Seminars in respiratory and critical care medicine
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Coccidioidal infection can manifest as pulmonary or extrapulmonary disease. Pulmonary coccidioidomycosis occurs in 95% of all cases and can be divided into three main categories: primary, complicated, and residual pulmonary coccidioidomycosis. The primary infection occurs with inhalation of airborne arthroconidia. ⋯ Progression of primary pulmonary disease to acute respiratory distress syndrome (ARDS) can also qualify as a complication. The third category of residual disease comprises only two entities: pulmonary nodule and fibrosis. This review focuses on uncomplicated and complicated pulmonary coccidioidomycosis and its management as outlined earlier in addition to special considerations of coccidioidal fungemia, pulmonary coccidioidomycosis in pregnancy, and organ transplantation.
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Cryptococcosis is a common opportunistic infection in acquired immunodeficiency syndrome (AIDS) patients, also occurring in other immunosuppressed patients and occasionally those with no apparent immunocompromise. The majority of cases are caused by the ubiquitous encapsulated yeast, Cryptococcus neoformans, whereas Cryptococcus GATTII accounts for a smaller proportion of cases, often in immunocompetent patients. Severe meningoencephalitis is the commonest presentation; however, pulmonary cryptococcosis in human immunodeficiency virus (HIV)-seropositive individuals is underdiagnosed and without appropriate treatment leads to severe disseminated disease. ⋯ Radiological presentations are varied and nonspecific, influenced by the underlying immune status of the patient. Diagnosis is based on isolation of Cryptococcus from, or detection of cryptococcal antigen in, a pulmonary specimen, coupled with appropriate clinical, radiological, and histopathological findings. Antifungal treatment with amphotericin B +/- flucytosine is recommended for severe disease, whereas fluconazole is the treatment of choice for mild and localized infections.
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This review describes recent evidence relevant to the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Because venous thromboembolism (VTE) is a spectrum of disease that includes both of these disorders, many of the therapeutic options are common to both. At the time of diagnosis, effective treatment options for patients with VTE include unfractionated heparin, low molecular weight heparins (e.g., dalteparin, enoxaparin, tinzaparin), and pentasaccharides (e.g., fondaparinux). ⋯ Other treatment strategies such as vena caval filter placement and mechanical (or chemical) clot dissolution are discussed briefly. Anticoagulation with warfarin (or other oral vitamin K antagonists) is a highly effective strategy for the long-term prevention of VTE recurrence in most patients. In addition to presenting evidence relevant to the optimal duration of warfarin therapy, we highlight circumstances under which extended therapy with a parenteral agent such as a low molecular weight heparin might be preferable.
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Semin Respir Crit Care Med · Feb 2008
ReviewComputed tomography pulmonary angiography and venography: diagnostic and prognostic properties.
Computed tomography pulmonary angiography (CTPA) is now an established test in the diagnosis of suspected pulmonary embolism (PE). Some may argue that it has become the "one-stop" center for diagnosis and prognosis of acute PE and deep vein thrombosis (DVT). ⋯ The addition of computed tomography venography (CTV) increases the sensitivity, which may be worth the added radiation in certain patient populations. Although measures of right heart function, pulmonary artery pressures, and clot burden via CTPA need to be standardized and further validated prospectively, this test may also play a prominent role in determining short-term outcomes in patients with established acute PE.