Publications by authors named "Viboon Boonsarngsuk"

37 Publications

Malignant pleural mesothelioma in a kidney transplant recipient.

Thorac Cancer 2021 Mar 4. Epub 2021 Mar 4.

Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Post-transplantation malignancy is one of the most common complication-related mortality in transplant recipients. Here, we report the case of a kidney transplant patient for 2 years with malignant pleural effusion that was subsequently diagnosed as malignant pleural mesothelioma.
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http://dx.doi.org/10.1111/1759-7714.13917DOI Listing
March 2021

Comparison of different transbronchial biopsy sampling techniques for the diagnosis of peripheral pulmonary lesions with radial endobronchial ultrasound-guided bronchoscopy: A prospective study.

Respir Investig 2020 Sep 11;58(5):381-386. Epub 2020 Apr 11.

Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand. Electronic address:

Background: Data regarding the transbronchial biopsy (TBB) techniques in radial endobronchial ultrasound (R-EBUS)-guided bronchoscopy are limited. The purpose of this study was to compare three R-EBUS-guided TBB techniques for the diagnosis of peripheral pulmonary lesions (PPLs).

Methods: A prospective pilot study was conducted including 90 patients with positive bronchus sign PPLs, who underwent R-EBUS-guided TBB. TBB techniques were performed in all patients using small biopsy forceps with a guide sheath (GS). These samples were submitted for both cell block histology (CB) and conventional histology (SB). Standard biopsy forceps were used to collect further samples that were submitted for conventional histology (LB). The diagnostic yields of the three techniques were compared.

Results: The mean diameter of the PPLs was 25.5 ± 8.2 mm and the final diagnoses included 70 malignant and 20 benign lesions. The overall diagnostic yield of R-EBUS-guided bronchoscopy was 82.2%. Although the difference was not statistically significant, CB provided the highest yield of the three TBB techniques: 68.9%, 65.6%, and 62.2% for CB, SB, and LB, respectively (P = 0.20). When the GS was removed and standard biopsy forceps were introduced, misplacement (detected by fluoroscopy) was observed in 24 cases, and LB provided a diagnosis in 11 cases. PPLs ≤20 mm were associated with misplacement (P = 0.003). After the exclusion of misplaced cases, the diagnostic yields were 69.7%, 71.2%, and 68.2% for CB, SB, and LB, respectively (P = 0.65).

Conclusions: Neither the size of biopsy forceps nor the histology process affected the diagnostic yield of R-EBUS-guided bronchoscopy.
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http://dx.doi.org/10.1016/j.resinv.2020.03.004DOI Listing
September 2020

A prospective randomized comparative study of high-flow nasal cannula oxygen and non-invasive ventilation in hypoxemic patients undergoing diagnostic flexible bronchoscopy.

J Thorac Dis 2019 May;11(5):1929-1939

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Background: Although oxygen supplementation during bronchoscopy in patients with pre-existing hypoxemia is provided, adequacy of oxygenation may not be achieved, resulting in the occurrence of respiratory failure that requires endotracheal tube intubation. The purpose of this study was to compare high-flow nasal cannula (HFNC) with non-invasive ventilation (NIV) in patients with pre-existing hypoxemia undergoing flexible bronchoscopy (FB) on the ability to maintain oxygen saturation during bronchoscopy.

Methods: A prospective randomized study was conducted in patients who had hypoxemia [defined as partial pressure of arterial oxygen (PaO) less than 70 mmHg at room air] and required FB for the diagnosis of abnormal pulmonary lesions. Patients were randomized to receive either HFNC or NIV during FB. The primary outcome was the lowest oxygen saturation level during FB.

Results: Fifty-one patients underwent randomization to HFNC (n=26) or NIV (n=25). Baseline characteristics in terms of age, Simplified Acute Physiologic Score II values, and cardiorespiratory parameters were similar in both groups. After receiving HFNC or NIV, oxygen saturation as measured by pulse oximeter (SpO) increased to greater than 90% in all cases. During FB, although the lowest SpO was similar in both groups, the lowest SpO <90% tended to occur more often in the HFNC group (34.6% 12.0%; P=0.057). In patients with baseline PaO <60 mmHg on ambient air, a decrease in PaO from preprocedure to the end of FB was less in the NIV group (-13.7 -57.0 mmHg; P=0.019). After FB, the occurrence of SpO <90% was 15.4% and 4.0% in the HFNC group and NIV group, respectively (P=0.17).

Conclusions: In overall, NIV and HFNC provided the similar effectiveness in prevention of hypoxemia in hypoxemic patients undergoing FB. However, in subgroup analysis, NIV provided greater adequacy and stability of oxygenation than HFNC in patients with baseline PaO <60 mmHg on ambient air.
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http://dx.doi.org/10.21037/jtd.2019.05.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6588771PMC
May 2019

Prevalence and risk factors of drug-resistant extrapulmonary tuberculosis.

Clin Respir J 2018 Jun 6;12(6):2101-2109. Epub 2018 Mar 6.

Microbiology Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.

