Vol 25, No 9 (2023): Otorhinolaryngology and pulmonology
Articles
Features of clinical manifestations and diagnosis of comorbidity of disseminated pulmonary tuberculosis, coronavirus, pneumocystis and pneumococcal pneumonia in patients with late stages of HIV infection with immunodeficiency
Abstract
Aim. To study the features of clinical manifestations and diagnosis of comorbidity of disseminated pulmonary tuberculosis, coronavirus, pneumocystis and pneumococcal pneumonia in patients with late stages of HIV infection with immunodeficiency.
Materials and methods. The prospective study included 120 newly identified patients with disseminated pulmonary tuberculosis with Mycobacterium tuberculosis, stage IVB of HIV infection, in the phase of progression and in the absence of antiretroviral therapy, aged 29–53 years, who were randomized into 1A and 2A main groups and 1B and 2B comparison groups. Group 1A included 29 patients with comorbidity and pneumocystis pneumonia and group 2A – 31 patients with comorbidity of disseminated pulmonary tuberculosis, coronovirus pneumococcal pneumonia, and group 1B and 2B comprised 29 and 31 similar patients, but without coronovirus pneumonia. To diagnose coronavirus pneumonia, PCR of SARS-CoV-2 RNA was used in smears from the nasopharynx and oropharynx, in sputum or in endotracheal aspirate. To detect Pneumocystis jirovecii, the causative agent of pneumocystis pneumonia, a microscopic examination of diagnostic material from the respiratory tract with Romanovsky–Giemse and Grokott–Gömöri coloration was carried out, and to detect Streptococcus pneumoniae, the causative agent of pneumococcal pneumonia, the diagnostic material was seeded on special nutrient media with determination of the drug resistance of the resulting culture to broad-spectrum antibiotics. Statistical data processing was carried out using the Microsoft Office Excel 2019 program with the calculation of the average in the group and the standard error of the average, confidence interval.
Results. The comorbidity of disseminated pulmonary tuberculosis, coronavirus, pneumocystis and pneumococcal pneumonia in patients in the late stages of HIV infection, in the phase of progression and in the absence of antiretroviral therapy was characterized by severe immunodeficiency, generalization of tuberculosis with multiple extrapulmonary lesions and severe pneumonia. This determines the similarity of clinical manifestations and respiratory symptoms, and also makes it difficult to visualize computed tomographic changes consisting of a complex simultaneous combination of four pathological syndromes: dissemination, pleural pathology, increased pulmonary pattern and adenopathy. Simultaneous layering of several pathologies with the same type of clinical manifestations and computed tomographic changes requires a comprehensive etiological diagnosis of specific diseases to prescribe timely comprehensive treatment and reduce the lethality of this heavy contingent of patients.
Conclusion. Patients with disseminated pulmonary tuberculosis and HIV infection who are registered in the office of tuberculosis care for HIV-infected in the tuberculosis dispensary represent a high risk group of COVID-19 infection and the development of coronavirus pneumonia, and with severe immunodeficiency, pneumocystis and pneumococcal pneumonia, should be regularly subjected to preventive studies for timely detection of COVID-19, coronavirus, pneumocystis and pneumococcal pneumonia for the purpose of their emergency isolation and timely treatment.
551-557
Clinical features of the course of tuberculous meningitis in HIV-infected patients
Abstract
Background. Central nervous system tuberculosis is one of the most severe forms of extrapulmonary tuberculosis, which is due to an unfavorable clinical course, a high incidence of neurological complications and deaths. Despite this, the problem of early diagnosis is still not solved.
Aim. To study the clinical and laboratory-instrumental features of the early diagnosis of tuberculous meningitis in HIV-infected patients.
Materials and methods. A retrospective analysis of 31 case histories of patients with tuberculous lesions of the meninges and central nervous system in the late stages of HIV infection who were treated at the Clinical Tuberculosis Dispensary of Krasnodar Territory in 2020–2022 was carried out. The data of clinical manifestations of the disease, the results of laboratory and instrumental methods of examination were analyzed. Statistical data processing was performed by Microsoft Office Excel 2021 with the calculation of averages, standard deviation.
