Coccidioidomycosis is a disease caused by inhalation of arthrospores of the fungus Coccidioides immitis. It has been recognized as a clinical entity since 1892. It is related to activities that involves dust exposure. It is found in many regions of the western hemisphere with dry and alkaline soil. In Brazil it has been described almost exclusively in the Northeast region where drought periods may favor its growth in its soil. We report a case of fatal coccidioidomycosis, in an immunocompetent host, associated to the activity of armadillo hunting (Dasypus novemcynctus) in a rural area of Ceará state.

Keywords: Coccidioidomycosis. Occupational exposure. Armadillos.

Coccidioidomycosis, a fungal illness acquired by the inhalation of arthroconidia of Coccidioides sp., was first described in 1894. Coccidioidomycosis is mainly restricted to areas with arid climate, alkaline soil and low rainfall. Consequently, most of the reported cases in Brazil have occurred in the northeastern region. We report three cases of pulmonary coccidioidomycosis occurring between 2005 and 2006 in an endemic area in the state of Ceará, Brazil. The three patients were immunocompetent adult males, hunters of armadillos (Dasypus novemcinctus), with complaints of cough, fever, dyspnea and pleuritic pain. All three patients presented pulmonary involvement, and one also presented cutaneous lesions. Chest X-rays and CT scans of the patients revealed characteristic coccidioidomycosis lesions. The diagnosis was confirmed by serological testing. All of the patients evolved to cure after antifungal treatment.

Keywords: Coccidioidomycosis; Lung diseases, fungal; Coccidioides.

Coccidioidomycosis is a systemic mycosis caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. Infection is acquired by inhalation of infective arthroconidia that live in the soil. In 60% of cases, the infection is benign and resolves spontaneously. In the northern hemisphere, coccidioidomycosis is endemic to arid and semi-arid regions at latitudes between 40°N and 40°S, particularly in the southwestern United States and in northern Mexico. In the semi-arid northeastern region of Brazil, cases of coccidioidomycosis have recently been reported in four states: Piauí (100 cases); Ceará (20 cases); Maranhão (6 cases); and Bahia (2 cases). The illness manifests in one of three clinical forms: the primary pulmonary form; the progressive pulmonary form; or the disseminated form. On average, the symptoms of respiratory infection appear 10 days after exposure. The diagnosis is made by the isolation of Coccidioides sp. in culture or by positive results from smear microscopy (10% potassium hydroxide test), periodic acid-Schiff staining or silver staining of any suspect material (sputum, cerebrospinal fluid, skin exudate, lymph node aspirate, etc.) Agar gel immunodiffusion is the diagnostic test most widely used. The most common finding on X-rays and CT scans is diffuse distribution of multiple pulmonary nodules, most of which are cavitated. The recommended treatment is fluconazole or itraconazole, the mean dose ranging from 200 to 400 mg/day, although as much as 1,200 mg/day is used in certain cases. In severe cases, amphotericin B can be the drug of choice. In cases of neurological involvement, the recommended treatment is administration of fluconazole, at a minimum dose of 400 mg/day.

Keywords: Mycoses/immunology; Coccidioidomycosis; Lung diseases, fungal.

A male farmer, 20 years old, from the countryside of the State of Piauí, developed acute respiratory infection. Despite adequate antimicrobial therapy, there was worsening respiratory manifestations demanding mechanical ventilation. Radiographs showed diffuse pulmonary infiltrates. PaO2/FiO2 was 58. Direct microscopy and culture from tracheal aspirates disclosed Coccidioides immitis. Autochthonous cases of coccidioidomycosis have only recently been described in Brazil, most of them from the State of Piauí. C. immitis has been isolated from humans, dogs and armadillos (Dasypus novemcinctus), and also from soil samples of armadillo's burrows. Therapeutic failure to antimicrobials and patient's origin from recognized endemic areas should alert for the possibility of acute pulmonary coccidioidomycosis.

