Angelo Taveira Da Silva

BACKGROUND: Tuberous sclerosis complex is a genetic disorder affecting every organ system, but disease manifestations vary significantly among affected individuals. The diverse and varied presentations and progression can be life-threatening with significant impact on cost and quality of life. Current surveillance and management practices are highly variable among region and country, reflective of the fact that last consensus recommendations occurred in 1998 and an updated, comprehensive standard is lacking that incorporates the latest scientific evidence and current best clinical practices. METHODS: The 2012 International Tuberous Sclerosis Complex Consensus Group, comprising 79 specialists from 14 countries, was organized into 12 separate subcommittees, each led by a clinician with advanced expertise in tuberous sclerosis complex and the relevant medical subspecialty. Each subcommittee focused on a specific disease area with important clinical management implications and was charged with formulating key clinical questions to address within its focus area, reviewing relevant literature, evaluating the strength of data, and providing a recommendation accordingly. RESULTS: The updated consensus recommendations for clinical surveillance and management in tuberous sclerosis complex are summarized here. The recommendations are relevant to the entire lifespan of the patient, from infancy to adulthood, including both individuals where the diagnosis is newly made as well as individuals where the diagnosis already is established. CONCLUSIONS: The 2012 International Tuberous Sclerosis Complex Consensus Recommendations provide an evidence-based, standardized approach for optimal clinical care provided for individuals with tuberous sclerosis complex.

We reviewed the pulmonary history, dyspnea ratings, and pulmonary function test results in 16 patients with L-tryptophan-induced eosinophilia myalgia syndrome to determine the correlation between reported pulmonary complaints and pulmonary function abnormalities. All patients reported pulmonary symptoms. Dyspnea, seen in 14 of 16 (87 percent) patients, was the most common symptom. The severity of dyspnea was graded by the baseline dyspnea index and the oxygen cost diagram. Pulmonary function testing including maximal static inspiratory and expiratory pressures were measured. The DCO was diminished in 12 of 16 (75 percent) patients. The MSIP was decreased in seven out of ten (70 percent) and the MSEP was decreased in nine out of ten (90 percent) of those patients tested. There was a statistically significant correlation between the severity of dyspnea as graded by the BDI and OCD, and the decrease in DCO. These results and a review of the literature of the pulmonary manifestations of EMS lead us to conclude that patients with EMS have a high prevalence of dyspnea, and it appears to be caused by both lung parenchymal involvement, as well as respiratory muscle weakness. We reviewed the pulmonary history, dyspnea ratings, and pulmonary function test results in 16 patients with L-tryptophan-induced eosinophilia myalgia syndrome to determine the correlation between reported pulmonary complaints and pulmonary function abnormalities. All patients reported pulmonary symptoms. Dyspnea, seen in 14 of 16 (87 percent) patients, was the most common symptom. The severity of dyspnea was graded by the baseline dyspnea index and the oxygen cost diagram. Pulmonary function testing including maximal static inspiratory and expiratory pressures were measured. The DCO was diminished in 12 of 16 (75 percent) patients. The MSIP was decreased in seven out of ten (70 percent) and the MSEP was decreased in nine out of ten (90 percent) of those patients tested. There was a statistically significant correlation between the severity of dyspnea as graded by the BDI and OCD, and the decrease in DCO. These results and a review of the literature of the pulmonary manifestations of EMS lead us to conclude that patients with EMS have a high prevalence of dyspnea, and it appears to be caused by both lung parenchymal involvement, as well as respiratory muscle weakness. Eosinophilia myalgia syndrome is a recently described entity characterized by severe myalgias and eosinophilia that is associated with the consumption of L-tryptophan containing products.1Clauw DJ Nashel DJ Umhau A Katz P Tryptophan-associated eosinophilic connective-tissue disease.JAMA. 1990; 263: 1502-1506Crossref PubMed Scopus (74) Google Scholar, 2Røubenoff R Cote T Watson R Levin ML Hochberg MC Eosinophilia-myalgia syndrome due to 1-tryptophan ingestion.Arthritis Rheum. 