Results. Tuberculous lesions of the meninges and the central nervous system among HIV-infected people were more common in men of working age who were not previously registered in a tuberculosis dispensary. All HIV-infected patients had late stages of HIV infection with severe immunodeficiency: the content of CD4+ lymphocytes less than 100 cells was detected in 45.46%; from 100 to 200 cells/µl of CD4+ lymphocytes were recorded in 36.36%, more than 200 cells/µl in 18.18%. Also, in all the studied patients, the primary focus was established in the form of tuberculosis of the respiratory organs, represented in 56.52% of cases by disseminated pulmonary tuberculosis. More than 70% had generalized tuberculosis with damage to the kidneys, spleen, and peripheral lymph nodes. A feature of the manifestation of tuberculous meningitis in HIV-infected people can be considered a high frequency of acute increase in neurological symptoms. Of the cerebral manifestations, the most common were: headache, dizziness, photophobia. 13.04% of HIV-infected patients complained of nausea and vomiting. 91.30% showed signs of damage to the substance of the brain, represented by mono-, hemiparesis and damage to the cranial nerves, mainly III–IV, VI, VII pairs. The composition of CSF in HIV-positive patients revealed the presence of mild pleocytosis (up to 100 cells/µl) in 56.52% of cases. The nature of the change in the concentration of proteins, chlorides and glucose is nonspecific.
Conclusions. The study revealed the features of medical and social characteristics, clinical and laboratory and instrumental picture of tuberculous meningitis in HIV-infected patients and without HIV infection.
558-564
Comparative analysis of methods for creating virtual three-dimensional models of the lungs from computed tomography images in the practice of a tuberculosis organization using Materialise software
Abstract
Background. One of the important conditions for the final victory over tuberculosis is not only the prevention of its development and early detection, but also the provision of high-quality personalized medical care to the patient. Additive technologies and virtualization technologies are ways to fully reveal this principle in phthisiatric practice.
Aim. Demonstrate the possibilities and evaluate the labor costs (time spent on virtualization and the size of the final digital files of models) while working with the Mimics inPrint 2.0.0.159 and Mimics Medical 21.0.0.406 software systems in the aspect of virtual reconstruction of the lungs of a patient with a destructive form of tuberculosis.
Materials and methods. A comparative analysis of methods for creating virtual three-dimensional models of the lungs from CT images was carried out at the Nizhny Novgorod Regional Clinical Tuberculosis Dispensary. The study involved one patient with a destructive form of tuberculosis of the upper lobe of the left lung. Virtual three-dimensional models were made according to a specially developed algorithm. The time spent for the formation of virtual lung models was analyzed using the built-in function in the "Log" software. The analysis of the size of the obtained virtual lung models in the STL format was carried out using the operating system function from the Windows family "Properties", section "General", subsection "Size".
Results. The most practical software package for virtual lung reconstructions turned out to be Mimics inPrint 2.0.0.159 with the result of the time spent on creating a model of 2 minutes (Mimics Medical 21.0.0.406 – 7 minutes 17 seconds) and a model size of 125 megabytes (Mimics Medical 21.0.0.406 – 26.1 megabyte). The technical nuances and algorithms of lung reconstruction covered in the article using the Mimics inPrint 2.0.0.159 and Mimics Medical 21.0.0.406 software packages will allow the interested person not to make a mistake in realizing their scientific and practical interests in the process of providing personalized care to the patient. The article focuses on the main advantages of the Mimics inPrint 2.0.0.159 software package in comparison with Mimics Medical 21.0.0.406. A brief description of similar programs is given.
Conclusion. The studied software systems successfully coped with the goal assigned to them, which concerned the demonstration of their capabilities and the assessment of labor costs for virtualization. Mimics inPrint 2.0.0.159 turned out to be the most understandable and promising software and application complex for use in everyday clinical practice.