Background: Physicians are usually aware of the occurrence of drug-resistant (DR) pulmonary tuberculosis (PTB), but lack concern about DR-extrapulmonary TB (EPTB). Data regarding the prevalence and risk factors of DR-EPTB remain limited.

Objectives: To determine the prevalence and risk factors of DR-EPTB.

Methods: A retrospective study was performed in patients who had culture-proven Mycobacterium tuberculosis (MTB) from various specimens between January 2013 and December 2015. Patients were classified into three groups: PTB, EPTB and concomitant PTB and EPTB (PTB + EPTB). Clinical data, chest radiographic extent of disease and patterns of DR were collected.

Results: There were 1014 culture-proven MTB specimens (716 pulmonary specimens and 298 extrapulmonary specimens) from 986 patients (648 PTB, 218 EPTB and 120 PTB + EPTB). The prevalences of isoniazid-, rifampicin- and multidrug-resistant EPTB were 7.8%, .5% and .5%, respectively, which were lower than those of PTB. When PTB and EPTB coexisted, a higher rate of DR-TB was observed than for PTB alone. Of 338 EPTB patients, the extent of radiographic disease was associated with isoniazid-, rifampicin- and multidrug-resistant TB. Previous history of TB and use of steroids/immunosuppressive drugs were also associated with rifampicin- and multidrug-resistant TB in multivariate analysis.

Conclusions: The prevalence of DR-EPTB was high in patients who had concomitant PTB. Although the prevalences of rifampicin- and multidrug-resistant TB were low in isolated EPTB, the prevalence of isoniazid-resistant TB remained high. Therefore, drug susceptibility testing should be performed in EPTB patients, especially those who carry the aforementioned risk factors.
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http://dx.doi.org/10.1111/crj.12779DOI Listing
June 2018

A comparative study of conventional cytology and cell block method in the diagnosis of pleural effusion.

J Thorac Dis 2017 Sep;9(9):3161-3167

Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Background: In a patient with pleural effusion, cytological study (CS) is one of the most useful investigations, especially when malignancy is suspected. Instead of applying only CS, the pleural fluid can be further processed using the cell block (CB) technique, which may augment the diagnostic utility. The aim of this study was to compare the diagnostic yields of CS, CB, and the combination of both, regardless of the etiology of pleural effusion.

Methods: A cross-sectional study was conducted on patients with pleural effusions who underwent thoracentesis from June 2015 to May 2016. All samples were submitted for routine biochemical analysis, CS, and CB histology. The results of cytopathological studies were compared to the final diagnoses.

Results: Out of a total of 353 samples, the final diagnoses included 278 (78.8%) malignancies, 41 (11.6%) infectious diseases, 16 (4.5%) other inflammatory diseases, and 18 (5.1%) transudative pleural effusions. CS and CB provided a similar diagnostic yield (48.7% . 49.9%, P=0.69), while the combination of both gave a higher yield (57.2%) (P<0.001, compared with CS). Among 278 malignant pleural effusions (MPE), the diagnostic yields of CS and CB were 61.2% and 61.9%, respectively. Combined CS and CB improved the diagnostic yield to 71.2% (P<0.001). However, both CS and CB had low diagnostic yields in infectious pleuritis, other inflammatory diseases, and transudative pleural effusions.

Conclusions: In MPE, CB provides a similar diagnostic performance to CS, while application of both techniques can significantly increase the diagnostic yield. However, in other pleural diseases, CB and CS had limited values in diagnosis.
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http://dx.doi.org/10.21037/jtd.2017.08.52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708377PMC
September 2017

Endobronchial ultrasound elastography for the differentiation of benign and malignant lymph nodes - Reply.

Respirology 2017 07 26;22(5):1038. Epub 2017 Apr 26.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

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http://dx.doi.org/10.1111/resp.13058DOI Listing
July 2017

Diagnostic value of endobronchial ultrasound elastography for the differentiation of benign and malignant intrathoracic lymph nodes.

Respirology 2017 07 19;22(5):972-977. Epub 2017 Jan 19.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Background And Objective: Endobronchial ultrasound (EBUS) findings can be used for benign/malignant differentiation of lymph nodes (LNs). Recently, EBUS elastography has been introduced as a complementary modality in the evaluation of intrathoracic lymphadenopathy. We evaluated the ability of EBUS elastography to differentiate between benign and malignant LNs.

Methods: A prospective study was conducted on patients sent for evaluation of intrathoracic lymphadenopathy. LNs were classified qualitatively according to elastographic colour pattern: type 1, predominantly non-blue; type 2, partly blue, partly non-blue and type 3, predominantly blue. Quantitative elastography of LNs was measured by the strain ratio (SR). Qualitative and quantitative elastographies were compared for the final diagnosis of LNs.

Results: There were 120 LNs from 72 patients who underwent EBUS elastography. The final diagnosis included 96 malignant and 24 benign LNs. All of the 16 type 1 LNs proved to be benign diseases, while 95 of the 101 type 3 LNs were finally diagnosed as malignancies. Three LNs classified as type 2 proved to be two benign and one malignant. Malignant LNs presented a higher median SR than benign LNs (73.50 vs 1.29, P = 0.001). An SR of >2.5 and non-type 1 elastographic pattern achieved similar diagnostic performance in benign/malignant differentiation (sensitivity, 100% vs 100%; specificity, 70.8% vs 66.7%; positive predictive value, 93.2% vs 92.3%; negative predictive value, 100% vs 100%).