1990; 33: 930-938Crossref PubMed Scopus (11) Google Scholar, 3Varga J Heiman-Patterson TD Emery DL Griffin R Lally EV Uitto JJ et al.Clinical spectrum of the systemic manifestations of the eosinophilia-myalgia syndrome.Semin Arthritis Rheum. 1990; 19: 313-328Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 4Swygert LA Maes EF Sewell LE Miller L Falk H Kilbourne EM Eosinophilia-myalgia syndrome results of national surveillance.JAMA. 1990; 264: 1698-1703Crossref PubMed Scopus (156) Google Scholar As of August 1990, there had been over 1,500 cases of EMS reported to the Centers for Disease Control,5Update: Eosinophilia-myalgia syndrome associated with ingestion of 1-tryptophan—United States, through August 24, 1990.MMWR. 1990; 1: 587-589Google Scholar but it is probable that many cases went unreported and the true incidence may be higher. The CDC has defined the syndrome as the occurrence of severe myalgias associated with a peripheral eosinophil count of greater than 1,000/cu mm in the absence of an infection or a neoplasm that could explain the above findings.4Swygert LA Maes EF Sewell LE Miller L Falk H Kilbourne EM Eosinophilia-myalgia syndrome results of national surveillance.JAMA. 1990; 264: 1698-1703Crossref PubMed Scopus (156) Google Scholar The EMS is associated with a variety of manifestations other than eosinophilia and myalgias, including muscle weakness, dermatologic findings, fever, and neurologic involvement.1Clauw DJ Nashel DJ Umhau A Katz P Tryptophan-associated eosinophilic connective-tissue disease.JAMA. 1990; 263: 1502-1506Crossref PubMed Scopus (74) Google Scholar,3Varga J Heiman-Patterson TD Emery DL Griffin R Lally EV Uitto JJ et al.Clinical spectrum of the systemic manifestations of the eosinophilia-myalgia syndrome.Semin Arthritis Rheum. 1990; 19: 313-328Abstract Full Text PDF PubMed Scopus (40) Google Scholar,4Swygert LA Maes EF Sewell LE Miller L Falk H Kilbourne EM Eosinophilia-myalgia syndrome results of national surveillance.JAMA. 1990; 264: 1698-1703Crossref PubMed Scopus (156) Google Scholar,6Kaufman LD Finn AF Seidman RJ Pampati J Peress NS Miller F et al.Eosinophilic neuritis, perimyositis, and vasculitis associated with ingestion of L-tryptophan.J Rheum. 1990; 17: 795-800PubMed Google Scholar The prevalence of respiratory symptoms in patients with EMS has been reported to range from 25 to 59 percent3Varga J Heiman-Patterson TD Emery DL Griffin R Lally EV Uitto JJ et al.Clinical spectrum of the systemic manifestations of the eosinophilia-myalgia syndrome.Semin Arthritis Rheum. 1990; 19: 313-328Abstract Full Text PDF PubMed Scopus (40) Google Scholar,4Swygert LA Maes EF Sewell LE Miller L Falk H Kilbourne EM Eosinophilia-myalgia syndrome results of national surveillance.JAMA. 1990; 264: 1698-1703Crossref PubMed Scopus (156) Google Scholar,7Bulpitt KJ Verity A Clements PJ Paulus HE Association of 1-tryptophan and an illness resembling eosinophilic fascitis.Arthritis Rheum. 1990; 33: 918-929Crossref PubMed Scopus (15) Google Scholar, 8Shulman LE The eosinophilia-myalgia syndrome associated with ingestion of 1-tryptophan.Arthritis Rheum. 1990; 33: 913-917Crossref PubMed Scopus (38) Google Scholar, 9Martin RW Duffy J Engel AG Lei JT Bowles CA Moyer TP et al.The clinical spectrum of the eosinophilia-myalgia syndrome associated with 1-tryptophan ingestion.Ann Int Med. 1990; 113: 124-134Crossref PubMed Scopus (129) Google Scholar and includes dyspnea, cough, and pleuritic chest pain. The occurrence of pulmonary infiltrates, pleural effusions, and pulmonary hypertension have also been reported.3Varga J Heiman-Patterson TD Emery DL Griffin R Lally EV Uitto JJ et al.Clinical spectrum of the systemic manifestations of the eosinophilia-myalgia syndrome.Semin Arthritis Rheum. 1990; 19: 313-328Abstract Full Text PDF PubMed Scopus (40) Google Scholar,10Strumpf IJ Drucker RD Anders KH Cohen S Fajolu O Acute eosinophilic pulmonary disease associated with ingestion of L-tryptophan-containing products.Chest. 1991; 99: 8-13Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 11Tazelaar HD Myers JL Drage CW King TE Aguayo S Colby TV Pulmonary disease associated with L-tryptophan-induced eosinophilic myalgia syndrome.Chest. 