Presence of arterial hypoxemia in hepatic cirrhosis is a well-documented fact. Physiopathogenic mechanisms have been widely studied. It is assumed that there are alterations in pulmonary vessels which determine small and numerous arteriovenous shunts. Presence of anatomic intrapulmonary shunts, although well-documented, is small and could hardly explain such low levels of arterial oxigenation in cirrhotic patients. It is a premise that alterations occur in the pulmonary dynamics and that the diffusion of gases may be altered. Purpose: To evaluate the pulmonary function and arterial oxygenation levels in 55 patients with hepatic cirrhosis, with no other pulmonary, cardiac or hematologic diseases. They were submitted to evaluation of the pulmonary function through measurement of the forced vital capacity, forced expiratory volume in one second, and residual volume as well as diffusion capacity for carbon monoxide. Finally, arterial oxygenation was evaluated through arterial gasometry during air breathing and with 100% oxygen. Analysis of results allowed the authors to observe the presence of normal pulmonary flows and volumes (average of: FVC = 104.6%; FEV1 = 102.4%; residual volume = 117.4%); and diffusion capacity was diminished (average = 70.8%) in relation to predicted values. Arterial blood gases showed a mean PaO2 of 81.20 mmHg during air breathing and 515.4 mmHg when 100% oxygen was breathed. No correlations among PaO2 (with air breathing and with oxygen) and diffusion capacity were observed. In this study, flows and pulmonary volumes were normal in relation to the predicted values; however, diffusion of carbon monoxide was diminished. This diminished diffusion corroborates the existing idea of the so-called diffusion-perfusion imbalance as one of the mechanisms involved in the physiopathology of the hepatic pulmonary syndrome, even with no evidence of intrapulmonary morphological arteriovenous shunt.

Keywords: Hepatopulmonary syndrome. Pulmonary function. Hepatic cirrhosis.

Pulmonary thromboembolism (PTE) should be suspected in patients with risk factors for deep venous thrombosis (DVP) who present, either isolated or in association, malaise, dyspnea/tachypnea, sudden collapse or pulmonary hemorrhage syndrome. The diagnostic approach starts with basic tests (chest X-rays electrocardiographs, and arterial blood gas tensions) the results of which associated to medical history and to physical examination allow the classification of clinical suspicion as high, intermediate or low probability. This phase is important, both to support clinical suspicion of PTE and to exclude alternative diagnoses. In order to confirm or exclude PTE, one or several sophisticated imaging exams (lung isotope scanning, leg imaging, and pulmonary angiography) should be performed next, according to the findings of the chest X-ray. If there is undue delay in arranging investigations for patients with high clinical probability, heparin should be started, unless high risk to anticoagulation is present. In this review the diagnostic methods are discussed and some strategies for rapid investigation of PTE are shown with the main purpose of adapting them to Brazilian reality.

Keywords: Pulmonary thromboembolism. Diagnosis. Management strategy.

Background: A residency in Pulmonary Medicine represents the best source of training for those who wish to specialize in the area. In Brazil, the Comissão Nacional de Residência Médica (National Committee of Medical Residency) regulates such programs. Objective: To analyze the number of programs and their levels state of accreditation, the number of residents and the distribution of these programs and residents among the various institutions throughout Brazil. Methods: The list of programs furnished by the National Committee of Medical Residency in April 2003 was analyzed, and the basic criteria for accreditation in the area (according to the legislation currently in effect) were reviewed. Results: Of the 58 accredited programs, 35 are offered in hospitals in the southeastern region of Brazil, and 133 of the residents are also there. In contrast, there is only 1 accredited program, and there are only 3 residents enrolled in that program. Conclusion: Although all 58 programs are accredited, most are clustered in the southeastern region. It is therefore necessary that the Comissão Nacional de Residência Médica and the Sociedade Brasileira de Pneumologia e Tisiologia (Brazilian Society of Pulmonology and Phthisiology) begin a joint project in order to manage the creation of new programs. Thus, the number of programs and residents required for each of the various regions could be determined.

Keywords: Residency/Medical, Pulmonary Disease (Specialty), Internship and Residency

Palliative care was initially developed for patients with advanced cancer. The concept has evolved and now encompasses any life-threatening chronic disease. Studies carried out to compare end-of-life symptoms have shown that although symptoms such as pain and dyspnea are as prevalent in patients with lung disease as in patients with cancer, the former receive less palliative treatment than do the latter. There is a need to refute the idea that palliative care should be adopted only when curative treatment is no longer possible. Palliative care should be provided in conjunction with curative treatment at the time of diagnosis, by means of a joint decision-making process; that is, the patient and the physician should work together to plan the therapy, seeking to improve quality of life while reducing physical, psychological, and spiritual suffering.

Keywords: Palliative care; Pulmonary medicine; Quality of life.

Acute pulmonary thromboembolism (APTE) is a highly prevalent condition (104-183 cases per 100,000 person-years) and is potentially fatal. Approximately 20% of patients with APTE are hypotensive, being considered at high risk of death. In such patients, immediate lung reperfusion is necessary in order to reduce right ventricular afterload and to restore hemodynamic stability. To reduce pulmonary vascular resistance in APTE and, consequently, to improve right ventricular function, lung reperfusion strategies have been developed over time and widely studied in recent years. In this review, we focus on advances in the indication and use of systemic thrombolytic agents, as well as lung reperfusion via endovascular and classical surgical approaches, in APTE.