565-572
Experience in using Aterixen® in clinical practice. Results of the "SUPRA" observation program
Abstract
Background. The new medical product Aterixen® (XC221GI) has appeared on the pharmaceutical market in 2022. It was revealed, at preclinical stage, that the main anti-inflammatory drug's effect was assured by its effect on production of anti-inflammatory cytokines IL-6, IL-8 and chemokines IP-10 (CXCL10), MIG (CXCL9). The results of double-blind randomized placebo-controlled studies have shown high efficacy of the drug in the management of patients with new coronavirus infection (COVID-19) of different severity.
Aim. To evaluate experience of Atherixen® practical use among physicians and general practitioners.
Materials and methods. The observational program included patients aged from 18 to 60 years with confirmed diagnosis of mild COVID-19. All patients have signed voluntary informed consent to participate in the study. The study consisted of 2 periods: screening period and drug administration period. All patients received Aterixen® (100 mg tablets), 1 tablet 2 times per day for 14 days within the standard therapy outlined in the Temporary methodological recommendations on prevention, diagnosis, and treatment of COVID-19. Efficacy was assessed by mean disease duration and physician and patient treatment satisfaction via five-point Likert scale.
Results. The average disease duration did not exceed 9.5 days. It indicates the ability of Aterixen® to prevent the transition of the disease to moderate and severe forms. The degree of physician and patient treatment satisfaction via five-point Likert scale in the vast majority of cases corresponded to the highest grades. Moreover, no adverse events were reported during the study and all patients had high tolerability.
573-576
Community-acquired pneumonia: antibiotic therapy approach after the COVID-19 pandemic. A review
Abstract
Pneumonia is clearly differentiated from other focal inflammatory lung diseases of non-infectious origin. A patient with community-acquired pneumonia (CAP) should receive antibacterial drugs no later than 4 hours after the diagnosis. Initial antibacterial therapy in CAP should be based on factors affecting the potential causative agents and the risk of drug-resistant microorganisms. Rational use of amoxicillin in terms of dose and frequency in CAP patients without severe comorbidities and risk factors for PES pathogens, the use of β-lactam in combination with a macrolide or moxifloxacin monotherapy in high-risk groups of patients is the most effective strategy of empirical antibacterial therapy.
581-588
Differentiated approach to diagnosis and treatment to combined pathology of the pharynx, larynx and rhino-orbital zone: interdisciplinary interaction
Abstract
Background. The main complaint of patients with inflammatory diseases of the pharynx is a sore throat; rhino-orbital pathology, in turn, is manifested by symptoms associated with impaired nasal breathing, lacrimal drainage and other ophthalmological disorders. With pathology of the larynx, dysphonia is often present. As a rule, such patients initially fall into the hands of general practitioners, therapists and pediatricians, less often otolaryngologists, however, periodically the clinical situation requires the involvement of other specialists and additional laboratory and instrumental studies. The article presents a number of clinical observations of patients with combined pathology of the pharynx, larynx and rhino-orbital zone, who initially turned to an otolaryngologist, who subsequently required a team approach from various specialists.
Aim. Demonstration of a differentiated approach to the diagnosis and treatment of combined pathology of the pharynx, larynx and rhino-orbital zone within the framework of interdisciplinary interaction of specialists based on clinical observations of patients.
Materials and methods. We observed 5 patients who initially sought consultation with an otorhinolaryngologist with complaints of pain or discomfort in the throat, impaired nasal breathing, lacrimal drainage, itching in the eye area, and dysphonia.
Results. The article presents clinical cases of syphilis, leptotrichosis of the oropharynx, herpesvirus infection type VI, infectious mononucleosis, infectious-toxic paresis of the larynx, the diagnosis and treatment of which was carried out through interdisciplinary interaction of otorhinolaryngologists with doctors of other specialties. The presented observations demonstrate that, despite the reason for treatment, patients with combined pathology of the pharynx, larynx and rhino-orbital zone require the help of not only otolaryngologists, but also other specialists, primarily infectious disease specialists.
