Acute Eosinophilic Pneumonia (AEP) Caused by Clomipramine

Acute Eosinophilic Pneumonia (AEP) Caused by Clomipramine Clomipramine-induced acute eosinophilic pneumonia-like syndrome leading to acute respiratory failure: a report of first described case Drugs are well-known causes of eosinophilic lung disease and patients with drug-induced eosinophilic lung disease can have variable clinical presentations. Clinical features may range from asymptomatic eosinophilic infiltrates to acute eosinophilic pneumonia (AEP)-like syndrome leading to acute respiratory failure. This report describes the first case of clomipramine-induced AEP-like syndrome causing acute hypoxemic respiratory failure which was treated successfully. In conclusion, considering the increasing use of tricyclic antidepressants, physicians should be aware of this very rare and life-threatening complication of clomipramine. KeyWords: Clomipramine, acute eosinophilic pneumonia-like syndrome, treatment INTRODUCTION Many drugs have been associated with pulmonary complications of various types with an increasing number of the therapeutics. Respiratory system is a target for a variety of drugs because of its large contact surface and acting as a metabolism site for drugs. The patterns observed in drug-induced pulmonary toxicity are highly variable and depend on the localization of adverse reaction. Since most of the drug-induced pulmonary toxicities involve the lung parenchyma, the most common form of drug-induced lung toxicity is interstitial lung disease (1). Drugs theoretically can produce all histopathological patterns of interstitial lung disease, including hypersensitivity pneumonitis, organizing pneumonia, bronchiolitis obliterans organizing pneumonia, acute respiratory distress syndrome, granulomatous pneumonitis, and eosinophilic lung disease (2). More than 350 drugs are known to cause acute eosinophilic pneumonia (AEP)-like syndrome (3, 4). However pulmonary complications related to tricyclic antidepressants are uncommon. To our knowledge, only one case of AEP associated with the usage of clomipramine has been reported in PubMed in 1999, and in the aforementioned case clomipramine had been used not alone but with sertraline (5). This report describes the first and successfully treated severe case of AEP-like syndrome associated with clomipramine treatment alone. Written informed consent of the participant patient was obtained for the publication of this case report and any accompanying images. CASE REPORT A 38-year-old female was referred to our clinic from psychiatry department of another hospital. She had been newly diagnosed with panic attack and anxiety disorder one week prior to the appearance of respiratory symptoms. After admission to psychiatry polyclinic, clomipramine therapy was prescribed at a dose of 75 mg/day. After 6 days of clomipramine therapy, the patient exhibited dyspnea, increasing shortness of breath, dry cough, chest pain, and fever up to 39.20C. She was a housewife and had no work-life history. There was no past history of a chronic disease and her smoking history was 16 packs/year. She had never consumed illicit drugs, had no allergies, and had not visited a foreign country during the previous 5 years. On admission, the patient was in a respiratory distress, with a respiratory rate of 35 breaths/minute, a blood pressure of 110/70 mmHg, and a heart rate of about 140 beats/minute with sinus tachycardia. Examination of blood samples revealed only anemia (haemoglobin:9.4 g/dl). Number of leukocytes, thrombocytes, and results of blood chemistry were within normal limits. Erythrocyte sedimentation rate was 40 mm/h and serum level of C-reactive protein was 4.5 mg/dl. Measurement of arterial blood gas analysis on room air revealed pH: 7.44, PaCO2: 32 mmHg, PaO2: 49 mmHg, HCO3: 27 mmol/L and SaO2: 86% which was compatible with hypoxemic respiratory failure. Laboratory results including HIV testing, serological screening for vasculitis [autoantibodies to deoxyribonucleic acid (DNA), double stranded DNA, proteinase-3, myeloperoxidase, rheumatoid factor, and circulating immune complexes] and various pulmonary pathogens were negative. Stool tests for ova and pulmonary parasites were normal. The level of total serum immunoglobulin E (Ig E) was within normal limits (65 IU/ml) and antigen-spesific Ig E against Aspergillus fumigatus and Candida was negative. Her chest radiograph revealed a homogenous dense shadow located especially in the lower field of the right lung and some additional reticular opasities in the lower zone of the left lung (Figure 1). Computerized Tomography (CT) (Brilliance; Philips Medical System, Eindhoven, The Netherlands) of the thorax demonstrated patchy areas of ground-glass, thickened