BACKGROUND: The clinical evaluation of patients with post-infectious bronchiolitis obliterans (BO) is variable. OBJECTIVE: Substantiate the clinical characteristics, the evolution and the complementary tests of 48 patients with post-infectious bronchiolitis obliterans (BO). METHOD: Observational and retrospective study. Diagnosis of BO was based upon clinical criteria, CT scan findings and exclusion of other diseases. History prior to diagnosis and complementary tests were evaluated as well as initial and final values of oxygen saturation. RESULTS: Mean age of patients at the acute stage of the infectious disease was of 9.6. Thirty two of the patients were male. All were hospitalized during the acute stage, 14 of them (29%) in the ICU. Four patients died two years after onset of acute bronchiolitis. During evolution, all required emergency care due to exacerbation of the pulmonary condition and 24 (50%) were hospitalized, 2 of them in the ICU. The majority continued presenting cough, wheezing, crackles and hyperinflation, however to a lesser degree. Mean of initial arterial saturation was of 89% and final of 92%. The most common infectious agents in sputum samples were H. influenzae, S. pneumoniae and M. catarrhalis. Increased serum IgM and IgC were found in 9 and 7 patients, respectively. The most frequent findings at thorax CT scan were mosaic perfusion, bronchiectasis, atelectasis and bronchial wall thickening. CONCLUSION: Post infectious BO is a chronic and severe disease with persistent symptoms that in general affect infants. Positive serum cultures and increased serum immunoglobulins are suggestive of chronic infectious inflammatory condition.

Keywords: Bronchiolitis obliterans. Obstructive lung diseases.

Objective: To describe the pulmonary function in children and adolescents with postinfectious bronchiolitis oblite­rans (PIBO), as well as to evaluate potential risk factors for severe impairment of pulmonary function. Methods: The pulmonary function of 77 participants, aged 8-18 years, was assessed by spirometry and plethysmography. The following parameters were analyzed: FVC; FEV1; FEF25-75%; FEV1/FVC; RV; TLC; RV/TLC; intrathoracic gas volume; and specific airway resistance (sRaw). We used Poisson regression to investigate the following potential risk factors for severe impairment of pulmonary function: gender; age at first wheeze; age at diagnosis; family history of asthma; tobacco smoke exposure; length of hospital stay; and duration of mechanical ventilation. Results: The mean age was 13.5 years. There were pronounced decreases in FEV1 and FEF25-75%, as well as increases in RV and sRaw. These alterations are characteristic of obstructive airway disease. For the parameters that were the most affected, the mean values (percentage of predicted) were as follows: FEV1 = 45.9%; FEF25-75% = 21.5%; RV = 281.1%; RV/TLC = 236.2%; and sRaw = 665.3%. None of the potential risk factors studied showed a significant association with severely impaired pulmonary function. Conclusions: The patients with PIBO had a common pattern of severe pulmonary function impairment, characterized by marked airway obstruction and pronounced increases in RV and sRaw. The combination of spirometric and plethysmographic measurements can be more useful for assessing functional damage, as well as in the follow-up of these patients, than are either of these techniques used in isolation. Known risk factors for respiratory diseases do not seem to be associated with severely impaired pulmonary function in PIBO.

Keywords: Respiratory function tests; Airway obstruction; Bronchiolitis obliterans