1990; 97: 1032-1036Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 12Travis WD Kalafer ME Robin HS Luibel FJ Hypersensitivity pneumonitis and pulmonary vasculitis with eosinophilia in a patient taking an 1-tryptophan preparation.Ann Int Med. 1990; 112: 301-303Crossref PubMed Scopus (30) Google Scholar, 13Carton CK Elmer JC Whitehouse AC Clode JB Hustrulid RI Pulmonary involvement in the eosinophilia-myalgia syndrome.Chest. 1991; 99: 327-329Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 14Yakovlevitch M Siegel M Hoch DH Rutlen DL Pulmonary hypertension in a patient with tryptophan-induced eosinophilia-myalgia syndrome.Am J Med. 1991; 90: 272-273PubMed Scopus (8) Google Scholar, 15Banner AS Borochovitz D Acute respiratory failure caused by pulmonary vasculitis after L-tryptophan ingestion.Am Rev Respir Dis. 1991; 143: 661-664Crossref PubMed Scopus (8) Google Scholar Histopathologic studies of lung biopsy specimens have demonstrated the presence of interstitial pneumonitis, interstitial fibrosis and perivascular infiltrates by histiocytes, lymphocytes, eosinophils, and rare neutrophils.10Strumpf IJ Drucker RD Anders KH Cohen S Fajolu O Acute eosinophilic pulmonary disease associated with ingestion of L-tryptophan-containing products.Chest. 1991; 99: 8-13Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 11Tazelaar HD Myers JL Drage CW King TE Aguayo S Colby TV Pulmonary disease associated with L-tryptophan-induced eosinophilic myalgia syndrome.Chest. 1990; 97: 1032-1036Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 12Travis WD Kalafer ME Robin HS Luibel FJ Hypersensitivity pneumonitis and pulmonary vasculitis with eosinophilia in a patient taking an 1-tryptophan preparation.Ann Int Med. 1990; 112: 301-303Crossref PubMed Scopus (30) Google Scholar, 13Carton CK Elmer JC Whitehouse AC Clode JB Hustrulid RI Pulmonary involvement in the eosinophilia-myalgia syndrome.Chest. 1991; 99: 327-329Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Respiratory function abnormalities have been described in patients with EMS, but a clear relationship between these abnormalities and the presence of respiratory symptoms has yet to be established. We now report the results of a review of 16 patients with EMS in whom pulmonary symptoms were compared to pulmonary function tests. Of note, we found a much higher incidence of pulmonary symptoms than previously reported. These symptoms were often associated with abnormal diffusion capacity and maximal static respiratory pressures but normal chest x-ray films. Subjective dyspnea scores were found to correlate with reductions in the diffusion capacity. Our findings are discussed and compared with the published literature on the pulmonary manifestations of EMS. We reviewed the clinical history of 16 patients with EMS who were referred to the Division of Rheumatology at Georgetown University Hospital. All patients met the CDC definition for EMS: the presence of severe myalgias, an absolute eosinophil count of greater than 1,000 cells/cu mm, and the absence of infection or neoplasm that could explain the above findings.4Swygert LA Maes EF Sewell LE Miller L Falk H Kilbourne EM Eosinophilia-myalgia syndrome results of national surveillance.JAMA. 1990; 264: 1698-1703Crossref PubMed Scopus (156) Google Scholar After an initial evaluation, the patients were interviewed by one of the authors (CR). Two clinical methods were used to rate the severity of the patients' dyspnea, the OCD and the BDI.16Mahler DA Wells CK Evaluation of clinical methods for rating dyspnea.Chest. 1988; 93: 580-586Crossref PubMed Scopus (1116) Google Scholar,17Mahler DA Weinberg DH Wells CK Feinstein AR The measurement of dyspnea.Chest. 1984; 85: 751-758Crossref PubMed Scopus (1060) Google Scholar The BDI was administered by one of the authors (CR). After asking open-ended questions concerning the patients' symptoms, the observer then focused on specific criteria for the severity of breathlessness in each of the categories as outlined in the BDI.16Mahler DA Wells CK Evaluation of clinical methods for rating dyspnea.Chest. 1988; 93: 580-586Crossref PubMed Scopus (1116) Google Scholar,17Mahler DA Weinberg DH Wells CK Feinstein AR The measurement of dyspnea.Chest. 