Conclusion: EBUS elastography is a promising diagnostic modality for the differentiation of benign and malignant LNs during EBUS-guided transbronchial needle aspiration (TBNA). Qualitative and quantitative EBUS elastographies provide similar diagnostic performance.
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http://dx.doi.org/10.1111/resp.12979DOI Listing
July 2017

Endobronchial ultrasound-guided transbronchial needle aspiration rinse fluid polymerase chain reaction in the diagnosis of intrathoracic tuberculous lymphadenitis.

Infect Dis (Lond) 2017 Mar 21;49(3):193-199. Epub 2016 Oct 21.

b Microbiology Laboratory, Department of Pathology, Faculty of Medicine , Ramathibodi Hospital, Mahidol University , Bangkok , Thailand.

Background: Intrathoracic tuberculous (TB) lymphadenitis is a diagnostic challenge to the clinician. Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can obtain a sample from the affected lymph node, the diagnosis of TB lymphadenitis by cytopathology remains inaccurate.

Objective: To evaluate the efficacy of EBUS-TBNA rinse fluid TB polymerase chain reaction (PCR) assay for the diagnosis of intrathoracic TB lymphadenitis.

Methods: A retrospective study was conducted on 102 patients who underwent EBUS-TBNA for diagnostic evaluation of intrathoracic lymphadenopathy. EBUS-TBNA specimens were evaluated by cytopathological examination. Rinse fluid of the needle was routinely submitted for acid-fast bacillus (AFB) staining, mycobacterial culture, and TB-PCR using the Anyplex MTB/NTM real-time detection kit.

Results: Of 102 patients, 16 were diagnosed with intrathoracic TB lymphadenitis by either microbiology, cytopathology, or on clinical grounds. The sensitivity, specificity, positive predictive value, and negative predictive value of rinse fluid TB PCR assay were 56.2%, 100.0%, 100.0%, and 92.5%, respectively. Using the area under the ROC curve (AUC) as a measure of a diagnostic performance, TB-PCR had the highest AUC, compared with mycobacterial culture, AFB smear, and finding of necrotizing granulomatous inflammation (0.78, 0.75, 0.56, and 0.72, respectively). A combination of TB PCR, mycobacterial culture, and finding of necrotizing granulomatous inflammation provided the best diagnostic performance (sensitivity, specificity, positive predictive value, negative predictive value, and AUC of 75.0%, 100.0%, 100.0%, 95.6%, and 0.88, respectively).

Conclusions: EBUS-TBNA rinse fluid TB-PCR is useful in the diagnosis of intrathoracic TB lymphadenitis. Combining TB-PCR with mycobacterial culture and cytopathological findings improved the diagnosis performance.
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http://dx.doi.org/10.1080/23744235.2016.1244613DOI Listing
March 2017

Fractured metallic tracheostomy tube: A rare complication of tracheostomy.

Respir Med Case Rep 2016 14;19:46-8. Epub 2016 Jul 14.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Thailand.

Although tracheostomy is a well-accepted procedure for airway management, some early and late complications may occur. Fracture of the tracheostomy tube (TT) is a rare complication, particularly in a patient with long-term use. Herein we report a case of fractured metallic TT migrating into the tracheobronchial tree. Rigid bronchoscopy was performed through the tracheostomy stoma and the fractured tube was successfully removed by a balloon catheter. Appropriate cleaning, routine careful examination, and scheduled replacement of the TT may help prevent this complication.
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http://dx.doi.org/10.1016/j.rmcr.2016.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961798PMC
August 2016

Chronic Klebsiella pneumonia: a rare manifestation of Klebsiella pneumonia.

J Thorac Dis 2015 Sep;7(9):1661-4

1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, 2 Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.

K. pneumoniae can present as two forms of community-acquired pneumonia, acute and chronic. Although acute pneumonia may turn into necrotizing pneumonia, which results in a prolonged clinical course, it often has a rapidly progressive clinical course. In contrast, chronic Klebsiella pneumonia runs a protracted indolent course that mimics other chronic pulmonary infections and malignancies. Herein, we present two cases of chronic Klebsiella pneumonia. The diagnosis was made by microorganism identification, as well as absence of other potential causes. Clinical and radiographic findings improved after a prolonged course of antibiotic therapy.
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http://dx.doi.org/10.3978/j.issn.2072-1439.2015.09.31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598526PMC
September 2015

A case of recurrent pneumothorax related to oral methylphenidate.

J Thorac Dis 2015 Aug;7(8):E255-7

1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, 2 Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.

Primary spontaneous pneumothorax (PSP) commonly occurs in young, tall, and thin males, without any identifiable cause except for emphysema-like changes (ELCs). However, other risk factors may be overlooked. Herein, we report the case of a 19-year-old male who presented with recurrent spontaneous pneumothorax while taking oral methylphenidate.
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http://dx.doi.org/10.3978/j.issn.2072-1439.2015.07.36DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561279PMC
August 2015

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment.