Objective: To present aspects of the evolution of lipoid pneumonia in children, based on clinical, radiological and bronchoalveolar lavage fluid findings, emphasizing the importance of bronchoalveolar lavage for the diagnosis and treatment. Methods: We included 28 children, with a mean age of 20 months (range, 1-108 months), diagnosed with chronic pneumonia refractory to antimicrobial therapy, with TB or with a combination of the two. Most of the children had at least one risk factor for aspiration, and all of them had a history of mineral oil ingestion for intestinal constipation (23/28) or complicated ascaridiasis (5/28). Clinical evaluations, tomographic evaluations and analyses of bronchoalveolar lavage fluid were carried out at the beginning of treatment and throughout a follow-up period of 24 months. Results: Tachypnea and cough were the most common symptoms. The most common radiological alterations were areas of consolidation (23/28), perihilar infiltrates (13/28) and hyperinflation (11/28). Chest CT scans showed areas of consolidation with air bronchogram (24/28), decreased attenuation in the areas of consolidation (16/28), ground-glass opacities (3/28) and crazy-paving pattern (1/28). In the analysis of the bronchoalveolar lavage fluid, Sudan staining revealed foamy macrophages, confirming the diagnosis of lipoid pneumonia. After treatment with multiple bronchoalveolar lavages (mean = 9.6), 20 children became asymptomatic, 18 of those presenting normal tomographic images. Conclusions: A diagnosis of lipoid pneumonia should be considered in patients with chronic refractory pneumonia or TB, especially if there is a history of mineral oil ingestion. Bronchoscopy with multiple bronchoalveolar lavages was an efficient treatment for the clearance of mineral oil from the lung parenchyma and the prevention of fibrosis. This strategy contributed to reducing the morbidity of lipoid pneumonia, which remains a rare diagnosis.

Keywords: Pneumonia, lipid; Bronchoalveolar lavage; Treatment outcome.

Objective: To describe the clinical manifestations and bronchoscopic treatment of foreign body aspiration in children under 14 years of age, correlating the clinical aspects with the bronchoscopic findings. Methods: A retrospective, descriptive study analyzing data related to children under 14 years of age undergoing bronchoscopy due to clinical suspicion of foreign body aspiration at the State University at Campinas Hospital das Clinicas from January of 2000 to December of 2005. Results: The sample consisted of 69 patients, ranging in age from 8 months to 12 years/7 months (75.4% under 3 years of age), 62.3% of whom were male. The principal complaint was sudden-onset cough (75.4%), auscultation was abnormal in 74%, and dyspnea was observed in 29%. Radiological abnormalities were seen in 88% of the cases. Aspirations were primarily into the right lung (54.8%), and 30.7% of the foreign bodies were of vegetal origin (principally beans and peanuts). In the follow-up period, 29% presented complications (most commonly pneumonia), which were found to be associated with longer aspiration time (p = 0.03). Mechanical ventilation was required in 7 children (10.1%), and multiple bronchoscopies were performed in 5 (7.2%). Conclusion: A history of sudden-onset choking and cough, plus abnormal auscultation and radiological findings, characterizes the profile of foreign body aspiration. In such cases, bronchoscopy is indicated. Longer aspiration time translates to a higher the risk of complications. The high prevalence of foreign bodies of vegetal origin underscores the relevance of prevention programs aimed at children younger than 3 years of age.

Keywords: Foreign bodies; Bronchoscopy; Pediatrics.

48 years-old woman, asymptomatic, presented with radiographic findings of patchy airspace consolidation with nodular opacities in the upper right lobe, middle lobe and lingula. The differential diagnoses of neoplasms, sarcoidosis, granulomatous diseases and tuberculosis were considered. Diagnosis of Bronchiolitis obliterans organizing pneumonia was made by means of videothoracoscopy whereupon treatment with corticosteroids was begun. The patient had a positive evolution with resolution of the radiographic finding.

Keywords: bronchiolitis obliterans organizing pneumonia, bronchiolitis obliterans