1984; 85: 751-758Crossref PubMed Scopus (1060) Google Scholar The normal scale for the test is 12 with a range from 0 to 12. Subsequently, the patients were asked to mark on the OCD the level of exertion at which they became dyspneic. The test is then scored by measuring the distance from the bottom of the diagram to the mark. The normal score for this test is 100 mm with a range from 0 mm to 100 mm. Chest roentgenograms were obtained on 14 patients, and 2D echocardiogram with Doppler on eight patients. These were interpreted by blinded observers. After the interview, the patients underwent pulmonary function testing. Lung volumes and flow rates were measured with an automated spirometer. Functional residual capacity was measured by the helium closed circuit method and by body plethysmography to rule out the presence of air trapping in patients with a history of smoking or asthma. Values obtained were converted to body temperature pressure saturated conditions and were expressed as a percentage of predicted values using the data of Morris et al,18Morris JF Koski A Johnson LC Spirometric standards for healthy non-smoking adults.Am Rev Respir Dis. 1971; 103: 57-67PubMed Google Scholar Knudson et al,19Knudson RJ Slatin RC Lebowitz MD Burrows B The maximal expiratory flow-volume curve.Am Rev Respir Dis. 1976; 113: 587-600PubMed Google Scholar and Grimby and Soderholm.20Grimby G Soderholm B Spirometric studies in normal subject: III.Static lung volumes and maximal voluntary ventilation in adults with a note on physical fitness. Acta Med Scand. 1963; 173: 199-206Google Scholar Forced vital capacity and forced expiratory volume in one second were chosen from the best of three successive maximal expiratory maneuvers according to American Thoracic Society recommendations.21American Thoracic Society Snowbird Workshop on Standardization of Spirometry.Am Rev Respir Dis. 1979; 119: 831-838PubMed Google Scholar Diffusion capacity for carbon monoxide was measured by the single breath method of Ogilvie et al22Ogilvie CM Forster RE Blakemore WS Morton JW A standardized breath holding technique for the clinical measurement of the diffusing capacity of the lung for carbon monoxide.J Clin Invest. 1957; 36: 1-17Crossref PubMed Google Scholar according to ATS standards.23American Thoracic Society Single breath carbon monoxide diffusing capacity (transfer factor) recommendations for a standard technique.Am Rev Respir Dis. 1987; 136: 1299-1307Crossref PubMed Scopus (237) Google Scholar The DCO values were converted to standard temperature pressure dry condition. Adjustments of DCO to hemoglobin concentration and carboxyhemoglobin were performed according to ATS standards.23American Thoracic Society Single breath carbon monoxide diffusing capacity (transfer factor) recommendations for a standard technique.Am Rev Respir Dis. 1987; 136: 1299-1307Crossref PubMed Scopus (237) Google Scholar The DCO was expressed as a percentage of predicted normal values using the data of Crapo and Morris.24Crapo RO Morris AH Standardized single breath normal values for carbon monoxide diffusing capacity.Am Rev Respir Dis. 1981; 123: 185-189PubMed Google Scholar Predicted normal values for DCO had been previously validated in our laboratory by comparison with values obtained in healthy subjects. Maximal static respiratory pressures were measured with an instrument similar to that described by Black and Hyatt.25Black LF Hyatt RE Maximal respiratory pressures: normal values and relationship to age and sex.Am Rev Respir Dis. 1969; 99: 696-702PubMed Google Scholar Maximal inspiratory pressure was measured after expiration to residual volume. Maximal expiratory pressure was measured after inspiration to total lung capacity. Values were expressed as percentage of predicted, with normal values being derived from the equation described by Black and Hyatt.25Black LF Hyatt RE Maximal respiratory pressures: normal values and relationship to age and sex.Am Rev Respir Dis. 1969; 99: 696-702PubMed Google Scholar Results of all pulmonary function tests are presented as percentage of predicted values ± standard error of the mean. Values above 80 percent predicted were considered normal. Regression analysis and determination of Pearsons correlation coefficient and statistical significance were carried out to determine whether significant correlation existed between the symptoms of dyspnea as assessed by the BDI and OCD test and the pulmonary function abnormalities. The level of statistical significance was set at p<0.05. The clinical data for the 16 patients are summarized in Table 1. Fourteen patients were women (87 percent). Ages ranged from 34 to 69 years, with a mean of 50. Sixty-two percent (10 of 16) of the patients had a history of cigarette use, but only three were currently smoking. The EMS symptoms