Singapore Med J 2015 Jul;56(7):e120-3

Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.
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http://dx.doi.org/10.11622/smedj.2015115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520924PMC
July 2015

Comparison of diagnostic performances among bronchoscopic sampling techniques in the diagnosis of peripheral pulmonary lesions.

J Thorac Dis 2015 Apr;7(4):697-703

1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, 2 Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Background: There are many sampling techniques dedicated to radial endobronchial ultrasound (R-EBUS) guided flexible bronchoscopy (FB). However, data regarding the diagnostic performances among bronchoscopic sampling techniques is limited. This study was conducted to compare the diagnostic yields among bronchoscopic sampling techniques in the diagnosis of peripheral pulmonary lesions (PPLs).

Methods: A prospective study was conducted on 112 patients who were diagnosed with PPLs and underwent R-EBUS-guided FB between Oct 2012 and Sep 2014. Sampling techniques-including transbronchial biopsy (TBB), brushing cell block, brushing smear, rinsed fluid of brushing, and bronchoalveolar lavage (BAL)-were evaluated for the diagnosis.

Results: The mean diameter of the PPLs was 23.5±9.5 mm. The final diagnoses included 76 malignancies and 36 benign lesions. The overall diagnostic yield of R-EBUS-guided bronchoscopy was 80.4%; TBB gave the highest yield among the 112 specimens: 70.5%, 34.8%, 62.5%, 50.0% and 42.0% for TBB, brushing cell block, brushing smear, rinsed brushing fluid, and BAL fluid (BALF), respectively (P<0.001). TBB provided high diagnostic yield irrespective of the size and etiology of the PPLs. The combination of TBB and brushing smear achieved the maximum diagnostic yield. Of 31 infectious PPLs, BALF culture gave additional microbiological information in 20 cases.

Conclusions: TBB provided the highest diagnostic yield; however, to achieve the highest diagnostic performance, TBB, brushing smear and BAL techniques should be performed together.
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http://dx.doi.org/10.3978/j.issn.2072-1439.2015.04.31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4419296PMC
April 2015

Screening of obstructive sleep apnea during pregnancy: differences in predictive values of questionnaires across trimesters.

J Clin Sleep Med 2015 Jan 15;11(2):157-63. Epub 2015 Jan 15.

Stanford Center for Sleep Sciences and Medicine, Stanford University, Redwood City, CA.

Study Objectives: Evaluation of Berlin and Stop-Bang questionnaires in detecting obstructive sleep apnea (OSA) across trimesters of pregnancy.

Methods: Pregnant women from a high-risk pregnancy clinic were recruited to complete sleep evaluations including Berlin and Stop-Bang Questionnaires. Overnight testing with Watch-PAT200 for diagnosis of OSA (cutoff point of apnea-hypopnea index ≥5 events/h) was performed.

Results: Seventy-two singleton pregnant women participated in the study. Enrollment consisted of 23, 24, and 25 women during first, second, and third trimesters, respectively. Of 72 pregnancies, 23 patients (31.9%) had OSA. Prevalence of OSA classified by trimesters from first to third was 30.4%, 33.33%, and 32.0%, respectively. Overall predictive values of Berlin and Stop-Bang questionnaires were fair (ROC area under curve, AUC 0.72 for Berlin, p = 0.003; 0.75 for Stop-Bang, p = 0.001). When categorized according to trimesters, predictive values substantially improved in second (AUC: 0.84 for Berlin; 0.78 for Stop-Bang) and third trimesters (AUC: 0.81 for Berlin; 0.75 for Stop-Bang), whereas performances of both questionnaires during first trimester were poorer (AUC: 0.49 for Berlin; 0.71 for Stop-Bang). Multivariate analyses show that pre-pregnancy body mass index (BMI) in first trimester, snore often in second trimester, and weight gain and pregnancy BMI in third trimester were significantly associated with OSA.

Conclusions: In high-risk pregnancy, Berlin and Stop-Bang questionnaires were of limited usefulness in the first trimester. However their predictive values are acceptable as pregnancy progresses, particularly in second trimester. OSA in pregnancy seems to be a dynamic process with different predictors association during each trimester.
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http://dx.doi.org/10.5664/jcsm.4464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4298773PMC
January 2015

Determination of asbestos bodies in bronchoalveolar lavage fluids in Thailand.

J Med Assoc Thai 2014 May;97(5):554-9

Objective: Asbestos bodies (AB), ferroprotein-coated asbestos fiber may be present in bronchoalveolar lavage fluid (BALF) of asbestos exposed persons. The present study was conducted to evaluate the prevalence and number of asbestos bodies in the BALF of tenable asbestos exposed workers compare to general population in Thailand.

Material And Method: Thirty workers of cement pipe and roof tile factories using chrysotile asbestos and 30 unexposed patients that underwent diagnostic bronchoscopy were included in this study. Determination of asbestos bodies was made by membrane filtration method as described in earlier reports.