Objective: To determine whether air trapping (expressed as the percentage of air trapping relative to total lung volume [AT%]) correlates with clinical and functional parameters in children with obliterative bronchiolitis (OB). Methods: CT scans of 19 children with OB were post-processed for AT% quantification with the use of a fixed threshold of −950 HU (AT%950) and of thresholds selected with the aid of density masks (AT%DM). Patients were divided into three groups by AT% severity. We examined AT% correlations with oxygen saturation (SO2) at rest, six-minute walk distance (6MWD), minimum SO2 during the six-minute walk test (6MWT_SO2), FVC, FEV1, FEV1/FVC, and clinical parameters. Results: The 6MWD was longer in the patients with larger normal lung volumes (r = 0.53). We found that AT%950 showed significant correlations (before and after the exclusion of outliers, respectively) with the clinical score (r = 0.72; 0.80), FVC (r = 0.24; 0.59), FEV1 (r = −0.58; −0.67), and FEV1/FVC (r = −0.53; r = −0.62), as did AT%DM with the clinical score (r = 0.58; r = 0.63), SO2 at rest (r = −0.40; r = −0.61), 6MWT_SO2 (r = −0.24; r = −0.55), FVC (r = −0.44; r = −0.80), FEV1 (r = −0.65; r = −0.71), and FEV1/FVC (r = −0.41; r = −0.52). Conclusions: Our results show that AT% correlates significantly with clinical scores and pulmonary function test results in children with OB.

Keywords: Multidetector computed tomography; Respiratory function tests; Bronchiolitis obliterans.

A 54 year old female patient, public servant, ex-smoker, after two weeks of a common cold complained of cough with yellow sputum, nasal obstruction and facial pain. A chest X-ray showed a solitary nodular lesion in the upper left lobe. The patient was submitted to a left thoracotomy, which established the diagnosis of bronchiolitis obliterans organizing pneumonia (BOOP).

Post-infectious bronchiolitis obliterans (PIBO) is a small airways disease characterized by fixed airflow limitation. Therefore, inhaled bronchodilators and corticosteroids are not recommended as maintenance therapy options. The management of PIBO currently consists only of close monitoring of affected patients, aimed at the prevention and early treatment of pulmonary infections. In recent years, there has been an increase in the incidence of PIBO in the pediatric population. Patients with PIBO are characterized by a progressive decline in lung function, accompanied by a decrease in overall functional capacity. Here, we report the case of a relatively young man diagnosed with PIBO and followed for three years. After short- and long-term therapy with an inhaled corticosteroid/long-acting β2 agonist combination, together with an inhaled long-acting antimuscarinic, the patient showed relevant improvement of airway obstruction that had been irreversible at the time of the bronchodilator test. The lung function of the patient worsened when he interrupted the triple inhaled therapy. In addition, a 3-week pulmonary rehabilitation program markedly improved his physical performance.

Keywords: Bronchiolitis obliterans/therapy; Infection/complications; Adrenergic beta-2 receptor antagonists/therapeutic use; Administration, inhalation; Anti-inflammatory agents/therapeutic use; Muscarinic antagonists/therapeutic use; Lung diseases/rehabilitation.

There are few reports in the medical literature about association between bronchiolitis obliterans with organizing pneumonia (BOOP) and aspergilloma. This report shows the presence of both BOOP and pulmonary aspergilloma in a patient with adult T cell leukemia-lymphoma. It is suggested that these findings represent a random association rather than the expression of a nosologic unity.

Keywords: bronchiolitis obliterans; aspergillosis; T cell lymphoma; pneumonia

Most interstitial lung diseases (ILD) are indolent in nature, producing subacute or chronic symptoms that progress at various rates and are usually present for months to years before a diagnosis is established. This report describes a case of a fulminating and life-threatening variant of idiopathic bronchiolitis obliterans with organizing pneumonia (BOOP). Early suspicion, histologic diagnosis, and prompt initiation of corticosteroid therapy is important to prevent mortality.

Keywords: Bronchiolitis obliterans with organizing pneumonia (BOOP). Interstitial lung disease.

