Libor Fila

Abstract: BACKGROUND: Once the outbreak with Burkholderia cenocepacia ST32 was identified in the Prague cystic fibrosis (CF) centre, molecular tools were implemented into diagnostic routine in order to complement infection control measures with as accurate as possible microbiological service. In addition, genotyping techniques were applied as part of an infection surveillance program to assign species and strain status in samples positive for Burkholderia cepacia complex (Bcc). We sought to evaluate a usefulness of Bcc-specific PCR in infection control and to map evolution of the outbreak. METHODS: Since 2001, 6109 respiratory samples from 299 CF patients were examined not only by conventional culture, but also by PCR, detecting Bcc directly in sputum. RESULTS: Diagnosis of Bcc infection was established by culture in 54 patients already prior to 2001. As 39 more patients were diagnosed by culture and/or PCR during 2001-2010, this represented annual prevalence of 18.5%-28.9%. Twelve of 39 patients were culture negative at the time of their first PCR positivity. Although 2/3 of them became subsequently culture positive, the time delay in diagnostics of the infection by culture ranged from 1 to 22months. New cases of Bcc infection were detected every year, however a dramatic drop was observed for the epidemic strain ST32. CONCLUSION: A likely factor contributing to the end of ST32 epidemic was segregation of Bcc infected patients that included also patients with no culture, but PCR positivity. The diagnostic PCR led to timely identification of cases with 'culture-invisible' infection.

Abstract: BACKGROUND: Associations between nasal and bronchial impairment have been repeatedly described in chronic obstructive pulmonary disease (COPD), whereas nasal mucociliary clearance (MCC) in COPD patients is not yet fully understood. We studied nasal MCC parameters in COPD patients and compared them with healthy adults (HA) and with cystic fibrosis (CF) patients with compromised MCC. METHODOLOGY: An observational study of 98 COPD ex-smokers and subjects from control groups evaluated for nasal MCC time (NMCCt) and by digital video microscopy of nasal mucosa recording ciliary beat frequency (CBF) and ciliary beat pattern. RESULTS: The NMCCt was decreased in HA compared to those with COPD and decreased in those with COPD compared to those with CF. CBF in COPD was lower compared to HA. The index of ciliary dyskinesia in COPD patients differed from HA. We detected higher NMCCt and lower nasal CBF in patients with chronic bronchitis phenotype (CB) compared to non-CB patients. CONCLUSIONS: We confirmed the presence of impaired nasal MCC in COPD ex-smokers. These impairments were apparent predominantly in the CB phenotype.

Abstract: Haemoptysis is a common complication of cystic fibrosis bronchopulmonary disease, especially in adults with more advanced lung involvement. The choice of treatment depends on the severity of haemoptysis. Terlipressin administration is one of the conservative measures. We present a case report of an adult cystic fibrosis patient with massive haemoptysis, whose terlipressin treatment was complicated with severe hyponatraemia. This complication progressed despite fluid restriction and furosemide and natrium chloride administration. It was resolved within two days of terlipressin discontinuation. No other causes of hyponatraemia were identified. In this paper, we draw attention to severe hyponatraemia as a rare complication of terlipressin treatment. Strict monitoring of serum electrolytes and osmolality during treatment with vasopressin analogues is highly recommended.

Abstract: Background. Lung transplantation is a well established treatment for advanced lung diseases. Methods. We compared the clinical results of patients with cystic fibrosis (CF) entered into the waiting list with those of patients after lung transplantation. Results. Among 36 patients with CF on the waiting list, 23 underwent lung transplantation, 8 died, 3 are still on the waiting list, and 2 were excluded from the waiting list. The median waiting list time of 0.48 years (range, 0.03�2.37) was insignificantly longer for patients who died compared with transplanted patients (0.97 vs 0.44 years). Mortality of waiting-list patients was 25.8%. The median survival of transplant patients of 7.48 years (range 0.00�10.85 years) was significantly lower among patients who were colonized (BCC) versus those who were not Burkholderia cepacia complex (0.19 vs 7.48 years; P = .041). The 1-, 3-, and 5-year patient survivals after lung transplantation were 72.9, 54.4, and 54.4, respectively. Conclusion. The results of patients with cystic fibrosis on the waiting list versus after lung transplantation in our center were similar to those reported in the literature. We confirmed a less favorable prognosis of BCC-colonized patients.

