Iloprost for chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTPH) is an uncommon complication of pulmonary embolism. The treatment of choice is thromboendarterectomy, a safe and effective surgical procedure in expert hands. However, a fair number of patients are not considered candidates for thromboendarterectomy or do not accept the risk involved. Such patients may respond well to prostacyclin or its derivatives. In recent years new vasodilator drugs administered by a variety of routes have appeared on the market. These drugs have been studied mainly for their effects on primary pulmonary hypertension or hypertension associated with connective-tissue diseases. Few trials have assessed their efficacy in patients with CTPH, however. We report 2 cases of CTPH in which thromboendarterectomy was rejected. Neither of the patients responded to the conventional treatment of anticoagulants, diuretics, calcium antagonists, and angiotensin-converting enzyme inhibitors, but they did respond very well clinically, hemodynamically, and functionally to an inhaled prostacyclin analog, iloprost. We discuss the effects of iloprost in patients with CTPH, its mechanism of action, and its use as a potential pharmacological alternative to thromboendarterectomy. We also discuss new pulmonary vasodilators in general.

[Alveolar hemorrhage in mixed cryoglobulinemia associated with hepatitis C virus infection]. / Hemorragia alveolar en el seno de una crioglobulinemia mixta asociada a infección por el virus de la hepatitis C.

Alveolar hemorrhage in mixed cryoglobulinemia associated with hepatitis C virus infection. A 61 year-old woman with type II mixed cryoglobulinemia associated to hepatitis C virus infection has suffered alveolar hemorrhage with multiple pulmonary infiltrates, purpura, glomerulonephritis and polyneuropathy. The respiratory and kidney findings resolved with prednisone, but glomerulonephritis reappeared when interferon-alpha treatment was started and prednisone was reduced. This is the third case of alveolar hemorrhage and glomerulonephritis associated with mixed cryoglobulinemia reported in the literature. The lung involvement in mixed cryoglobulinemia is reviewed. The clinic manifestations (asthma, pleural effusion, hemoptysis or pulmonary fibrosis) are uncommon, but the lung involvement is very frequent if roentgenographic signs and necropsy findings are assessed.

[An unusual case of tuberculosis in an immunocompetent patient]. / Presentación inusual de tuberculosis en un paciente immunocompetente.

Gastric tuberculosis is a rare entity that often coincides with pulmonary involvement at the time of diagnosis. Many cases reported in developed countries are in immunodepressed patients, particularly those with HIV infection. We report the case of a 43-year-old man who presented with weight loss of 14 kg, persistent vomiting and bilateral pulmonary nodes measuring 1.5 to 3 cm in diameter. An ulcerous, hypertrophic gastric lesion was observed by oral digestive endoscopy, such that the clinical, radiologic and endoscopic profile initially suggested gastric neoplasia with bilateral pulmonary metastasis. Examination of the gastric biopsy and of the bronchial aspirate revealed the presence of acid-alcohol resistant bacilli; a culture in Löwenstein-Jenssen medium was positive for Mycobacterium tuberculosis. The patient responded satisfactorily to short-term specific treatment with three drugs.