Background: Mediastinal affections are common and encompass a great number of different diagnoses. Objective: To analyze the clinical aspects and the therapeutic response of 114 patients with mediastinal diseases treated at the Thoracic Surgery Department of Santa Casa de São Paulo Hospital, from 1979 and 1997. Method: The patients were grouped according to the benign or malignant nature of the disease, and the two groups were compared regarding gender, age bracket, symptomatology, topography of the lesion, mortality, and response to treatment. Results: Sixty-three patients had neoplasia: 31 benign and 32 malignant. Fifty-one cases were not neoplastic. No difference was found between the groups regarding gender or age bracket. Half of the patients were between 20 and 49 years of age. The anterior mediastinum was the most frequently affected compartment (66 patients), followed by the upper mediastinum (18 patients), the posterior mediastinum (16 patients), and the middle mediastinum (14 patients). The most frequent histological types were: benign thymus diseases (N = 40), mesenchymal tumors (N = 17), lymphomas (N = 15), neural tumors (N = 9), and germ cell tumors (N = 8). Malignant tumors were more frequently symptomatic (91%), and benign tumors were more frequent in asymptomatic patients (92%). The most frequent symptoms were related to myastenia gravis, followed by dyspnea and chest pain. Weight loss, anorexia and fever were significantly more frequent in patients with malignant neoplasias. Conclusions: Regarding the clinical aspects we can state that benign lesions were predominant, that mediastinal diseases were more prevalent in young adults, and that benign lesions were more frequent in asymptomatic patients. Treatment (clinical/surgical) was effective in most patients, benefiting approximately 90% of the patients with benign affections and 45% of the patients with malignant tumors. In 73% of the benign affections, surgical treatment was capable of achieving the cure. Mortality resulting from complications was 1.75%.

Keywords: Key words - Mediastinum. Mediastinal disease/epidemiology. Mediastinal neoplasms.

Objective: To analyze the association of dysglycemia with clinical, laboratory, and radiographic characteristics of patients with pulmonary tuberculosis (PTB), as well as with their tuberculo-sis treatment outcomes. Methods: This was a longitudinal study involving 140 patients diag-nosed with PTB (positive cultures for Mycobacterium tuberculosis or positive Xpert MTB/RIF results from sputum samples). Patients were evaluated at diagnosis (M0), after completing the second month of treatment (M2), and at the end of treatment (MEND). At M0, the pati-ents were classified into three groups: normoglycemia+PTB (NGTB); pre-diabetes melli-tus+PTB (PDMTB), and diabetes mellitus+PTB (DMTB), in accordance with glycated hemoglo-bin levels (< 5.7%, 5.7%-6.4%, and = 6.5%, respectively). Treatment outcomes were classified as favorable (cure or treatment completion) and unfavorable (death, loss to follow-up, or treatment failure). Results: In our sample, 76 patients (61.4%) had dysglycemia, 20 of whom (14.3%) had DM at M0. The patients with dysglycemia, in comparison with those in the NGTB group, more frequently presented with positive sputum smear microscopy (94.2% vs. 75.9%; p = 0.003); cavities (80.2% vs. 63.0%; p = 0.03); bilateral lesions (67.4% vs. 46.0%; p = 0.02); and higher median of affected thirds of the lungs (3.0 vs. 2.0; p = 0.03) on chest radiography. No significant differences regarding outcomes were found among the groups, but tuberculosis lethality was higher in the DMTB group than in the PDMTB and NGTB groups (20% vs. 2.2%). Conclusions: PTB patients with dysglycemia had laboratory and radiographic manifestations indicative of more advanced disease, and the risk of death was higher in the DMTB group. These findings reinforce the recommendation for early screening for DM in patients with newly diagnosed tuberculosis in order to reduce the risk of death during treatment.

Keywords: Tuberculosis/diagnosis; Tuberculosis/diagnostic imaging; Tuberculosis/therapy; Diabetes mellitus; Treatment outcome.