Conclusion. In order to improve the quality of diagnosis, routing and treatment of patients with combined pathology of the pharynx and rhino-orbital zone, it is necessary to develop interdisciplinary interaction and create conditions for expanding the professional erudition of doctors dealing with the problems of pathology of the same anatomical areas.
589-595
Therapy of tonsillopharyngitis: advantages of an integrated approach. A review
Abstract
The problem of pain in the pharynx continues to be the focus of attention of scientists and practitioners for many decades. Despite the emergence of modern methods of diagnosis and treatment, the problem of pharyngoalgia is far from being solved. It has now been established that more than 500 possible etiological factors can be the cause of pharyngoalgia, but the leading place is occupied by inflammatory diseases of the pharynx and palatine tonsils. Taking into account the wide distribution of this nosology among the population and the high risk of complications, especially in childhood, the issues related to the search for effective therapeutic regimens and ways to prevent the development of complications are still relevant. Definitely, the treatment should be safe, comprehensive, justified and individually selected in each case. Adequate therapy started in time allows avoiding the development of adverse effects, reducing the treatment time and improving the patient's quality of life. And for a doctor, it is extremely important to know the differences in the clinical picture of pharyngoalgia caused by different types of microorganisms: bacteria, viruses or fungal flora, since these differences will be decisive in the further tactics of treating the patient. This article is devoted to highlighting the issues of the complex use of the lysine salt of ketoprofen in local and systemic form. The parameters of the analgesic and anti-inflammatory action of the lysine salt of ketoprofen are characterized, and a new scheme for the treatment of inflammatory diseases of the pharynx within a single molecule is proposed. The article also pays attention to the prevention of complications and relapses, and discusses the advantages of the drug pidotimod in immunomodulatory therapy.
596-602
Monoclonal antibody therapy for COVID-19 during pregnancy
Abstract
Aim. Pregnancy worsens COVID-19 and has been listed by the US Food and Drug Administration as a high risk factor for complicating COVID-19. The severe course of a new coronavirus infection in some pregnant patients has created the prerequisites for the search for treatment methods that can reduce the likelihood of adverse outcomes. One of these therapy options is treatment with virus-neutralizing antibodies – monoclonal antibodies. Experience with the use of monoclonal antibodies for the treatment of pregnant women is very limited, but in 2021 pregnancy was recognized as a high risk factor for the course of a new coronavirus infection, making it possible to use this group of drugs.
Materials and methods. We described the experience of COVID-19 monoclonal antibody therapy during pregnancy in the Republic of Tatarstan. A retrospective analysis of 18 case histories of pregnant patients with mild and moderate course of confirmed coronavirus infection, treated with monoclonal antibodies (casirivimab/imdevimab) from March 2022 to June 2022, was carried out on the basis of the Perinatal Center of the Republican Clinical Hospital, Kazan, Republic of Tatarstan.
Results. All patients tolerated the administration of casirivimab/imdevimab satisfactorily; no adverse drug reactions were identified. Subjective improvement was observed on the 3rd day of MCA treatment. Delivery through the natural birth canal was carried out on time in 11 women; by caesarean section on time – in 5 patients. A follow-up study of children born to 18 patients who had COVID-19 was collected. The age of the children at the time of information collection ranged from 10 months – 1 year 1 month. Currently, all children are healthy and developing according to their age.
Conclusion. In all pregnant patients with a new coronavirus infection with mild to moderate course, the administration of casirivimab/imdevimab was an effective method of treating the new coronavirus infection. The follow-up of children born from 18 patients was followed: the children’s condition was satisfactory, their development corresponded to their age.