interlobular septae and homogenous consolidations with air-bronchograms especially in the middle and lower zones of the right lung (Figure 2). The patient was admitted to the intensive care unit because of the need for non-invasive mechanical ventilation. She underwent bronchoscopy (Aquilion; Toshiba, Tokyo, Japan) with bronchoalveolar lavage (BAL). During the bronchoscopy procedure the bronchi appeared inflamed and contained increased secretions. Gram stain and cultures of the bronchial washings did not reveal any infectious organism. Total cell count on BAL was 182 cells/mL with 30% eosinophils, 8% neutrophils, 55% macrophages, and 7% lymphocytes. Special stains and cultures for mycobacteria, Pneumocystis jiroveci, fungi, Legionella pneumophila were negative. Serology testing for cold agglutinins were negative. Intravenous methylprednisolone 60 mg/day (1 mg/kg/day) was initiated on admission. Then dose of the methylprednisolone was gradually tapered and methylprednisolone was discontinued after 4 weeks. The chest radiograph of the patient cleared markedly within 15 days of the treatment (Figure 3). The patient was discharged 18 days after admission. Follow-up examinations one and four weeks after discharge revealed normal laboratory results and a normal chest radiograph. Pulmonary function tests 3 months after admission showed no ventilatory defect. Last contact with her was a polyclinic visit for control one year after discharge and she was free of respiratory symptoms. DISCUSSION The eosinophilic lung diseases are a heterogeneous group of pulmonary disorders characterized by increased numbers of eosinophils in the airway or lung parenchyma, and drugs are well known causes of eosinophilic lung disease (6). Patients with drug-induced eosinophilic lung disease can have variable presentations, ranging from asymptomatic transient eosinophilic infiltrates to AEP-like syndrome leading to acute respiratory failure, depending on the drug involved. AEP is described as a clinical entity which involves acute onset of symptoms within ≠¤5-7 days, fever ≠¥37.20C, hypoxemia, bilateral alveolar or mixed alveolar and interstitial infiltrates, and lung eosinophilia (percentage of eosinophils ≠¥25% in BAL and/or predominance of eosinophils in open lung biopsy). In addition, without any history of hypersensitivity to drugs, no evidence of infection, and no other known cause of eosinophilic lung disease (7, 8). Similarly, patient in this case had newly onset respiratory symptoms, fever and mixed alveolar and interstitial infiltrates suggesting an interstitial lung disease. In addition, a bronchoscopy with BAL revealed presence of importantly increased percentage of eosinophils (30%) in the lavage fluid. Based on the results of BAL, radiological features and her clinical course, she was diagnosed as potentially having an AEP-like syndrome related to clomipramine. Unlike patients with other eosinophilic lung diseases, most of the patients with AEP have normal peripheral blood eosinophil count (8). The level of total serum IgE can be elevated, however it is not used as a diagnostic tool (9). In this case, the patient had both normal peripheral blood eosinophil count and normal level of total serum Ig E. The diagnosis can easily be obtained with BAL and lung biopsy is not an obligation for the diagnosis of AEP in most cases. If needed, the purpose of lung biopsy is to exclude other diseases that can mimic AEP. When lung biopsy is performed, the histopathological features are characterized by diffuse alveolar damage with interstitial and alveolar eosinophils (10). There was no need for lung biopsy in this case and diagnosis could be established with the help of BAL cell count. In some cases discontinuation of the drug is enough for resolution of the radiological features. However, some patients experience a severe disease and require corticosteroid treatment. Generally, response to corticosteroids is rapid and most of the patients have significant clinical improvement within 24 to 48 hours. The optimal dose and duration of corticosteroids have not been determined exactly (8, 10). Commonly used doses of intravenous methylprednisolone in case series range from 60 to 1000 mg per day until respiratory failure resolves. Thereafter, the patient can be switched to oral prednisone, and the steroids can be tapered off over 2 to 12 weeks. In this case, 60 mg/day intravenous methylprednisolone was administered on admission and dose of the corticosteroid was regulated according to resolution of radiological findings. Corticosteroid treatment was terminated after 4 weeks. In conclusion, physicians should be aware of rare, life-threatening and treatable AEP-like syndrome because of clomipramine.