Abstract: For a long time, cystic fibrosis (CF) was dealt with pediatricians. However, papers dealing with less severe disease in adults occured together with descriptions of devastating forms in childhood many years ago. At first, Czech internists were intersted in adult CF. Since the 1980s, however, pulmonologists have attended to these patients because of predominant lung involvement. The Department of Pulmonology of the University Hospital in Prague-Motol was the first that start caring for adult CF patients in 1987. Since 2000, it have been joined by other CF centres in departments of pulmonary medicine in university hospitals in Hradec Králové, Brno, Olomouc and Plzen due to increasing number of adult CF patients. The article provides an overview of papers dealing with CF written by Czech pulmonologists. Two case reports, fifteen original articles, eleven reviews, two monographs and seven monograph chapters in the period 1978-2009 were identified. Comments on individual papers are presented in the discussion. The authors believe that the article brings lots of useful information for interested readers.

Abstract: Examination of exhaled breath condensate belongs to experimental methods that are used in many pulmonary diseases and it can take part in the study of their pathophysiology. Its contribution to diagnostics and to monitoring of response to treatment is also evaluated. Many biomarkers of inflammation and oxidative stress were studied in exhaled breath condensate in cystic fibrosis. Examination of pH of exhaled breath condensate is considered to be useful in evaluation of inflammatory acidification of airways, together with evaluation of response to antibiotic treatment of pulmonary exacerbation, due to immediately accessible result. Other important biomarkers include 8-isoprostane and 3-nitrotyrosine as markers of oxidative stress (both with negative correlation with pulmonary function) and leukotriene B4 as marker of neutrophilic inflammation. Opposite to other pulmonary diseases, hydrogen peroxide does not belong to useful markers of oxidative stress in cystic fibrosis, due to abundant reduced thiols and glutathione peroxidase in sputum of these patients. Attempts to detect bacterial DNA in exhaled breath condensate in cystic fibrosis also failed. In spite of mentioned progress, examination of exhaled breath condensate remains a research method and it has not been introduced into clinical practice.

Abstract: Introduction: Most of cystic fibrosis (CF) patients survive now into adulthood and they are transferred to pulmonologist care. Aims: An overview of progress in care for CF adults in Czech Republic and evaluation of relationship of pulmonary function, nutritional status and airway colonization. Methods: All adult CF patients followed in pulmonary departments from December 1987 to December 2007 were included into study. Data about survival status, pulmonary function, nutritional status, airway colonization and other pulmonary and extrapulmonary manifestations of CF were collected from patients´ records. Results: Total of 206 patients (96 females) were followed. Pancreatic insufficiency was present in 175 (85.0 %), liver disease in 61 (29.6 %) and insulin treatment in 58 (28.2 %) patients. Bone disease was found in 70 (46.7 %) from 150 examined patients. Sixty-two patients (23 females) died at mean age 25.4 ± 5.5 years (median 24.3 years). Worse survival was recorded in patients with Burkholderia cepacia complex (BCC) airway colonization (24.4 ± 4.0 vs. 28.5 ± 7.0 years, p = 0.012). One hundred forty-four living patients were followed to date of the 31st December 2007 with mean age 27.5 ± 6.5 years (median 26.5 years), FEV1 64.4 ± 28.5 % pred. and BMI 20.9 ± 3.1 kg/m2. Worse pulmonary function was present in patients with BCC colonization (FEV1 58.8 ± 21.9 vs. 67.8 ± 27.3 % pred., p = 0.041) and in malnourished patients (FEV1 49.5 ± 18.5 vs. 69.7 ± 25.9 % pred., p < 0.0001). BCC colonization was found in 54 (37.5 %), Pseudomonas aeruginosa (PA) colonization in 92 (63.9 %) and colonization without BCC or PA in 40 (27.8 %) patients, respectively. Malnutrition (BMI <19.0 kg/m2) was recorded in 38 (26.4 %) patients. Conclusion: This study confirms growing number of CF adults in Czech Republic, close relationship of pulmonary function and nutritional status and also unfavourable influence of BCC colonization.