Results: The findings were positive in six workers and in one control subject (0.1-3.6 vs. 0.2 AB/ml of BALF, p = 0.449).

Conclusion: AB was identified in workers more often than in pulmonary disease patient. Two of workers had more than 1 AB/ml of BALF.
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May 2014

Airway obstruction caused by penicilliosis: a case report and review of the literature.

Arch Bronconeumol 2015 May 25;51(5):e25-8. Epub 2014 Jun 25.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Tailandia.

Penicilliosis is an opportunistic infection in HIV-infected and other immunocompromised patients mostly in Southeast Asia, Southern China, Hong Kong, and Taiwan, with respiratory manifestations in about one-third of patients. We report the case of a 26-year-old non-HIV immunocompromised patient presenting with an airway obstruction caused by penicilliosis, together with a review of the literature of this rare condition.
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http://dx.doi.org/10.1016/j.arbres.2014.04.015DOI Listing
May 2015

Diagnosis of peripheral pulmonary lesions with radial probe endobronchial ultrasound-guided bronchoscopy.

Arch Bronconeumol 2014 Sep 18;50(9):379-83. Epub 2014 Apr 18.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Tailandia.

Introduction: The diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists. Radial probe endobronchial ultrasound (R-EBUS) has been developed to enhance diagnostic yield. The objective of this study was to evaluate the effectiveness of R-EBUS in the diagnosis of PPLs.

Methods: A retrospective study was conducted on 174 patients diagnosed with PPLs who underwent EBUS-guided bronchoscopy. Histological examination of specimens obtained by transbronchial lung biopsy (TBLB) and cytological examinations of brushing smear, brush rinse fluid and bronchoalveolar lavage fluid (BALF) were evaluated for the diagnosis.

Results: The mean diameter of the PPLs was 25.1 ± 10.7 mm. The final diagnoses included 129 malignancies and 45 benign lesions. The overall diagnostic yield of EBUS-guided bronchoscopy was 79.9%. Neither size nor etiology of the PPLs influenced the diagnostic performance of EBUS-guided bronchoscopy (82.9% vs. 74.6% for PPLs>20mm and PPLs≤20mm; p=0.19, and 82.9% vs. 71.1% for malignancy and benign diseases; p=0.09). TBLB rendered the highest yield among these specimens (69.0%, 50.6%, 42.0%, and 44.3% for TBLB, brushing smear, brush rinse fluid, and BALF, respectively; p<0.001). The combination of TBLB, brush smear, and BALF provided the greatest diagnostic yield, while brush rinse fluid did not add benefits to the outcomes.

Conclusion: R-EBUS-guided bronchoscopy is a useful technique in the diagnosis of PPLs. To achieve the highest diagnostic performance, TBLB, brushing smear and bronchoalveolar lavage should be performed together.
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http://dx.doi.org/10.1016/j.arbres.2014.02.018DOI Listing
September 2014

Clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment.

Diagn Interv Radiol 2013 Nov-Dec;19(6):438-46

From the Departments of Radiology (T.S. e-mail: W.S.), Pulmonary and Critical Care Medicine (V.B.), Infectious Diseases (S.P.W.), and Pathology (P.I.), Ramathibodi Hospital, Mahidol University Faculty of Medicine, Bangkok, Thailand; Banmi Hospital (W.S.), Lopburi Province, Thailand.

Purpose: We aimed to investigate clinical and radiologic manifestations of pulmonary cryptococcosis in immunocompetent patients and their outcomes after treatment.

Materials And Methods: We retrospectively reviewed the medical records, initial and follow-up chest computed tomography scans and/or radiographs for initial clinical and radiologic manifestations and outcomes following antifungal treatment of 12 immunocompetent patients diagnosed with pulmonary cryptococcosis between 1990 and 2012.

Results: Twelve patients (age range, 21-62 years; males, eight patients [66.7%]) were included. Nine (75%) patients were symptomatic, eight of whom had disseminated infection with central nervous system involvement. Initial pulmonary abnormalities consisted of single nodules/masses (n=5), single segmental or lobar mass-like consolidation (n=3), multiple cavitary and noncavitary nodules (n=1), and multifocal consolidation plus nodules (n=3). These lesions ranged from less than 1 cm to 15 cm in greatest diameter. Distinct subpleural and lower lung predominance was observed. Seven patients (58.3%) had one or more atypical/aggressive findings, namely endobronchial obstruction (n=4), calcified (n=1) or enlarged (n=4) mediastinal/hilar lymph nodes, vascular compression (n=1), pericardial involvement (n=1), and pleural involvement (n=2). Following antifungal therapy, radiologic resolution was variable within the first six months of eight nonsurgical cases. Substantial (>75%) improvement with some residual abnormalities, bronchiectasis, cavitation, and/or fibrotic changes were frequently observed after 12-24 months of treatment (n=6).