were present for a mean of 14.9 months with a range from 11 to 23 months at the time of the study. Most patients had been treated with prednisone (15 of 16 patients) in dosages ranging from 10 to 60 mg/day (mean dose of 25 mg/day) for a mean of 7.5 months.Table 1Clinical History and BDI and OCD ResultsNumber/Age/SexDuration of Disease, moPack YearsSymptomsBDI ScoreOCD ScoreDuration of Therapy, moAverage Dose Prednisone1/44/F1618Dyspnea, cough, wheeze6551215 chest in a All patients had at one to the respiratory was the most common seen in 14 patients (87 percent). Sixty-two percent (10 of 16) had chest percent of 16) had chest percent of 16) had and percent of 16) of a The mean BDI score was was with a range of to 12. The mean OCD score for the was was with a range of to Results of chest roentgenograms and Doppler are in Table Chest roentgenograms were abnormal in only of 14 patients with and volume and pulmonary hypertension and Doppler performed in eight patients was normal in had and had and pulmonary pressures of of dyspnea, this patient had which pulmonary hypertension (mean pulmonary pressure mm with findings on pulmonary this patient had an smoking history and had pulmonary symptoms that the of and Doppler pulmonary in a Results of pulmonary function tests are in Table The mean was decreased to ± 10 percent of flow was found in seven patients, had a history of and only one of these patients had a history of A was seen in patients, but one of these patients had a history of for of in percent of predicted normal for which is expressed as a in percent of predicted normal for which is expressed as a in a percent of the patients of 16) had a decreased and the mean DCO for the normal (70 ± percent). of 10 patients had a decrease in MSEP and seven of these patients also had a decrease in the ten patients the mean MSEP and MSIP were ± and ± percent of predicted The symptoms of dyspnea as graded by the BDI and OCD had a statistically significant correlation with one both the BDI and the OCD had statistically significant correlation with the presence of a decreased DCO and described by et in LE The eosinophilia-myalgia syndrome associated with ingestion of 1-tryptophan.Arthritis Rheum. 1990; 33: 913-917Crossref PubMed Scopus (38) Google Scholar EMS is now to of in the as well as in other There is that EMS is associated with ingestion of L-tryptophan containing a LF Hyatt RE Maximal respiratory pressures: normal values and relationship to age and sex.Am Rev Respir Dis. 1969; 99: 696-702PubMed Google CW DA et of the of the eosinophilia-myalgia syndrome associated with J Med. 1990; PubMed Scopus Google Scholar The clinical manifestations of EMS are the of the the months of the includes severe myalgias, and The of the which for a and is includes muscle and weakness, as well as and are for an eosinophil count in the of the and in and correlate with disease Eosinophilia-myalgia syndrome associated with ingestion of 1-tryptophan—United States, through August 24, 1990.MMWR. 1990; 1: 587-589Google Scholar Pulmonary of this disease have been in and have described a range of pulmonary manifestations in EMS including pulmonary hypertension the in one pulmonary and respiratory failure to muscle M Siegel M Hoch DH Rutlen DL Pulmonary hypertension in a patient with tryptophan-induced eosinophilia-myalgia syndrome.Am J Med. 1991; 90: 272-273PubMed Scopus (8) Google AS Borochovitz D Acute respiratory failure caused by pulmonary vasculitis after L-tryptophan ingestion.Am Rev Respir Dis. 1991; 143: 661-664Crossref PubMed Scopus (8) Google M RC respiratory failure due to L-tryptophan-induced eosinophilic 1991; 99: Full Text Full Text PDF PubMed Scopus Google Scholar there are on the pulmonary et HD Myers JL Drage CW King TE Aguayo S Colby TV Pulmonary disease associated with L-tryptophan-induced eosinophilic myalgia syndrome.Chest. 1990; 97: 1032-1036Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar reported patients with pulmonary disease associated with EMS. had interstitial on chest x-ray had disease by pulmonary function and all had lung biopsy specimens interstitial infiltrates and et IJ Drucker RD Anders KH Cohen S Fajolu O Acute eosinophilic pulmonary disease associated with ingestion of L-tryptophan-containing products.Chest. 1991; 99: 8-13Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar reported patients with EMS pulmonary infiltrates, pleural effusions, and lung biopsy performed on three patients demonstrated pneumonitis and to et CK Elmer JC Whitehouse AC Clode JB Hustrulid RI Pulmonary involvement in the eosinophilia-myalgia syndrome.Chest. 