Abstract: Bronchopulmonary disease in cystic fibrosis (CF) is coupled with neutrophilic inflammation. Leukotriene (LT) B4 is an important chemoattractant for neutrophilic leukocytes. Supplementation with n-3 polyunsaturated fatty acids (PUFA) leads to synthesis of biologically less active LTB5. The aim of this study was to compare inflammatory markers (pH and LTB4) in exhaled breath condensate (EBC) in stable CF and healthy controls, to evaluate their relation to lung function, nutritional status and systemic inflammatory markers, and also to assess the effect of supplementation with n-3 PUFA. Twelve stable CF patients (5 males) with a mean age of 25.6 years had higher concentrations of EBC LTB4 (174.6 vs. 82.6 pg/ml; p = 0.011) and insignificantly lower values of EBC pH (5.95 vs. 6.13) when compared with healthy controls (n = 12; 4 males; mean age 27.3 years). In CF patients, EBC LTB4 concentration correlated with serum C-reactive protein concentration (r = 0.629; p = 0.028) and EBC pH value correlated with the body mass index (r = 0.639; p = 0.025) and blood neutrophil granulocytes count (r = �0.686; p = 0.014). After six weeks of n-3 PUFA supplementation (doses corresponding to 1.3 % of calorie intake), nine CF patients had higher EBC pH values (6.08 vs. 6.32; p = 0.042) and insignificantly lower EBC LTB4 concentration (173.0 vs. 120.5 pg/ml). We conclude that CF patients have more pronounced inflammatory parameters in EBC when compared with healthy controls. EBC inflammatory parameters correlated with systemic inflammatory markers. After n-3 PUFA treatment, EBC LTB4 concentration tended to be lower and EBC was significantly less acid which may reflect less intense neutrophilic inflammation.

Abstract: BACKGROUND: LINE-1 (long interspersed element-1) or L1-mediated retrotransposition is a potent force in human genome evolution and an occasional cause of human genetic disease. Since the first report of two de novo L1 insertions in the F8 gene causing hemophilia A, more than 50 L1-mediated retrotranspositional events have been identified as causing human genetic disease. However, a significant bias has generally militated against the detection of these pathological events at autosomal loci. Based upon this and other observations, we surmised that some previously unresolved cystic fibrosis chromosomes might carry hitherto undetected L1-mediated retrotranspositional insertions at the CFTR locus. This study represents an attempt to identify such mutational events. METHODS: 100 previously unresolved cystic fibrosis chromosomes were carefully reanalyzed using quantitative high-performance liquid chromatography (QHPLC). RESULTS: Two simple Alu insertions were identified in the CFTR gene, within exons 16 and 17b respectively. CONCLUSIONS: Our findings have not only revealed a previously unknown mutational mechanism responsible for cystic fibrosis but also represent an important addition to the already diverse spectrum of known CFTR gene mutations. Experience with the CFTR gene suggests that pathological L1-mediated retrotranspositional events may also have been overlooked at other gene loci and should always be considered in cases that appear to be refractory to analysis.

Abstract: Patients with cystic fibrosis (CF) are susceptible to chronic respiratory infections that considerably affect their long-term prognosis. Burkholderia cepacia complex and Pseudomonas aeruginosa are the most severe pathogens that can cause epidemic outbreaks within a CF population. To prevent their potential spread, early and reliable diagnostics along with transmissible strain identification is required. Molecular genetic methods allow highly sensitive and specific detection of bacteria belonging to B. cepacia complex and their speciation. Furthermore, the typing techniques help identify the strains capable of transmission among patients. The Prague CF Centre has been combating the widespread infection of B. cepacia complex caused by the strain ST-32 for more than 10 years. The current drop in its incidence is a likely consequence of strict infection control, which is monitored by applying molecular microbiological tools.