Conclusion: Pulmonary cryptococcosis in immunocompetent patients frequently causes disseminated infection with atypical/aggressive radiologic findings that are gradually and/or incompletely resolved after treatment. The presence of nonenhanced low-attenuation areas within subpleural consolidation or mass and the absence of tree-in-bud appearance should raise concern for pulmonary cryptococcosis, particularly in patients presenting with meningitis.
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http://dx.doi.org/10.5152/dir.2013.13049DOI Listing
July 2014

The effect of aspiration pressure over endobronchial ultrasound-guided transbronchial needle aspiration on the diagnosis of intrathoracic lymphadenopathies.

Lung 2013 Aug 1;191(4):435-40. Epub 2013 Jun 1.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.

Background: Data regarding the effect of aspiration pressure over endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) on the diagnosis of intrathoracic lymphadenopathies is limited. The aim of this study was to compare the effect of three levels of aspiration pressure over EBUS-TBNA on the diagnostic yield and numbers of diagnostic cells.

Methods: A prospective study was conducted on 66 patients with enlarged intrathoracic lymph nodes. Three levels of aspiration pressure (0, 20, and 40 mL) were applied after the needle pierced the target and the needle's position was confirmed by EBUS images. The diagnostic yield and the numbers of diagnostic cells attained with each pressure from the same target were compared. The cellularity of the obtained diagnostic cells was classified into four grades (inadequate, minimal, moderate, and numerous) by a cytopathologist in a blinded study.

Results: The mean nodal size was 19.1 ± 6.2 mm. The final diagnoses included 53 malignant and 13 benign lymphadenopathies. Adequate lymph node samples were obtained in 63 patients (95.5%), and EBUS-TBNA revealed definite diagnosis for 58 patients (87.9%). Negative pressure of 40 mL provided a diagnostic yield similar to that of 20 mL (83.3 vs. 75.8%; p = 0.23), but both showed higher diagnostic yields than zero pressure. In terms of cellularity of the specimen, however, high negative pressure (40 mL) gave higher numbers of adequate cells than the comparators (p < 0.001).

Conclusion: Negative pressure should be applied in an EBUS-TBNA procedure. Although the diagnostic yield was not different, high negative pressure was superior to low negative pressure in obtaining numbers of adequate cells.
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http://dx.doi.org/10.1007/s00408-013-9480-6DOI Listing
August 2013

Tracheobronchial involvement in relapsing polychondritis diagnosed on endobronchial ultrasound.

Intern Med 2013 1;52(7):801-5. Epub 2013 Apr 1.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand.

Respiratory tract chondritis is not uncommon in patients with relapsing polychondritis (RP); however, diagnosing this condition remains problematic, especially in patients whose extrapulmonary manifestations do not predominate, as there are broad differential diagnoses of airway obstruction. We herein report the case of a 56-year-old man who presented with cough and dyspnea. Computed tomography of the chest demonstrated diffuse smooth thickening of the visualized tracheobronchial wall with a moderately narrowed lumen. Airway chondritis was diagnosed on endobronchial ultrasound following demonstration of thickening of the submucosal and cartilaginous layers in the anterior and lateral aspects of the bronchial wall, while the posterior region expressed less involvement. In conjunction with nasal and auricular chondritis, which were previously overlooked, RP was finally diagnosed.
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http://dx.doi.org/10.2169/internalmedicine.52.9416DOI Listing
January 2014

Combination of adenosine deaminase activity and polymerase chain reaction in bronchoalveolar lavage fluid in the diagnosis of smear-negative active pulmonary tuberculosis.

Int J Infect Dis 2012 Sep 26;16(9):e663-8. Epub 2012 Jun 26.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.

Background: Some studies have assessed the diagnostic value of adenosine deaminase (ADA) activity in bronchoalveolar lavage fluid (BALF) in the diagnosis of pulmonary tuberculosis (TB). However, a conclusion has not been reached due to the limited number of patients with various pulmonary diseases used as comparators. The objective of this study was to evaluate the efficacy of BALF ADA activity and TB PCR assay for diagnosing pulmonary TB.

Methods: BAL samples from 424 patients with acid-fast bacillus-negative sputum smears who underwent bronchoscopy for diagnostic evaluations of pulmonary diseases, were prospectively analyzed for ADA activity and TB PCR.

Results: The median ADA activity of TB cases was significantly different from that of patients with solid tumor without endobronchial obstruction (p<0.001), inactive TB (p=0.04), and other (p=0.038), while this was not the case for the other pulmonary diseases. A cutoff BALF ADA activity of ≥3 U/l provided a sensitivity of 58.7% and specificity of 81.8% to differentiate TB from solid tumor without endobronchial obstruction. The sensitivity of TB PCR in BALF was 28.1% with a specificity of 99.0%. The area under the receiver operating characteristic (ROC) curve to differentiate TB from solid tumor without endobronchial obstruction was significantly higher for the combination of ADA activity ≥3 U/l and TB PCR (0.77) than for ADA activity ≥3 U/l alone (0.70, p<0.001) or for TB PCR alone (0.64, p<0.001). The sensitivity of the combination of ADA activity ≥3 U/l and TB PCR was 72.7% and the specificity was 81.8%. In TB cases, a greater radiographic extent of disease was associated with a higher median ADA activity (p=0.017).