Objective: To analyze the clinicopathological aspects of bronchioloalveolar carcinoma (BAC) and the survival in a sample of patients at clinical stage I. Methods: A retrospective study involving 26 patients diagnosed with clinical stage I BAC and undergoing surgery at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro, in the city of Rio de Janeiro, Brazil, between 1987 and 2007. We analyzed clinicopathological and radiological aspects, as well as mortality and survival. The data, which were collected from the medical charts of the patients, were statistically analyzed. Results: Females predominated (n = 16). The mean age at diagnosis was 68.5 years. Most patients were active smokers (69.2%). The most common forms of presentation of BAC were the asymptomatic form (84.6%) and the nodular form (88.5%). Involvement of the upper lobes predominated (57.7%). Stage IB was the most common pathological stage, followed by stages IA and IIB (46.2%, 38.4% and 15.4%, respectively). There was no in-hospital mortality. Four patients died during the postoperative follow-up, with a mean disease-free survival time of 21.3 months. The overall five-year survival rate was 83%. The probability of survival for the patients diagnosed after 1999 showed a trend toward an increase when compared with that for those diagnosed up through 1999 (three-year survival rate: 92% vs. 68%; p = 0.07). Conclusions: The clinicopathological aspects of this study sample were similar to those of patients with BAC evaluated in previous studies.

Keywords: Adenocarcinoma, bronchiolo-alveolar; Carcinoma, non-small-cell lung; Lung; Smoking.

O diafragma é o principal músculo da respiração e age de forma contínua e ininterrupta para mantê-la. Muitas patologias podem causar disfunção diafragmática, que é geralmente subdiagnosticada na prática clínica em virtude de sua apresentação inespecífica. Embora várias técnicas tenham sido usadas na avaliação da função diafragmática, o diagnóstico de disfunção diafragmática ainda é problemático. A ultrassonografia diafragmática ganhou importância em virtude de suas muitas vantagens: não é invasiva, não expõe os pacientes à radiação, está amplamente disponível, fornece resultados imediatos, é altamente precisa e é repetível à beira do leito. Vários autores descreveram técnicas ultrassonográficas para avaliar a excursão e o espessamento diafragmático na zona de aposição. Estudos recentes propuseram a padronização dos métodos. Este artigo de revisão analisa a utilidade da ultrassonografia na avaliação da função diafragmática, abordando os detalhes da técnica, os principais achados e as aplicações clínicas.

Keywords: Ultrassonografia; Diafragma/diagnóstico por imagem; Músculos respiratórios; Estado terminal; Doenças respiratórias; Doenças neuromusculares.

Objective: Post-infectious bronchiolitis obliterans (PIBO) is a clinical entity that has been classified as constrictive, fixed obstruction of the lumen by fibrotic tissue. However, recent studies using impulse oscillometry have reported bronchodilator responses in PIBO patients. The objective of this study was to evaluate bronchodilator responses in pediatric PIBO patients, comparing different criteria to define the response. Methods: We evaluated pediatric patients diagnosed with PIBO and treated at one of two pediatric pulmonology outpatient clinics in the city of Porto Alegre, Brazil. Spirometric parameters were measured in accordance with international recommendations. Results: We included a total of 72 pediatric PIBO patients. The mean pre- and post-bronchodilator values were clearly lower than the reference values for all parameters, especially FEF25‑75%. There were post-bronchodilator improvements. When measured as mean percent increases, FEV1 and FEF25-75%, improved by 11% and 20%, respectively. However, when the absolute values were calculated, the mean FEV1 and FEF25-75% both increased by only 0.1 L. We found that age at viral aggression, a family history of asthma, and allergy had no significant effects on bronchodilator responses. Conclusions: Pediatric patients with PIBO have peripheral airway obstruction that is responsive to treatment but is not completely reversible with a bronchodilator. The concept of PIBO as fixed, irreversible obstruction does not seem to apply to this population. Our data suggest that airway obstruction is variable in PIBO patients, a finding that could have major clinical implications.

Keywords: Bronchiolitis obliterans; Infection/complications; Airway obstruction; Bronchodilator agents.