Abstract: Pulmonary involvement in cystic fibrosis (CF) patients is accompanied by neutrophilic inflammation and impaired metabolism of nitric oxide (NO). Oxidative metabolites of NO are detectable in exhaled breath condensate (EBC). The artile deals with changes of EBC composition after treatment with inhaled corticosteroids (ICS), namely the pH and concentrations of nitrites (NO2�) a nitrates (NO3�). Ten CF patients aged 23.4 ± 3.8 years were treated with ICS (budesonide 800 µg twice daily) for three months. The pH of EBC was examined without deaeration immediately after collection. Concentrations of NO2� a NO3� in EBC were assayed by liquid chromatography after derivatization with diaminonaphthalene. Healthy controls (n=12) were aged 27.2 ± 2.7 years. No significant change was detected in CF patients after ICS treatment in studied clinical parameters (BMI, FEV1, serum CRP and blood neutrophil cell count in peripheral blood). EBC composition showed a significant increase of the pH (from 5.49 ± 0.68 to 6.17 ± 0.31; p = 0.005) and concentration of NO3� (from 7.3 ± 1.8 to 20.9 ± 10.0 μmol/l; p = 0.003). No significant change was revealed in EBC concentration of NO2�. The composition of EBC in CF patients differed significantly from values in healthy controls in these parameters: lower pH before treatment with ICS (p=0.01) and lower concetrations of NO3� before (p<0.001) and after (p=0.046) treatment with ICS, respectively. We conclude that ICS treatment in stable CF patients led to significant changes of EBC pH and NO3� concentration. Furthermore, CF patients have lower EBC pH and NO3� concentration than healthy controls. Treatment with ICS resulted in the same values of the pH as in healthy controls but concentration of NO3� remained decreased.

Abstract: In cystic fibrosis involvement of pancreas usually presents as exocrine pancreatic insufficiency. Some patients, however, have exocrine pancreatic sufficiency. The paper analyses the clinical manifestations in patients presenting with cystic fibrosis with exocrine pancreatic sufficiency (5 men and 6 women, mean age 28.7. years) and compares them with the clinical manifestation in F508del homotygotes (10 men and 12 women, mean age 24.9 years) with exocrine pancreatic insufficiency. In patients with exocrine pancreatic sufficiency the diagnosis of cystic fibrosis was established in later age (mean age 16.4 years vs. 1.9 years, p=0.003). These patients had lower concentration of sweat chlorides (72 vs. 94 mmol/l, p=0.004), higher fecal elastase 1 (580 vs. 15 μg/g, p<0.0001), better nutritional status (body mass index 22.9. vs. 20.9 kg/m2, p=0.011) and less frequent colonization of the respiratory tract with typical Gram-negative bacteria (5 out of 11 vs. 19 out of 22, p=0.033). The tendency of patients with exocrine pancreatic sufficiency to better parameters of pulmonary function, to better clinical and radiological score and to better exercise tolerance did not reach statistical significance, just as a tendency towards more frequent incidence of recurrent or chronic pancreatitis and less frequent incidence of diabetes and hepatopathy. We found no difference in the incidence of nasal polyposis, allergic bronchopulmonary aspergillosis, pneumothorax, haemoptysis and metabolic bone disease. We did not have sufficient data to assess the incidence of obstructive azoospermia. In the absence of steatorrhoea and malnutrition and because of variable involvement of the respiratory tract, the diagnosis of cystic fibrosis in the presence of exocrine pancreatic sufficiency is difficult. However, in the view of possible consequences for the patient (gradual progression of the disease) and consequences for his blood relatives (including prenatal diagnosis) we have to think of this disease in the differential diagnosis of conditions with recurrent and chronic sinobronchial symptoms.