Conclusions: BALF ADA had limited value in differentiating pulmonary TB from some other pulmonary diseases. To differentiate TB from solid tumor without endobronchial obstruction, a combination of BALF ADA and TB PCR had marked additive diagnostic value.
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http://dx.doi.org/10.1016/j.ijid.2012.05.006DOI Listing
September 2012

A patient with subcutaneous emphysema following endotracheal intubation.

Respir Care 2012 Jul 23;57(7):1191-4. Epub 2012 Jan 23.

Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

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http://dx.doi.org/10.4187/respcare.01459DOI Listing
July 2012

Endobronchial ultrasound plus fluoroscopy versus fluoroscopy-guided bronchoscopy: a comparison of diagnostic yields in peripheral pulmonary lesions.

Lung 2012 Apr 3;190(2):233-7. Epub 2012 Jan 3.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.

Background: Even though fluoroscopy-guided bronchoscopy has been well developed, the diagnostic yield of peripheral pulmonary lesions (PPLs) remains unsatisfying. Therefore, endobronchial ultrasound (EBUS) has been implemented recently to enhance the possibility of attaining true diagnosis. However, there are few studies that directly compare the success rate of fiber-optic bronchoscopy with fluoroscopic guidance to that of EBUS guidance in the diagnosis of PPLs in the same institute and in the same study period. The aim of this study was to compare the performance of EBUS plus fluoroscopy guidance with that of fluoroscopy-guided bronchoscopy in the diagnosis of PPLs.

Methods: A retrospective study was conducted on 114 patients who were diagnosed with PPLs and underwent either EBUS plus fluoroscopy or fluoroscopy-guided bronchoscopy. The diagnostic yields of both modalities were calculated.

Results: The mean diameter of the PPLs measured by computed tomography of the chest was 23.7 mm. EBUS plus fluoroscopy obtained higher diagnostic yield than fluoroscopy-guided bronchoscopy (82.5 vs. 57.9%; P = 0.004). Subgroup analysis demonstrated that for PPLs larger than 20 mm, the accuracy of EBUS plus fluoroscopy was not different from that of the fluoroscopy-guided technique (85.7 vs. 72.2%, respectively; P = 0.19). In contrast, for lesions smaller than 20 mm, EBUS plus fluoroscopy guidance provided significantly greater diagnostic performance than fluoroscopy-guided bronchoscopy (79.3 vs. 33.3%; P = 0.001).

Conclusions: Bronchoscopy under EBUS and fluoroscopy guidance improved the diagnostic yield of PPLs, especially of those smaller than 20 mm in diameter.
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http://dx.doi.org/10.1007/s00408-011-9359-3DOI Listing
April 2012

Homemade talc spray atomizer dedicated to flexible-rigid pleuroscope.

Clin Respir J 2012 Jan 8;6(1):40-5. Epub 2011 Jun 8.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Background: Thoracoscopic talc poudrage is the preferred technique for medical pleurodesis. However, commercial talc spray atomizers are not applicable with the flexible-rigid pleuroscope. Therefore, we developed a simple and cheap homemade talc spray atomizer dedicated to flexible-rigid pleuroscope.

Objective: To describe the experience in performing talc poudrage using our homemade talc spray atomizer.

Methods: A retrospective review was performed in 22 consecutive patients with symptomatic malignant pleural effusion undergoing thoracoscopic talc poudrage by our talc spray atomizer with the aim of performing a palliative pleurodesis.

Results: Under direct flexible-rigid pleuroscopic guidance, we could instill talc throughout the pleural cavity with our talc spray atomizer in all cases. The median procedure time to instill the whole talc was 4 min 15 s. The successful pleurodesis was achieved in 77.3%.

Conclusions: We have introduced a homemade talc spray atomizer dedicated to the flexible-rigid pleuroscope. Uniform distribution of talc could be achieved without additional port placement.
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http://dx.doi.org/10.1111/j.1752-699X.2011.00243.xDOI Listing
January 2012

Puzzling bronchial trifurcation.

Respir Care 2011 Aug 15;56(8):1206-8. Epub 2011 Apr 15.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

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http://dx.doi.org/10.4187/respcare.01200DOI Listing
August 2011

False-positive serum and bronchoalveolar lavage Aspergillus galactomannan assays caused by different antibiotics.

Scand J Infect Dis 2010 Jul;42(6-7):461-8

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Our objective was to identify false-positive serum and bronchoalveolar lavage (BAL) fluid galactomannan (GM) tests caused by various antibiotics commonly used in general practice. Serum and BAL samples from patients who did not have the diagnostic criteria of invasive aspergillosis and received different antibiotics were prospectively analyzed for GM. Serum and BAL samples were also collected from patients who did not receive antibiotics. At the cut-off index of >or=0.5, false-positive serum results were found in patients who received amoxicillin-clavulanate, piperacillin-tazobactam, cefepime, and cefoperazone-sulbactam (26.7%, 58.3%, 14.3%, and 66.7%, respectively). Fungal colonization in BAL samples had a higher BAL GM than those without fungal colonization. In 71 patients who had a negative BAL culture for fungi, at the cut-off value of >or=1.0, false-positive BAL fluid results were found in patients who received amoxicillin-clavulanate (27.3%), piperacillin-tazobactam (50%), cefepime (16.7%), carbapenem (45.5%), and ceftriaxone (45.5%). False-positive serum and BAL GM assays were also detected in patients who did not receive any antibiotics. In summary, this study demonstrates the false-positive GM levels in serum and BAL caused by beta-lactam antibiotics that are commonly used in general practice. Physicians should be aware of this possible interference.
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http://dx.doi.org/10.3109/00365541003602064DOI Listing
July 2010

Autoaspiration versus manual aspiration in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy.