Brother of Sleep

Brother of Sleep is presented in a very romantic and musical style. It focuses on Elias who was born a musical genius. He does not only have a musical talent but also has an unbelievable gift to see and feel things beyond the usual. This makes him very strange in the eyes of the townspeople. He grows up with his friend Peter and his sister Elsbeth. At the beginning the main character appears to be enjoying his gift of music. However, as he grows older and understands his environment more, he starts to become trapped in an inescapable life. He was caught between his emotions and his calling for music.His musical gift has prevented him to follow his heart which terribly longs for the love of Elsbeth. Although Elsbeth also loved Elias, things got twisted and she marries another man. In the movie, it was portrayed that Elias knew beforehand that Elsbeth was meant for another man. Despite this, Elias was still devastated with the loss of his love and he decided to kill himself. He decided not to sleep which he considers the best way to end his life. Only age 22 when he died, the main character was a victim of himself and his environment. I think that the plot of the story is unique and at the same time very rich in morals.It was a very vivid way of presenting audiences with dilemmas which normally arise in people with talents who wish to do other things that they love. It was a sort of eye-opener for many who have watched. Moreover, I think the creation of the film is very artistic because of the incorporation of music, which is very relevant to the plot, as well as the use of twists and humors in the story. Although there are some technical flaws, Brother of Sleep is a movie worth watching especially for those people who love music and who enjoy old settings. Reference: Robert Schneider. (1996). Brother of Sleep

Microsoft Outlook® User Manual Critique - 1171 Words

Microsoft Outlook ® User Manual Critique XXXX XXXX English 221 December 12, 2010 XXXX Microsoft Outlook ® User Manual Critique The objective of this paper will be to evaluate Microsoft manual for Outlook ®. According to Torkzadeh (1988), author of The Quality of User Documentation, â€Å"User documentation is an important tool for communications. It enhances the value of an application to the user and in turn, improves user satisfaction† (p. 99). When designing a manual Ganier (2007) suggests in his article, Comparative User-Focused Evaluation of User Guides, the strategy for a user manual should focus on 3 characteristics: format, structure, and its content. Ganier in his article also includes the criteria for measuring the†¦show more content†¦Practicality, the second criteria, as it applies to a user manual or an instruction, is whether or not the manual or instruction is designed and applicable to actual use. Overall, the manual is useful if the user is looking for instruction on performing a specific task. The user e-manual does a good job of explaining the various functions of the Outlook ® application. The tool bar menu items include navigation buttons which allow the user to easily move the focus of the manual back one page at a time or by clicking on the home button, to return to the first page. Simplicity is the lack of complexity, or intricacy, (Merriam-Webster’s, 2010). The Outlook ® user e-manual fulfills the definition of simplicity in its ability to reach a diverse target audience, with the ability to read and understand the content. Both basic and advanced users can utilize the search function of the manual to find instructions on the topic being searched. Basic tasks, such as creating an e-mail, or tasks for more advanced users, can easily be found in the manual. The user e-manual lacks overall efficiency as it does not give the user the ability to accomplish a task with ease and speed. The user e-manual should allow the user, no matter what their experience level with the application, to be able to access the information in the most efficient manner. The Outlook ® userShow MoreRelatedFashion Marketing17446 Words   |  70 Pagesall the classes either rulers or the group that was being ruled, had changed from time to time and in different civilisation. In the same aspect even then a focused view was with common individuals, as they also follow a firm path in the fashion outlook (Easey, 2003). Generally the changes maintained within a civilisation was because of the exhibiting the supremacy over other using clothing, but even using accessories, jewellery, hairstyles and 4 of 8 A.A.Haseebuddin Context of FashionRead MoreCase Study148348 Words   |  594 PagesInstructor’s Manual Exploring Strategy Ninth edition Gerry Johnson Richard Whittington Kevan Scholes Steve Pyle For further instructor material please visit: www.pearsoned.co.uk/mystrategylab ISBN: 978-0-273-73557-1 (printed) ISBN: 978-0-273-73552-6 (web) ï £ © Pearson Education Limited 2011 Lecturers adopting the main text are permitted to download and photocopy the manual as required. Pearson Education Limited Edinburgh Gate Harlow Essex CM20 2JE England and Associated CompaniesRead MoreTestbook Answers112756 Words   |  452 PagesScott, Financial Accounting Theory, 6th Edition Instructor’s Manual Chapter 2 Suggested Solutions to Questions and Problems 1. P.V. Ltd. Income Statement for Year 2 Accretion of discount (10% Ãâ€" 286.36) $28.64 P.V. Ltd. Balance Sheet As at Time 2 Financial Asset Cash Shareholders’ Equity $315.00 Opening balance Net income $286.36 28.64 Capital Asset Present value 0.00 $315.00 $315.00 Note that cash includes interest at 10% on opening cash balance of $150Read MoreAccounting Information System