Abstract: Patients presenting cystic fibrosis are a risk group in danger of airways colonization with non-tuberculous mycobacteria. This is why sputum samples of these patients have to be regularly investigated for the presence of mycobacteria. Chronic colonization of the airways by gramnegative bacteria capable of resisting decontamination somewhat complicate the detection of mycobacteria. In a retrospective analysis we assessed both the efficacy of decontamination with 2.7% sodium laurylsulphate and 0.9% soiudm hydroxide and the proportion of sputum samples with bacterial supercolonization. We evaluated 162 sputum samples from 42 patients (25 women), mean age 24.2 (19.9-41.9) years. In 13 instances there was chronic colonization with Pseudomonas aeruginosa, in 29 instances with Burkholderia cenocepacia. Supercolonization with non-specific bacterial flora was seen in 23 out of 51 samples from patients (45.1%) colonized with Pseudomonas aeruginosa and in 71 out of 111 samples from patients (64.0%) colonized with Burkholderia cenocepacia (p<0.05). No sample was microscopicaly positive, only one sample was positive upon culture (Mycobacterium avium in a woman colonized with Pseudomonas aeruginosa). All the remaining samples had negative cultures. In 14 the investigated patients (33.3.%) we found only contaminated culture media. Our investigation demonstrated an inadequate efficacy of the decontamination method used and a more frequent non-specific contamination of culture media in airways colonization with Burkholderia cenocepacia than in colonization with Pseudomonas aeruginosa.

Abstract: Churg-Strauss syndrome (CSS) is a rare systemic disease, characterized by bronchial asthma, hypereosinophilia, and necrotizing vasculitis of small- and medium-size vessels with extravascular eosinophilic granulommas. While, in most cases, it is the lung, peripheral nervous system, and skin, which become affected, involvement of the heart, gastrointestinal system, kidneys, and the central nervous system is associated with a very poor prognosis. The onset of vasculitis is usually preceded by bronchial asthma by several years. This case report describes the course of hospitalization of a 37-year-old patient, admitted for symptoms of myocarditis rapidly developing into severe heart failure. Based on other symptoms and examinations, CSS was diagnosed four days after hospital admission; despite aggressive therapy, heart failure worsened progressively to cardiogenic shock. Multiorgan failure developed, caused at least partly by specific-organ vasculitis. Despite aggressive management of systemic disease and its organ complication, the patient died on day 7 post-hospitalization from refractory shock and multiorgan failure. This case report presents CSS as a rare but serious disease, which has to be considered in patints with a history of asthma, myocarditis, and hypereosinophilia.

Abstract: Stenotrophomonas maltophilia is an important pathogen in intensive care units and dpts of anaesthesiology and resuscitation. It may be the cause of serious nosocomial infections. In recent years this pathogen has been more and more frequently isolated in the sputum of patients presenting with cystic fibrosis. The reason could be the use of anti-pseudomonal antibiotics, in the first place beta-lactam antibiotics and aminoglycosides, as Stenotrophomonas maltophilia tends to be resistant to these antibiotics. In cystic fibrosis patients the bacterium is mostly found only once or there may be intermitent colonization - chronic colonization occurs only in some 10% of cases. So far, the impact of Stenotrophomonas maltohpilia colonization on the course of cystic fibrosis is not quite clear. Neither a more rapid decrease of pulmonary function nor an effect on survival have been demonstrated. Treatment is only recommended should there be a deterioration of the clinical condition without any apparent reason. Cystic fibrosis patients colonized with Stenotrophomonas maltophilia have to be isolated from patients without cystic fibrosis, who are on immunosuppression or use plastic aids, e.g. cannulae, drains etc. The authors present their own experience with this pathogen in patients presenting with cystic fibrosis treated in adult ward of the CF centre in Prague.

Abstract: Background. Patients with cystic fibrosis are at risk of development of bone disease. In this paper we evaluate relationship between bone mineral density and routinely monitored clinical parameters. Methods and Results. We retrospectively evaluated relationships between bone mineral density and nutritional status, pulmonary function and bacterial colonization of airways in 50 adults with cystic fibrosis (26 females and 24 males, aged 24.9±3.9 years), relationships between lumbar spine bone mineral density and inflammatory markers in stable disease were evaluated in subgroup of 39 patients (21 females and 18 males, aged 24.6±3.6 years). Prevalence of bone disease reached 36%. We found significant correlation between bone mineral density (T-score) and nutritional status (body mass index, p=0.0015) and concentration of C-reactive protein (p=0.0091). Pulmonary function tends to correlate with bone mineral density (forced expiratory volume in 1 sec. % predicted, p=0.0552). We did not reveal any significant correlation between bone mineral density and bacterial colonization of airway and further inflammatory markers (neutrophil cell count and concentration of immunoglobulin G). Conclusion. Among routinely monitored clinical parameters in adults with cystic fibrosis, worse nutritional status, worse pulmonary function and prominent systemic inflammatory response to bronchopulmonary infection expressed as concentration of C-reactive protein, give evidence for risk of development of bone disease.