1991; 99: 327-329Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar recently reported three cases of EMS with dyspnea and decreased DCO in which high dose only caused et J Heiman-Patterson TD Emery DL Griffin R Lally EV Uitto JJ et al.Clinical spectrum of the systemic manifestations of the eosinophilia-myalgia syndrome.Semin Arthritis Rheum. 1990; 19: 313-328Abstract Full Text PDF PubMed Scopus (40) Google Scholar reported patients of which percent had pulmonary symptoms, and percent had abnormal chest x-ray with infiltrates or pleural Pulmonary function testing demonstrated a DCO in 10 of patients percent). patients underwent lung biopsy or which demonstrated the presence of Our patient was of previously reported with percent women and a mean age of is a of the patient who Our that patients with EMS have a much higher prevalence of respiratory symptoms than previously with at one found in was the most common seen in percent of the patients. 10 of 16 patients were three and one had a history of it is that the respiratory of dyspnea, chest and were due to lung disease as only of the had of mean lung volumes and flow rates were normal and the mean was normal ± 10 percent). The higher prevalence of respiratory symptoms seen in our be by studies patients in the of the our patients had EMS for an of months to the time of our patients were the presence of pulmonary symptoms, and may have been to report these of the patients in our were referred for a our of patients as a may have had severe disease than the patients previously reported. testing of dyspnea, assessed by the BDI and the OCD, well with each the BDI and OCD test results with a decrease in DCO. these may in the of the disease and the to We a decrease in DCO in percent of our patients, similar to the percent seen in a of patients reported by et J Heiman-Patterson TD Emery DL Griffin R Lally EV Uitto JJ et al.Clinical spectrum of the systemic manifestations of the eosinophilia-myalgia syndrome.Semin Arthritis Rheum. 1990; 19: 313-328Abstract Full Text PDF PubMed Scopus (40) Google Scholar The decrease in DCO in patients with EMS may be due to of lung biopsy specimens obtained from patients with EMS have the presence of interstitial pneumonitis, pulmonary and perivascular infiltrates pulmonary and IJ Drucker RD Anders KH Cohen S Fajolu O Acute eosinophilic pulmonary disease associated with ingestion of L-tryptophan-containing products.Chest. 1991; 99: 8-13Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 11Tazelaar HD Myers JL Drage CW King TE Aguayo S Colby TV Pulmonary disease associated with L-tryptophan-induced eosinophilic myalgia syndrome.Chest. 1990; 97: 1032-1036Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 12Travis WD Kalafer ME Robin HS Luibel FJ Hypersensitivity pneumonitis and pulmonary vasculitis with eosinophilia in a patient taking an 1-tryptophan preparation.Ann Int Med. 1990; 112: 301-303Crossref PubMed Scopus (30) Google Scholar The of interstitial pneumonitis and as well as vasculitis could explain the decreased DCO. be that in percent of the patients, the diffusion to normal for lung volume which significant pulmonary disease an it is that the decrease in diffusion capacity is in to decreased lung to interstitial pneumonitis respiratory muscle or The high prevalence of decreased maximal static found in nine of ten patients respiratory muscle as the of these et M RC respiratory failure due to L-tryptophan-induced eosinophilic 1991; 99: Full Text Full Text PDF PubMed Scopus Google Scholar reported respiratory failure in a patient with EMS which they was to respiratory muscle weakness, the of the failure peripheral muscle and both with The respiratory muscle is in EMS, severe myalgias, and are all in this condition. of the we that this is an and the a patient with EMS to of maximal static pressure standard pulmonary function as these studies are respiratory symptoms, dyspnea, in patients with EMS. The severity of dyspnea with a in diffusion as well as in maximal static respiratory These findings, with the previously reported described in the lung and that dyspnea is to the pulmonary parenchymal respiratory muscle and pulmonary the of a correlation between methods for the of dyspnea and pulmonary that these methods may be in of the disease and to used with pulmonary function testing.