Chapter 1137115 Words   |  549 Pagesinto an in-class group activity. Students are divided up in groups, told to close their books, and given 15 minutes to: a. Think through the business processes, key decisions, and information needs issues in their group. b. Identify the external users of information and specify the information received from and sent to each of them. One group is selected to present their answers to the class. The other groups are told to challenge the group’s answers, provide alternative answers, and chip inRead MoreMarketing Mistakes and Successes175322 Words   |  702 Pages10 9 8 7 6 5 4 3 2 1 PREFACE Welcome to the 30th anniversary of Marketing Mistakes and Successes with this 11th edition. Who would have thought that interest in mistakes would be so enduring? Many of you are past users, a few even for decades. I hope you will find this new edition a worthy successor to earlier editions. I think this may even be my best book. The new Google and Starbucks cases should arouse keen student interest, and may even inspire another generationRead MoreProject Mgmt296381 Words   |  1186 Pagesvideos, Microsoft Project Video Tutorials and Web links. The trial version of Microsoft Project software is included on its own CD-ROM free with the text. Acknowledgments We would like to thank Richard Bruce, Ottawa University for updating the Test Bank and Online Quizzes; Charlie Cook, University of West Alabama for revising the PowerPoint slides; Oliver F. Lehmann for providing access to PMBOK study questions; and Mink for accuracy checking the text and Instructor’s Resource Manual contentRead MoreArticle: Performance Appraisal and Performance Management35812 Words   |  144 Pagesterm is performance appraisal (Prasad, 2005). III. Criticism of Performance Appraisal In the present era almost all the organization have some kind of employees appraisal system, though the systems are not free from critics. First dominant critique is the management framework using appraisal as an â€Å"orthodox† technique that seeks remedies the weakness and proposal of appraisals as a system to develop performance (Beach 2005). The orthodox approach argues about the purpose of performance appraisalRead MoreOrganisational Theory230255 Words   |  922 Pagespostmodernism anything new? The history Post-industrialism and the information society The virtual organization Neo-fordism, flexible specialization and post-fordism The regulation school Institutionalist school The ‘managerialist’ school The flexible firm – critique Postmodern organizations – the work of Stewart Clegg and Paul Heydebrand Conclusions 198 198 200 202 205 206 211 213 215 217 220 225 227 234 Chapter 6 Postmodernism as a philosophy: the ultimate challenge to organization theory? IntroductionRead MoreContemporary Issues in Management Accounting211377 Words   |  846 Pagesother users of accounting information often perceive changes in their information needs. Consequently, providers of accounting information within organizations respond to many of these desired changes by redesigning management accounting systems and restructuring their output. The impetus for change may also originate from outside the organization. Many scholars, consultants, and commentators on management accounting are purveyors of ideas about what accounting should be. In response, users of accountingRead MoreStrategic Human Resource Management View.Pdf Uploaded Successfully133347 Words   |  534 Pagesleads to fast response and high-quality products and services.4 Page 3 STRATEGIC HUMAN RESOURCE MANAGEMENT Section One According to Lawler, these investments will become increasingly important due to forecasts of shifts in skill needs from manual to cerebral. Contemporary management practices indicate that many leading companies have recognized the strategic importance of human resources and have adopted an investment perspective toward these resources. Further, there is greater awareness

Liberty Is The State Of Being Free Within Society - 954 Words

Liberty is the state of being free within society from oppressive restrictions imposed by authority on one s way of life, behavior, or political views. Slavery in the United States played an enormous role in building the country we all live in today. This dark part of our nation’s history affected the lives of thousands of African people who were taken from their homelands and families to be forced to work on farms and factories without pay and to be thought of as no more than farm equipment or property. Even though many of these oppressed people did not experience freedom or liberty in their lifetime, they desired it greatly and fought hard to secure a better life than theirs for the future of their children and families. The way they fought back against slavery was through slave revolts, runaway slaves, and ordinary acts of resistance. It was very ironic that while American colonists were trying to gain independence from Great Britain and establish themselves as a new nation with equal rights to all people, that they still did not consider slavery to be a crime against human rights. Especially since the colonists thought they deserved these rights that Great Britain was keeping them from. One way African slaves fought back against slavery was by revolting. The Stono Rebellion of 1739, was a slave uprising in South Carolina that led to a severe tightening of the slave code and the temporary imposition of a prohibitive tax on imported slaves. Nat Turner Rebellion was oneShow MoreRelatedBrooke Johnson. Political Ideologies . Essay 1. 