV infection (C3 classification) and acute respiratory disease are more manifest locally in the lung than peripherally in blood. Lung depletion of CD4 T cells in the lung can be predicted based on blood levels.

Bronchioloalveolar carcinoma is an infrequent malignant lung tumor, specially in patients younger than 50. Diagnosis is difficult and usually late, because its clinical and radiologic features are similar to other lung diseases and because its poor histopathologic differentiation from other primitive o metastatic adenocarcinoma. We report a case of multinodular, diffuse and bilateral bronchioloalveolar carcinoma in a young woman without previous lung disease which suspected diagnosis was by broncho-aspirated cytology and open lung biopsy was necessary for its confirmation.

Chronic eosinophilic pneumonia (CEP) is characterized by non-specific clinical presentation, interstitial radiological signs, peripheral acini and pulmonary infiltration by eosinophils, accompanied or not by peripheral eosinophilia. Response to treatment with steroids is spectacular. We describe 4 patients with CEP, one diagnosed by response to treatment and the others by bronchoalveolar lavage (BAL). No patient had asthma; 1 also had peripheral eosinophilia. All received long-term treatment with steroids, and there were no relapses. Response to treatment was slow in 2 patients, but obliterans bronchiolitis with or without organizing pneumonia could not be demonstrated. We emphasize the safety and efficiency of BAL for diagnosis of CEP.

Pneumomediastinum cases admitted to our Respiratory Intensive Care Unit during the past 15 years are reviewed. After excluding secondary and iatrogenic pneumomediastinum, spontaneous pneumomediastinum was diagnosed in seven patients being all of them males. The causative conditions were status asthmaticus in four patients, intense cough in two and Valsalva manoeuver in one patient. The most frequent symptoms were dyspnea, chest pain and odynophagia. Subcutaneous emphysema appeared in six patients and there was associated pneumothorax in two cases. ECG was normal in six patients. All cases of spontaneous pneumomediastinum had a satisfactory evolution with conservative treatment resolving in four to eight days.

A case of pneumothorax during the 8th week of pregnancy is described. The literature is reviewed. We highlight the rareness of the case and discuss of possible relationship with protector hormonal factors.

A case of a patient receiving chemotherapy because of breast cancer who developed adult respiratory distress caused by Pneumocystis carinii pneumonia is presented. The evolution was good after treatment with 20 mg/kg/day of trimethoprim and 100 mg/kg/day of sulfamethoxazole.