J Bronchology Interv Pulmonol 2009 Oct;16(4):236-40

*Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University †Cytology Unit, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand ‡Division of Chest Surgery, St Marianna University School of Medicine, Kawasaki, Japan.

Background: Traditionally, aspiration with high negative pressure is recommended to obtain a specimen in transbronchial needle aspiration (TBNA). Undeniably, however, the assistant experiences difficulty in the generation of the negative pressure and precise control of the syringe while performing the procedure.

Objective: To evaluate the effectiveness of the autoaspiration method created by our plunger lock in comparison with the conventional manual aspiration in the diagnosis of intrathoracic lymphadenopathy by TBNA.

Methods: A prospective study was conducted on all patients referred for diagnostic TBNA of enlarged intrathoracic lymph nodes. Both automatic and manual aspiration techniques were performed after the needle had been completely inserted into the nodes. The diagnostic yield and the numbers of diagnostic cells or benign lymphoid cells obtained by each technique were compared in the same node.

Results: A total of 31 intrathoracic lymph nodes in 24 patients were prospectively studied. Twenty-four nodes (77.4%) were malignancies whereas 7 nodes (22.6%) were benign disease. Adequate lymph node samples were obtained in 30 targets (96.8%), and TBNA revealed definite diagnosis for 25 nodes (80.6%). Both aspiration techniques showed exactly the same diagnostic yield. However, the autoaspiration technique provided significantly more adequate samples than manual aspiration techniques did (P=0.003).

Conclusion: The autoaspiration method using our plunger lock was superior to the manual method in obtaining the numbers of adequate samples in TBNA procedures.
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http://dx.doi.org/10.1097/LBR.0b013e3181b767e5DOI Listing
October 2009

Bronchial anthracostenosis with mediastinal fibrosis associated with long-term wood-smoke exposure.

Respirology 2009 Sep;14(7):1060-3

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Bronchial anthracostenosis describes a disease entity consisting of bronchial destruction, deformity and stenosis related to dark pigmentation on bronchoscopy in patients with a history of coal workers' pneumoconiosis or chronic exposure to biomass smoke. The combined occurrence of bronchial anthracostenosis and mediastinal fibrosis in association with wood-smoke exposure has not been previously reported. This case report describes a non-cigarette smoking elderly woman who developed bronchial anthracostenosis and mediastinal fibrosis after long-term exposure to wood smoke. Clinical and radiological improvements were achieved after treatment with corticosteroid and tamoxifen. Awareness of this unusual entity will help to avoid misdiagnosis of malignancy or unnecessary thoracotomy.
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http://dx.doi.org/10.1111/j.1440-1843.2009.01604.xDOI Listing
September 2009

Self-learning experience in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy.

J Med Assoc Thai 2009 Feb;92(2):175-81

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Background: Lack of a training program and experience result in underutilized transbronchial needle aspiration (TBNA). Pulmonologists who are not graduated from Europe or the United States might have little chance to learn and gain experience in this procedure.

Objective: To determine the authors' diagnostic yield from self-learning TBNA in diagnosis of intrathoracic lymphadenopathy.

Material And Method: After reviewing a videotape recorded TBNA procedure repetitively and receiving training in tracheobronchial lung model, the authors performed TBNA according to standard techniques using 21-guage cytology needles connected to a flexible bronchoscope in diagnosis of intrathoracic lymphadenopathy and performed data collection on all TBNA procedures at Ramathibodi Hospital, a tertiary university hospital in Bangkok, Thailand between January 1, 2006 and December 31, 2007.

Results: Thirty-eight consecutive patients were examined Twenty-seven nodes (71.1%) were malignancies and II nodes (28.9%) were benign diseases. During the first 6-month, the authors' diagnostic yield and frequency of adequate specimens were low. With some modification of the TBNA technique and learning experience, the frequency of inadequate specimens significant decreased from 36.4% to 0% (p = 0.03). Although the diagnostic yield increased from 45.5% to 84.6%, it did not reach statistical significance (p = 0.09). No complication, in either the patients or the bronchoscopes, was found.

Conclusion: TBNA is a safe procedure that can be self-mastered by pulmonologists with interest, intent, and who exert themselves. TBNA performance will be improved over time with practice.
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February 2009

Puzzling bronchi.

Respiration 2009 7;77(1):107-9. Epub 2008 Oct 7.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

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http://dx.doi.org/10.1159/000162878DOI Listing
March 2009