2/24/17.1583 Words   |  7 Pagestoleration, limited government, equal opportunity, and a commitment to free market. There are different forms of liberalism that one may identify with, such as classical liberalism, neo-liberalism, egalitarianism, and libertarianism. Each of these forms have different consequences or interpretations of some of the characteristics of liberalism. Two really key components of liberalism shared among the subcategories are liberty and rule of law. Even though liberals share a broad set of values and preferencesRead MoreThe Importance Of Freedom On Freedom816 Words   |  4 Pagesof Government, Locke discusses how to be free is to preserve one’s self: â€Å"To be free from such force is the only security of my preservation; and reason bids me look on him, as an enemy to my preservation, who would take away that freedom which is the fence to it.† Locke explains that others become involved with preserving life in another in order to secure one’s own liberty. Thus, it is also important to preserve liberty within mankind to keep oneself free. This idea of helping another keep one’sRead MoreAnalysis of Differnt Forms of Liberty1723 Words   |  7 PagesThe concept of liberty is important to this very day. Liberty initially means to be fundamentally free within ones society from any types of oppression, either from higher authority or from having diff erent form ideologies that can be political or social. Liberty is a form of power that lets one act on their sets and values. In this paper, concept of liberty will be discussed on behalf of two philosophers, John Locke and Jean- Jacques Rousseau. Although liberty provides one to act as they pleaseRead MoreWhat Have Theorists Meant by Liberty? Essay example1589 Words   |  7 PagesLiberty is a value that each person in a democratic society takes for granted. Taking this value from us, would remove the opportunity for individuals to make their own choices in life. Liberty is not a value that is constant throughout the various societies in the world, citizens of developed Western countries could be described has having considerably more liberty when compared with many of the less developed Arab nations. Theorists have studied the concept of liberty for centuries and thereRead MoreWhat Is Liberty?1383 Words   |  6 PagesWhat is Liberty? When being purposed the question â€Å"What is liberty?† one can only delve into the many different avenues that is possible to form the answer. Each of the philosophers we studied has a different outlook on what exactly the word liberty means and how it correlates with society, these are the avenues in which we will venture through to form our thought. Historically and politically speaking, liberty is one of the most controversial philosophies brought to the table and the argumentsRead MoreThe Political And Moral Thought Of Rousseau And Kant1571 Words   |  7 Pagescivil state, which I suggest, are both flawed and inapplicable to real life. In this paper, I first compare and contrast the conceptions of freedom according to the two philosophers. Then I discuss why those conceptions are flawed. Finally, I provide a possible alternative: instead of clinging on the idea of the free will, I turn to the idea of free action, a less arbitrary conception of freedom. In On the Social Contract, Rousseau discusses three kinds of freedom , namely, natural liberty, civilRead MoreCritical Account of Mill’s Liberty Principle Essay1360 Words   |  6 PagesThere are essentially two polar views in relation to the liberty of people within society. Anarchist fundamentally believe that the state should have no power to impose limits on its people, whilst those in favour of total government control, believe that liberty should be disregarded and the state allowed to implement any law or policy that it so chooses. In his work ‘On Liberty (1859), John Stuart Mill outlines an alternative, which is a mix of these polar policies. He produced a formula whichRead MoreThe Justice Of Distributions And Its Impact On The Economics Of A Society1358 Words   |  6 Pagesapproaches to the justice of distributions in societies and there are arguments that can be made to support each of them. Three types of approaches are distribution justice based on a distr ibutive approach that was introduced by John Rawls, emergent which was advocated by Robert Nozick and a market democratic hybrid supported by Tomasi. This paper will illustrate the basic premise of each of these approaches and the impacts that they have on the economics of a society. After briefly explaining these threeRead MoreState of Nature and Freedom: Leviathan by Thomas Hobbes1424 Words   |  6 PagesState of Nature and Freedom In the Leviathan, Thomas Hobbes places limits on the freedom of individuals in the social contract, as well as individuals in the state of nature. Hobbes writes that in the state nature, â€Å"the liberty each man hath to use his own power as he will himself for the preservation of his own nature; doing anything which, in his own judgement and reason, he shall conceive to be the aptest means there unto† (ch. 14,  ¶1). An individual’s will is only free when there is no extraneousRead MoreVarying Concepts of Freedom1515 Words   |  7 Pagesthese freed black group thought about their status now and how they survived in a society that once made them slaves. They answered clearly that freedom mean the capability to develop from one’s own labor and what was necessary to do this was the access to land. What was Freedom? The understanding of freedom of African-Americans was simply molded by their experiences as slaves and how they observed the free society surrounding them. African-Americans were delighted with the chance to demonstrate