Abstract: Pneumonias remain a serious health problem in the Czech Republic. Their incidence is assessed as 1000/100.000 with a mortality of 10-20%. The general public and sometimes even professionals tend to consider pneumonias as a banal, easily treated diseases. In a group of 226 patients diagnosed always in the period January to April over a period of three years (199-2001) we carried out a retrospective evaluation and defined risk factors of the incidence, the approach to diagnosis, treatment and their results. 80% of the patients had some associated disease (or diseases), 38% were smokers. Before admission to hospital 70% had temperatures over 37.5°C. Only 15% were free of cough, 11% reported haemoptysis. In 11% of the subjects the course of pneumonia was complicated by an exudate, in 31% of the subjects we performed bronchoscopy, which in 10% of them revealed a tumour. The patogen was estabilished in 54% of the cases, most frequent were Gram-negative pathogens. Streptococcus pneumoniae was found as the mein etiological agent in 11.5% and Mycoplasma pneumoniae in 19% of the patients. 22 subjects died, of these half presented other serious diseases. The results are in line with data in international and domestic literature; we did not confirm a predominance of streptococcal pneumonias. It would seem that now there are increasingly more pneumonias caused by Mycoplasma and Chlamydia.

Abstract: BACKGROUND: Benign stenoses of main respiratory pathways develop usually in patients after intubation or tracheostomy. Incidence of such states is not known, they are frequently diagnosed too late, and there are different views of their treatment. In order to contribute to the improvement of our knowledge of this serious impairment we followed prospectively all patients with this diagnose at our department since March 1998. METHODS AND RESULTS: The group of 31 patients with benign stenoses of non-tumorous origin diagnosed and treated at the TRN of the Teaching Hospital Motol in years 1998 to 2000 consisted of 24 males and 7 females, age median was 52 years. Stenosis was caused in 27 patients by intubation, in 4 patients by some other causes. At admission we performed in 30 patients electrocauterization and dilatation of stenosis, one patient was immediately indicated for surgery. Beside two cases we always achieved sufficient patency of stenosis and weighted indication to surgery. We sent for surgery 15 patients, 10 patients were permanently healed using methods of interventional bronchoscopy, including introduction of stent in 6 cases. From the remaining 6 patients, two of them are planned for resection of stenosis, four are inoperable from various reasons, and two died of causes not related to stenosis. CONCLUSIONS: Based on our experience we recommend as an optimal management of such patients is the dilatation or removal of stenosis and then always to consider resection of trachea. In inoperable cases methods of interventional bronchoscopy should be used. Authors recommend sending all patients intubated longer than 2 days for bronchoscopic examination in interval of 2 months.

Abstract: Authors present contemporary knowledge of amyloidosis of the respiratory system. They give an overview of etiopathogenesis, clinical findings, diagnostics and therapeutic possibilities of the particular forms of amyloidosis of the respiratory tract.

Abstract: Authors describe the present situation concerning the incidence, diagnostics and treatment of patients with pleural effusion. In the groups of these patients hospitalised in the pulmonary department there was 63 affected. The most frequent diagnosis was lung cancer (25), other malignancies (15), pneumonia (10), TB (3) and state after pericardectomy (3). In this article are discused other aspects of care about patients with malignant and paramalignant effusion in patients with lung and breast cancer including the results of pleurodesis. The results are very similar to those described with the first author 10 years ago. The most frequent types of effusions in the pulmonary department are still the malignant and paramalignant ones.

Abstract: