Cow milk allergens are the first antigens children have contact with. The symptoms, which are frequently multi-systemic, may be related to the gastrointestinal tract, to the skin and, more rarely, to the respiratory tract. Objective: To describe some clinic and epidemiological characteristics of children who have cow milk allergy and present respiratory symptoms. Patients and method: This retrospective study included 17 children who presented respiratory problems immediately after ingesting cow milk, showed no symptoms as cow milk was excluded from their diets for a period of 4 to 6 weeks, and presented recurrent symptoms as cow milk was reintroduced into their diet in a hospital environment. Results: No difference was observed between genders. Family atopic antecedents were present in 14 of the 17 children. Mean exclusive breast-feeding period was 2.9 months and the onset of symptoms occurred at an average of 3.6 months. Eight of the ten tests conducted to evaluate immediate cutaneous hypersensitivity to cow milk were positive. Clinical manifestations observed were: wheezing infants (9), asthma (5), repetition otitis (2), selective IgA deficiency related to wheezing and allergic rhinoconjunctivitis (1). Conclusion: Regarding wheezing infants, cow milk allergy should be included as a differential diagnosis and exclusive breast-feeding should be stimulated in cases of atopic family antecedents. However, a precise diagnosis is vital to prevent unnecessary food deprivation.

Keywords: Milk hipersensitivity. Milk substitutes. Respiratory signs and symptoms. Respiratory diseases.

The authors present a 62-year-old male patient who had pulmonary nocardiosis with poor evolution. He also presented mental confusion, septic shock and a significant leukocytosis. Poor evolution happened even when sulfamethoxazole + trimethoprim replaced by ceftriaxone + clindamycin as an antibiotic therapy were used. Diagnostic methods, epidemiology and therapy of this infection are discussed and revised. The authors emphasize the importance of an early diagnosis, isolation in culture, and antibiogram examination of Nocardia ssp samples for therapeutic adapting.

Keywords: Pneumonia. Nocardia.

Objective: To describe the differences in the clinical and radiological presentation of tuberculosis in the presence or absence of HIV infection. Methods: A sample of 231 consecutive adults with active pulmonary tuberculosis admitted to a tuberculosis hospital were studied, assessing HIV infection, AIDS, and associated factors, as well as re-evaluating chest X-rays. Results: There were 113 HIV-positive patients (49%) Comparing the 113 HIV-positive patients (49%) to the 118 HIV-negative patients (51%), the former presented a higher frequency of atypical pulmonary tuberculosis (pulmonary lesions accompanied by intrathoracic lymph node enlargement), hematogenous tuberculosis, and pulmonary tuberculosis accompanied by superficial lymph node enlargement, as well as presenting less pulmonary cavitation. The same was found when HIV-positive patients with AIDS were compared to those without AIDS. There were no differences between the HIV-positive patients without AIDS and the HIV-negative patients. Median CD4 counts were lower in HIV-positive patients with intrathoracic lymph node enlargement and pulmonary lesions than in the HIV-positive patients with pulmonary lesions only (47 vs. 266 cells/mm3; p < 0.0001), in HIV-positive patients with AIDS than in those without AIDS (136 vs. 398 cells/mm3; p < 0.0001) and in patients with atypical pulmonary tuberculosis than in those with other forms of tuberculosis (31 vs. 258 cells/mm3; p < 0.01). Conclusion: Atypical forms and disseminated disease predominate among patients with advanced immunosuppression. In regions where TB prevalence is high, the presence of atypical pulmonary tuberculosis or pulmonary tuberculosis accompanied by superficial lymph node enlargement should be considered an AIDS-defining condition.

Keywords: Tuberculosis, pulmonary; HIV infections; Radiography, thoracic.

Schistosomiasis is a disease that, in Brazil, is caused by Schistosoma mansoni and is transmitted by snails of the genus Biomphalaria. This species occurs in Africa, the Antilles and South America. The parasite, developing to the adult stage in the vascular system of the host, migrates to the mesenteric veins. Each female lays approximately 400 eggs per day, and these travel from the submucosa to the intestinal lumen. There have been reported cases in which S. mansoni eggs were identified in the lungs of patients with no evidence of liver fibrosis. We report a case with this atypical presentation of the disease. The patient presented nonpleuritic chest pain, significant weight loss and dry cough. A CT scan revealed an irregular tumor in the left lower lobe. However, a lung biopsy revealed non-viable S. mansoni eggs. The patient presented no clinical signs of pulmonary or portal hypertension; nor was either identified through diagnostic tests.

Keywords: Schistosomiasis; Schistosoma mansoni; Lung diseases, parasitic.

Wegener's granulomatosis is a multisystemic inflammatory illness of unknown etiology, characterized by vasculitis of small and medium caliber vessels. The most common clinical manifestations involve the upper respiratory tract, lungs and kidneys. Common alterations in imaging studies include pulmonary opacities and bilateral multiple nodules, cavitations occurring in 50% of the cases. Treatment includes corticosteroids and immunosuppressants. We describe an atypical case of a 61-year-old man initially investigated due to suspicion of a unilateral lung tumor, which proved to be, in fact, a case of Wegener's granulomatosis.

Keywords: Wegener's Granulomatosis; Vasculitis; Diagnosis, differential; Lung neoplasms.

Objective: To identify symptoms of dysphagia in individuals with COPD, based on their responses on a self-perception questionnaire. Methods: The study comprised 35 individuals with COPD and 35 healthy individuals, matched for age and gender. The study group was assessed regarding COPD severity; sensation of dyspnea; body mass index (BMI); and symptoms of dysphagia. The control group was assessed regarding BMI and symptoms of dysphagia. Results: The most common symptoms of dysphagia in the study group were pharyngeal symptoms/airway protection (p < 0.001); esophageal symptoms/history of pneumonia (p < 0.001); and nutritional symptoms (p < 0.001). Positive correlations were found between the following pairs of variables: FEV1 and BMI (r = 0.567; p < 0.001); pharyngeal symptoms/airway protection and dyspnea (r = 0.408; p = 0.015); and esophageal symptoms/history of pneumonia and pharyngeal symptoms/airway protection (r = 0.531; p = 0.001). There was a negative correlation between nutritional symptoms and BMI (r = −0.046; p < 0.008). Conclusions: Our results show that the individuals with COPD presented with symptoms of dysphagia that were associated with the pharyngeal and esophageal phases of swallowing, as well as with the mechanism of airway protection, a history of pneumonia, and nutritional symptoms.

Keywords: Deglutition disorders; Pulmonary disease, chronic obstructive; Pathological conditions, signs and symptoms.

A case is presented of a 36 year-old woman, with metastatic lung choriocarcinoma with atypical clinical and radiological presentation. The finding of pulmonary hypertension indicated the possibility of pulmonary thromboembolism, still, the definitive diagnosis and cause of pulmonary embolism were done in the autopsy. The authors discuss the manners of choriocarcinoma metastasis presentation, its repercussions and the latent period which may exist until it presents evidence of neoplasm.

Keywords: Choriocarcinoma. Pulmonary embolism.

We present a protocol to test a new surgical procedure for the treatment of patients with diffuse lung emphysema who, after having received the golden standard treatment (pulmonary rehabilitation), continue to present respiratory failure with disabling dyspnea. Ten patients with severe lung hyperinflation will be evaluated. The method proposed is designed to create alternative expiratory passages for air trapped in the emphysematous lung by draining the lung parenchyma, thereby establishing communication between the alveoli and the external environment. The ten patients selected will be required to meet the inclusion criteria and to give written informed consent. Those ten patients will be included in the study pending the approval of the Ethics in Research Committee of the São Paulo Santa Casa School of Medicine, São Paulo, Brazil. The protocol we will employ in order to evaluate the proposed procedure is feasible and will show whether debilitated patients suffering from diffuse pulmonary emphysema can benefit from this procedure, which could represent an alternative to lung transplant or lung volume reduction surgery, the only options currently available.

Keywords: Pulmonary emphysema; Pulmonary disease, chronic obstructive; Lung, hyperlucent.

The disease caused by the new coronavirus (SARS-CoV-2), designated COVID-19, emerged in late 2019 in China, in the city of Wuhan (Hubei province), and showed exponential growth in that country. It subsequently spread to all continents, and infection with SARS-CoV-2 is now classified as a pandemic. Given the magnitude achieved, scientific interest in COVID-19 has also grown in the international literature, including its manifestations on imaging studies, particularly on CT. To date, no case series have been published in Brazil. Therefore, our objective was to describe the CT findings in an initial series of 12 patients.

Keywords: Coronavirus infections; Coronavirus; Multidetector computed tomography.

The prevalence of respiratory symptoms in populations at risk or in populations not at risk is an indirect indicator of acute and chronic respiratory diseases, with a high grade of confidence from an epidemiological point of view. In order to contribute to this, the authors carried out a prevalence study among workers with occupational exposure to silica dust in a marble plant. The authors selected workers who worked with hard granite stone, slate and marble. Workers were submitted to a standardized questionnaire and 84 people were studied. All were male, mean age was (± SD) 26.2 (± 7.4 years), and had had short time of exposure to dust (52 workers worked less than 5 years in the marble industry). Thirty-four were smokers (10.0 (± 2.3) pack years), 9 former smokers, and 41 non-smokers. Twenty-four had cough, 30 sputum, 1 dyspnea grade III, 5 wheezing. Thirty-eight presented at least one of the studied respiratory symptoms and 9 presented chronic bronchitis. The lung function evaluated in 82 workers through spirometry was normal in 78 of the cases and an obstructive pattern was detected in 4 of them. A significant statistical association between chronic bronchitis and exposure time to stone dust was found (OR = 5.37; 95% CI = 1.01-28.74). However, that association was lost after other factors, such as cigarette smoking and age, were evaluated (OR = 1.21; 95% CI = 0.12-11.93). The association between smoking and bronchitis (OR = 14.18; 95% CI = 1.80-111.62) remained marginally significant even after controlling exposure time to stone dust and age (OR = 6.34; 95% CI = 0.76-52.94). Results suggest that among the marble industry workers studied, the prevalence of chronic bronchitis is more strongly associated to smoking to with exposure time to stone dust.

Objective: To investigate the symptoms most frequently found in children with a polysomnographic diagnosis of obstructive sleep apneahypopnea syndrome (OSAHS). Methods: We evaluated 38 children consecutively referred to the sleep laboratory with suspicion of OSAHS between June of 2003 and December of 2004. The patients were submitted to a pre-sleep questionnaire and to polysomnography. Results: The mean age was 7.8 ± 4 years (range, 2-15 years), and 50% of the children were male. Children without apnea accounted for 7.9% of the sample. The obstructive sleep apnea observed in the remainder was mild in 42.1%, moderate in 28.9% and severe in 22.1%. Severe cases of apnea were most common among children under the age of six (pre-school age). In children with OSAHS, the most common symptoms were snoring and nasal obstruction, which were observed in 74.3 and 72.7% of the children, respectively. Excessive sleepiness and bruxism were seen in 29.4 and 34.3%, respectively, and reflux disease was seen in only 3.1%. Restless legs and difficulty in falling asleep were identified in 65 and 33%, respectively. All of the children diagnosed with severe OSAHS also presented snoring and bruxism. Conclusions: Snoring and nasal obstruction were the most common symptoms found in our sample of children and adolescents with OSAHS. In addition, OSAHS severity was associated with being in the lower age bracket.

Keywords: Obstructive sleep apnea; Polysomnography; Pediatrics; Snoring.

Castleman's disease is a rare lymphoproliferative disorder, with focal or systemic lymph node involvement, which rarely affects the lung parenchyma. We report the case of an asymptomatic immunocompetent male patient who had the rarest histological variant of the disease, a nodular parenchymal presentation. The patient underwent lobectomy, and the postoperative evolution was favorable. In the last 10 years, there have been only five reports of Castleman's disease presenting as a solitary pulmonary nodule. This case underscores the fact that Castleman's disease, albeit rare, should be included in the differential diagnosis of pulmonary nodules.

Keywords: Giant lymph node hyperplasia; Lymphoproliferative disorders; Solitary pulmonary nodule.

Objective: To characterize clinical phenotypes of severe asthma. Methods: A total of 111 patients were retrospectively evaluated at a specialized outpatient clinic. A systematic protocol for patient evaluation and follow-up was applied. Treatment compliance and control of the disease at the end of follow-up were defined by clinical and functional data. Patients who did not meet asthma control criteria after six months despite compliance with treatment and correct use of medication were characterized as treatment-resistant. Phenotypes were determined by factorial analysis and compared using various tests. Results: At the end of follow-up, 88 patients were considered treatment compliant and 23 were considered noncompliant. Factorial analysis of the compliant patients identified four phenotypes: phenotype 1 (28 patients) comprised patients who were treatment-resistant, more often presenting nocturnal symptoms and exacerbations, as well as more often using rescue bronchodilators; phenotype 2 (48 patients) comprised patients with persistent airflow limitation, lower ratios of forced expiratory volume in one second/forced vital capacity at baseline, more advanced age and longer duration of symptoms; phenotype 3 (42 patients) comprised patients with allergic rhinosinusitis who were nonsmokers and presented predominantly reversible airflow obstruction; and phenotype 4 (15 patients) comprised cases with a history of aspirin intolerance to acetylsalicylic acid associated with near-fatal asthma. Conclusions: A significant number of patients with severe asthma are noncompliant with treatment. Although many patients with severe asthma have persistent airflow obstruction, the most relevant clinical phenotype comprises patients who are resistant to the typical treatment.

Keywords: Asthma; Asthma/prevention & control; Asthma/treatment.

Objective: To evaluate the presence and severity of symptoms of anxiety and depression in individuals with asthma or chronic obstructive pulmonary disease. Methods: In order to evaluate symptoms of anxiety and depression, specific instruments of quantification (the State-Trait Anxiety Inventory and the Beck Depression Inventory, respectively) were administered to patients at an outpatient clinic for the treatment of asthma and chronic obstructive pulmonary disease. The population comprised 189 randomly and prospectively selected patients that were divided into three study groups (each with a different therapeutic objective): 40 patients with controlled asthma, 100 patients with uncontrolled asthma, and 49 patients with chronic obstructive pulmonary disease. Included among the variables studied, as part of the methodology, were symptoms of anxiety and depression. The data obtained were compared taking into consideration demographic and functional aspects, as well as the severity of the symptoms of anxiety and depression. Results: Among the asthma patients, the prevalence of moderate or severe anxiety was significantly higher than that observed among those with chronic obstructive pulmonary disease (p <  0.001). The uncontrolled asthma group presented significantly higher rates of depressive symptoms than did the controlled asthma group (p < 0.05). Conclusion: The frequency of symptoms of anxiety and depression is greater among asthma patients than among patients with chronic obstructive pulmonary disease, which can make clinical control difficult.

Keywords: Anxiety; Depression; Asthma; Pulmonary disease; Chronic obstructive

Objective: To evaluate the prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients, describing the major clinical syndromes diagnosed and the outcomes of the patients. Methods: A cross-sectional study conducted in the emergency room of a tertiary care university hospital. Between November of 2008 and November of 2009, we reviewed the total number of emergency room visits per day. Children and adults who presented with at least one respiratory symptom were included in the study. The electronic medical records were reviewed, and the major characteristics of the patients were recorded. Results: During the study period, there were 37,059 emergency room visits, of which 11,953 (32.3%) were motivated by respiratory symptoms. The prevalence of emergency room visits due to respiratory symptoms was 28.7% and 38.9% among adults and children, respectively. In adults, the rates of hospitalization and mortality were 21.2% and 2.7%, respectively, compared with 11.9% and 0.3%, respectively, in children. Among the adults, the time from symptom onset to emergency room visit correlated positively with the need for hospitalization (p < 0.0001), the length of the hospital stay (p < 0.0001), and the mortality rate (p = 0.028). Conclusions: We found a high prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients. Our results could inform decisions regarding the planning of prevention measures. Further epidemiological studies are needed in order to clarify the risk factors for severe respiratory symptoms.