577-580
Exacerbation of chronic obstructive pulmonary disease: discussion of controversies. A review
Abstract
The paper discusses the controversial issues of infectious exacerbation of chronic obstructive pulmonary disease. Researchers and practitioners share a common understanding of rational patient management, which involves the evolution of exacerbation terminology, the impact of viral infection and air pollutants, the significance of biomarkers, and the appropriate antibiotic therapy regimens. Clinical reflections on the current causes of chronic obstructive pulmonary disease exacerbations and modern therapeutic options are presented.
603-610
Mucoactive therapy in community-acquired pneumonia
Abstract
Aim. To study the clinical efficacy of Bronchipret® syrup compared with the standard (real-world practice) mucoactive therapy for patients with viral pneumonia.
Materials and methods. The observation study included patients 18–70 years old who presented with productive cough and were admitted to the pulmonology department with medically confirmed community-acquired pneumonia (CAP). The study included 60 patients; Group 1 included 30 patients who received Bronchipret® syrup 5.4 mL 3 times a day for up to 10–14 days. The other 30 patients with CAP were included in Group 2 (control), in which other mucoactive drugs were used at the discretion of the physician: acetylcysteine in 56.7% of patients, ambroxol in 30%, and bromhexine in 13.3%. The duration of therapy was established by a physician for a period of 10–14 days.
Results. A significant decrease in sputum secretion was observed during treatment with Bronchipret® (Group 1) on average on day 4 (after 4.3±1.2 days) and after 4.5±0.9 days in group 2. A decrease in the severity of daytime cough in Group 1 was observed after 4.9±1.2 days vs. 5.1±1.1 days in Group 2. The nocturnal cough stopped in 2.7±1.3 days in Group 1 and 2.6±0.9 days in Group 2.
Conclusion. The data support the use of combined products containing ivy and thyme in patients with CAP and mucolytics.
611-615
Modern concepts of antimicrobial therapy regimens for exacerbation of chronic obstructive pulmonary disease: A review
Abstract
The publication discusses modern antimicrobial therapy regimens in patients with exacerbation of chronic obstructive pain. Lung diseases from the perspective of the updated version of national recommendations. Indications for prescribing antibiotics, etiological exacerbation risk factors, risk factors for encountering microorganisms with antibiotic resistance mechanisms, selection algorithm antimicrobial drug.
616-621
Rational mucolytic therapy with ambroxol: controversial and indisputable. A review
Abstract
Many years of experience in the use of ambroxol is based on its ability to regulate the basic mechanisms of physiological production and transport of bronchial mucus. The main indication for ambroxol is the mucolytic therapy of acute and chronic bronchopulmonary diseases associated with hypersecretion and impaired mucus transport. Ambroxol has a number of the following properties: high secretolytic activity (promotes mucus clearance, facilitates expectoration of sputum, reduces productive cough); anti-inflammatory and antioxidant activity; local analgesic (anesthetic) effect through the blockade of sodium channels of cell membranes. The effect of anesthesia of the mucous membranes is attributed to the new pharmacological action of ambroxol, useful in the treatment of acute respiratory tract infections. The efficacy and safety of ambroxol in clinical practice has been confirmed by half a century of experience in its administration. The purpose of this publication was an up-to-date assessment of the controversial and indisputable chemical, pharmacological, clinical data on the properties of ambroxol in the concept of modern “recovery mucolytic therapy” that can improve the therapy and prognosis of patients with tracheobronchial secretion hypersecretion, impaired mucociliary clearance and unproductive cough.