Keywords: Embolism; Shock; Hypotension; Thrombolytic therapy; Reperfusion; Hemorrhage.

The authors present a case of a patient with Behçet's disease who complained about sudden dyspnea while performing light physical exercises, about non-productive cough, weakness, and frontal headache; he also presented significant weight loss in the last month while being treated for an alleged tuberculosis. After going through an episode of massive hemophthisis, his clinical history and physical examination were reevaluated and his new diagnosis was concluded to be Behçet's disease. Thus, the authors started treatment by giving immunosuppressive drugs and corticosteroids and, as a consequence, regression of the aneurysm was noted. In this article the authors discuss the clinical, radiological, histopathologic and therapeutic features of this syndrome.

Keywords: Behçet's disease. Pulmonary arterial aneurysms.

Objective - To verify the incidence of the wounds of the pulmonary hilum in a public hospital Emergency Unit, and the mortality rate. Means of access, operative techniques and tatics of operation used were also evaluated. Patients and methods - One thousand, one hundred and twenty-four patients with chest trauma were registered at the thoracic surgery unit from April, 1992 to October, 1996. A hundred eighty-two thoracotomies (16.19%) were performed and indication for lung resection was present in only four cases (2.20%). Results - The way of access most commonly used was anterolateral, in three cases, and posterolateral in another case. Two lobectomies and one pneumonectomy were performed. In only one patient a clamping of the hilum was utilized, but the patient died due to massive bleeding. Two other patients died in a total of three deaths. There was only one survivor in this series, who did not present any complication. Conclusion - A low incidence of indication for lung resections was observed in trauma, however, mortality was extremely high due to the lesion involving a high life risk. The most commonly used access was the anterolateral because of the short time needed to clamp the pulmonary hilum, and it was used for all cases of success.

Keywords: Thoracic trauma. Lobectomy. Pneumonectomy.

Primary pulmonary hypertension (PPH) is a disease of rare, unclear etiology, leading to elevations in pulmonary artery pressure and pulmonary vascular resistance. The vascular lesions range from mild - consisting of neo-intimal proliferation - to severe - characterized by concentric intimal fibrosis, plexiform lesions, and necrotizing arteritis. There have been since 1987 reports describing the association between human immunodeficiency virus (HIV) and PPH, with as many as 60 patients in 1997. The role of HIV in the pathogenesis remains unclear. It is reported a case of a woman in whom this association was observed.

Keywords: Primary pulmonary hypertension. Human immunodeficiency virus.

In order to evaluate which prognostic factors were significant to the survival of patients with idiopathic pulmonary fibrosis (IPF), 121 histologically confirmed cases of the disease were studied at the Pereira Filho Hospital from 1970 to 1996. All patients were submitted to a standard thorax X-ray and spirometry and answered a standardized questionnaire when admitted to hospital. They also underwent diffusion tests (34 cases), total lung capacity (28), blood gas analysis (106), bronchoalveolar lavage (39), rheumatoid analyses (45), and thoracic CT (24). For further analysis, the patients were classified into two groups: group A (2-year survival) with 55 patients, and group B (more than 5-year survival) with 24 patients; these features were also analyzed according to their significance to survival. Age, increased dyspnea index, long symptomatic period, FVC, DCO, PaO2 and SaO2 reduction, honeycombing intensity, and greater profusion of the reticular pattern on HRCT were considered indicative of worse prognosis. A reduced FEV1 and TLC were also associated with shorter survival. The use of those criteria which had shown statistical significance when evaluated together may determine a more accurate prognostic evaluation of IPF patients resulting in social and therapeutic benefits to patient management.

Keywords: Pulmonary fibrosis. Interstitial lung diseases. Prognosis. Prospective studies. Survival analysis.

Objective: The reproduction of an experimental emphysema model in rats by intratracheal instillation of papain was proposed for the evaluation of lung volume reduction surgeries. Method: The study used orotracheal instillation of papain (20 mg/kg) dissolved in 0.9% saline solution. Forty days after instillation, animals underwent mechanical ventilation. Elastance and resistance of the respiratory system were measured, and the rats were sacrificed by having their lungs removed. The pulmonary tissue of the animals was qualitatively analyzed with hematoxylineosin staining and submitted to morphometric analysis for the measurement of the mean alveolar diameter. The pulmonary tissue was also subjected to resorcin-fuchsin staining for the identification of elastic fibers, which were quantified in alveolar septa by digital imaging. Results: In the animals instilled with papain, the histological analysis of the lungs showed pan-acinar emphysema, with rupture of alveolar septa and hyperdistention. Morphometric analysis showed higher mean values for mean alveolar diameter in the lungs of the animals submitted to papain (149.08 μm and 100.56 μm) as compared to the group receiving saline solution (64.08 μm and 75.90 μm). The quantification of elastic fibers of alveolar septa of papain-treated animals was 70% lower than in the animals receiving saline solution. Mechanic ventilation did not show differences in respiratory system resistance of animals receiving papain or saline solution. Respiratory system elastance was lower in the group receiving papain than in the group receiving saline solution, showing a functional status compatible with pulmonary emphysema, with decreased elasticity of the pulmonary tissue. Conclusion: The reproduction of an experimental model of pan-acinar pulmonary emphysema in rats was achieved by papain instillation through the respiratory tree with functional and morphologic evidences.

Keywords: Pulmonary emphysema. Experimental model. Papain. Rats. Drug instillations.

Objective: To describe the clinical and functional findings recently reported in the medical literature for patients diagnosed with emphysema involving the upper lobes and idiopathic pulmonary fibrosis (IPF) involving the lower lobes. Methods: Eleven patients with emphysema and IPF were identified retrospectively. All of the patients underwent high-resolution computed tomography of the lung and pulmonary function tests. Results: Of the 11 patients, 8 were male and 3 were female. The mean age was 70.7 ± 7.2 years (range, 61-86 years). All of the patients were smokers (mean smoking history, 61.5 ± 43.5 pack-years). The mean values of forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and FEV1/FVC were 72.1 ± 12.7%, 68.2 ± 11.9% and 74.4 ± 10.8, respectively. Lung volumes were normal in 7 patients. A restrictive pattern was observed in 3 patients, and hyperinflation was present in one. The diffusing capacity was moderatelyto- severely reduced in all of the patients (mean, 27.7% ± 12.9% of predicted). Ten of the 11 patients performed the six-minute walk test. The mean distance covered was 358.4 ± 143.1 m, and 9 of the 10 patients presented desaturation ≥ 4%. Echocardiographic findings suggestive of pulmonary hypertension were present in 4 patients (mean systolic pulmonary artery pressure, 61.8 mmHg; range, 36-84 mmHg). Conclusions: The concomitant presence of emphysema and IPF causes characteristic changes on pulmonary function tests. The most significant finding is a discrepancy between diffusing capacity and spirometry results.

Keywords: Pulmonary emphysema; Pulmonary fibrosis; Lung Diseases, interstitial; Anoxia; Hypertension, pulmonary.

Chronic obstructive pulmonary disease is progressive and is characterized by abnormal inflammation of the lungs in response to inhalation of noxious particles or toxic gases, especially cigarette smoke. Although this infirmity primarily affects the lungs, diverse extrapulmonary manifestations have been described. The likely mechanisms involved in the local and systemic inflammation seen in this disease include an increase in the number of inflammatory cells (resulting in abnormal production of inflammatory cytokines) and an imbalance between the formation of reactive oxygen species and antioxidant capacity (leading to oxidative stress). Weakened physical condition secondary to airflow limitation can also lead to the development of altered muscle function. Chronic obstructive pulmonary disease presents diverse systemic effects including nutritional depletion and musculoskeletal dysfunction (causing a reduction in exercise tolerance), as well as other effects related to the comorbidities generally observed in these patients. These manifestations have been correlated with survival and overall health status in chronic obstructive pulmonary disease patients. In view of these facts, the aim of this review was to discuss findings in the literature related to the systemic manifestations of chronic obstructive pulmonary disease, emphasizing the role played by systemic inflammation and evaluating various therapeutic strategies.

Keywords: Pulmonary disease, chronic obstructive/complications; Nutritional status; Exercise tolerance;

We reviewed original articles in the field of pulmonary medicine that had been recently published in 12 Brazilian journals-general or specialty journals-excluding the Brazilian Journal of Pulmonology. All were journals indexed for the Institute for Scientific Information Web of Knowledge. The selection of articles was based on the "continuously variable rating" concept. We have organized the articles by category.

Keywords: Pulmonary medicine; Medical oncology; Research; Infectious disease medicine.

In this study, we report a case of pulmonary cryptococcosis in a patient presenting respiratory symptoms and a lung mass on the chest X-ray. The patient had no concomitant diseases, was seronegative for human immunodeficiency virus and was not receiving immunosuppressive therapy of any kind. The diagnosis was confirmed through transbronchial biopsy and bronchoalveolar lavage. The patient was treated as an outpatient with fluconazole (300 mg/day for six months), evolving to clinical improvement and partial regression of the lung mass, as seen on a second chest X-ray. The current case illustrates an unusual presentation of pulmonary cryptococcosis and raises questions regarding the therapeutic approaches proposed in the literature.

Keywords: Cryptococcosis; Lung diseases, fungal; Lung/radiography; Immunocompetence