In the present report, we describe an unusual presentation of post-infectious bronchiolitis obliterans accompanied by pulmonary hemosiderosis in a nine-year-old boy with persistent respiratory symptoms subsequent to an episode of acute bronchiolitis occurring at the age of seven months. After the episode, the persistent respiratory symptoms worsened significantly, and, by the age of seven, the patient began to have difficulty breathing after minimal exertion. Computed tomography of the chest presented findings consistent with bronchiolitis obliterans. Open lung biopsy revealed numerous hemosiderin-laden macrophages, as well as other findings consistent with bronchiolitis obliterans. Pulmonary hemosiderosis can occasionally be accompanied by bronchiolitis obliterans in children with severe sequelae after an episode of viral infection.

Keywords: Bronchoalveolar lavage; Bronchiolitis obliterans; Hemosiderosis; Case reports [Publication type]

Objective: To characterize a population of patients with bronchiectasis, correlating clinical, radiological, and functional aspects with the severity of dyspnea. Methods: This was a cross-sectional study involving adult patients with HRCT-confirmed bronchiectasis, categorized according to the severity of dyspnea (as being mildly or severely symptomatic, on the basis of the modified Medical Research Council scale). We correlated the severity of dyspnea with clinical parameters, functional parameters (spirometry values, lung volumes, and DLCO), and CT parameters. Results: We evaluated 114 patients, 47 (41%) of whom were men. The median age (interquartile range) was 42 years (30-55 years). The most common form was idiopathic bronchiectasis. Of the 114 patients, 20 (17.5%) were colonized with Pseudomonas aeruginosa and 59 (51.8%) were under continuous treatment with macrolides. When we applied the Exacerbation in the previous year, FEV1, Age, Colonization, Extension, and Dyspnea score, the severity of dyspnea was categorized as moderate in 54 patients (47.4%), whereas it was categorized as mild in 50 (43.9%) when we applied the Bronchiectasis Severity Index. The most common lung function pattern was one of obstruction, seen in 95 patients (83.3%), and air trapping was seen in 77 patients (68.7%). The prevalence of an obstructive pattern on spirometry was higher among the patients with dyspnea that was more severe, and most functional parameters showed reasonable accuracy in discriminating between levels of dyspnea severity. Conclusions: Patients with bronchiectasis and dyspnea that was more severe had greater functional impairment. The measurement of lung volumes complemented the spirometry data. Because bronchiectasis is a complex, heterogeneous condition, a single variable does not seem to be sufficient to provide an overall characterization of the clinical condition.

Keywords: Bronchiectasis; Dyspnea; Respiratory function tests; Multidetector computed tomography; Plethysmography.

Tuberculosis continues to be a public health priority in many countries. In 2015, tuberculosis killed 1.4 million people, including 210,000 children. Despite the recent progress made in the control of tuberculosis in Brazil, it is still one of the countries with the highest tuberculosis burdens. In 2015, there were 69,000 reported cases of tuberculosis in Brazil and tuberculosis was the cause of 4,500 deaths in the country. In 2014, the World Health Organization approved the End TB Strategy, which set a target date of 2035 for meeting its goals of reducing the tuberculosis incidence by 90% and reducing the number of tuberculosis deaths by 95%. However, to achieve those goals in Brazil, there is a need for collaboration among the various sectors involved in tuberculosis control and for the prioritization of activities, including control measures targeting the most vulnerable populations. Children are highly vulnerable to tuberculosis, and there are particularities specific to pediatric patients regarding tuberculosis development (rapid progression from infection to active disease), prevention (low effectiveness of vaccination against the pulmonary forms and limited availability of preventive treatment of latent tuberculosis infection), diagnosis (a low rate of bacteriologically confirmed diagnosis), and treatment (poor availability of child-friendly anti-tuberculosis drugs). In this review, we discuss the epidemiology, clinical manifestations, and prevention of tuberculosis in childhood and adolescence, highlighting the peculiarities of active and latent tuberculosis in those age groups, in order to prompt reflection on new approaches to the management of pediatric tuberculosis within the framework of the End TB Strategy.

Keywords: Tuberculosis, pulmonary/prevention & control; Mycobacterium tuberculosis; Lung diseases/etiology; Child; Adolescent.