623-628
Functional and organic dysphonia in voice professionals (lecture)
Abstract
An urgent task of otorhinolaryngology (phoniatry) is the diagnosis and treatment of disorders of voice function in voice professionals or persons of voice-speech professions. An undiagnosed laryngeal disease worsens the quality of life of patients, creates difficulties in communication and can even lead to professional unfitness, because the patient does not withstand the necessary vocal load. The leading role in the modern diagnosis of laryngeal diseases belongs to endoscopic research methods – video endoscopy and video endostroboscopy. All disorders of voice function are classified as functional and organic. Recent studies have shown that from 30.5 to 40% of voice professionals who have applied for phoniatric care suffer from functional disorders. Functional changes are understood to mean changes in which laryngoscopic examination does not always reveal any visible pathology. But with the help of special research methods, such as stroboscopy (videostroboscopy), spectral analysis of the voice, pathognomonic changes can be determined, and the patient presents characteristic complaints. More often than others, hypotonic and hypo-hypertonic dysphonia are diagnosed. Organic laryngeal diseases are characteristic of 69.5% of patients with dysphonia. They are represented by various nosological forms. Certain difficulties arise in the diagnosis of professional laryngitis and vascular pathology of the larynx. The lecture presents pathognomonic clinical changes of the larynx in voice professionals, knowledge of which is necessary for practical doctors to make a diagnosis.
629-635
Radical surgery on the middle ear in the treatment of cholesteatoma: history or reality? A review
Abstract
Radical surgery on the middle ear is primarily associated with such pathology as cholesteatoma and ear neoplasms. And if in the case of tumors radicalism in ear surgery is justified, then in the surgery of the cholesteatomic process there is a need to discuss this issue. The existence of acquired cholesteatoma was recognized more than three centuries ago. Without timely detection and intervention, cholesteatomas can increase to gigantic sizes and lead to numerous intracranial and extracranial complications. Due to its aggressive growth, invasive nature and potentially fatal consequences of intracranial complications, acquired cholesteatoma remains the cause of morbidity and death in those who do not have access to advanced medical care. Currently, there are no effective non-surgical methods of treatment. The article provides a brief overview of the main issues related to acquired middle ear cholesteatoma, and discusses the practical
637-641
Microsurgery of chronic laryngeal diseases using fiber optic lasers. A review
Abstract
Background. The treatment of chronic diseases of the larynx is an urgent issue. Chronic larynx masses account for up to 55–70% of the upper respiratory tract proliferative diseases. The incidence of vocal apparatus disorders is stable due to increased load on the vocal apparatus, neuro-emotional stress, non-compliance with voice hygiene (smoking, alcohol consumption), nasal and pharyngeal inflammatory diseases, sensibilization, and gastrointestinal disorders. Dysphonia, voice timbre changes, and vocal fatigue are presented in 7–12% of otorhinolaryngologist patients. Delayed treatment of chronic larynx diseases can lead to upper respiratory obstruction, reduced exercise and self-care tolerance, and disablement in people with voice and speech professions.
Aim. To address current treatment methods for chronic diseases of the larynx. Modern surgical and non-surgical treatments of chronic larynx diseases aim to restore voice quality and respiratory function. Over the past 50 years, laser-assisted phonosurgery has gained popularity due to the many benefits of biological tissue exposure to electromagnetic energy and low rates of intra- and postoperative complications.
Materials and methods. The literature review was performed using electronic medical libraries and professional printed papers. According to local and foreign data, laryngeal laser surgery is highly precise, minimally invasive, associated with no blood loss, and highly effective. Historically, CO2 laser has been used for the longest time in laryngeal surgery. Modern medical technology has recently introduced surgical systems with novel technicalities for clinical use. In such devices, the laser energy is transmitted through a flexible optical fiber instead of a mirror system, as in the CO2 laser, which has made new surgical high-energy systems more affordable for equipping medical institutions. Currently, the following fiber-optic laser systems are most often used to treat chronic diseases of the larynx: potassium-titanyl-phosphate, diode laser, and "blue" laser with a wavelength of 445 nm.
Results. The literature review and analysis of surgical treatment outcomes using fiber-optic laser devices in patients with chronic larynx diseases showed high safety and effectiveness of modern treatments, providing fast recovery of voice and respiratory function.
Conclusion. The development of laser devices, including domestic ones, with new wavelengths, makes it possible to work in contact mode in an inert gas environment, which opens up new opportunities for phonosurgery.
642-647
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