A retrospective study of chest pain in benign asbestos pleural disease.

PURPOSE: The aims of this review were to ascertain the incidence of asbestos-related chest pain at presentation in two groups of patients referred with asbestos diseases and the demographics, comorbidities, and chest computed tomography findings associated with chest pain. METHODS: Medical charts of patients presenting 1995-2008, audited for quality assurance, were chosen at random by data managers. Patients with mesothelioma, lung cancer, and angina were excluded. Rigorous attempts had been taken by the authors to exclude other causes of chest pain. RESULTS: There were 167 patients who were medicolegal referrals (Group 1) and 115 clinical referrals (Group 2). Although the patients in Group 1 had more severe disease generally than Group 2, the proportion with pain was not significantly different (45.5% and 55.7%, mean duration 4.8 years, range 1-22 years). Group 1 had more severe disease as a rule. However, the proportion with pain in Groups 1 and 2, respectively, was as follows: diffuse pleural thickening (50.8% and 67.6%, P=0.072), pleural plaques (47.0% and 59.7%, P=0.076), folded atelectasis (70.6% and 83.3%, P=1.000), and asbestosis (43.6% and 53.3%, P=0.346). Of all those with folded atelectasis, 73.9% had pain. CONCLUSION: Chest pain appears to be much more common in patients with benign asbestos diseases than is currently recognized, particularly in those with folded atelectasis and is not restricted to litigants. Improved recognition of this entity is needed along with practical management guidelines for the general practitioner. Further studies are envisaged by the authors.

Cryptococcosis and sarcoidosis: strange bed-fellows. A report of five cases.

BACKGROUND AND AIM: Sarcoidosis is known to predispose to cryptococcal infection. In this case series, variations in presentation, diagnostic dilemmas and responses to treatment are highlighted. METHODS: Of several hundred patients referred to the sarcoidosis clinic at The Prince Charles Hospital, Brisbane and to the private clinic of the co-author between 1990 and 2002, five subsequently developed cryptococcal infections as a complication of sarcoidosis. All five subjects were treated by the co-author (RKAA). A review of the literature was also performed. RESULTS: Cryptococcal infection occurred in 4 patients with sarcoidosis being treated with steroids and one patient who was not on treatment. All responded to antifungal therapy. Cryptococcosis was diagnosed by transbronchial (2), bronchial (1) and cutaneous (2) biopsies. Fluconazole was used in those with pulmonary infections but not in cutaneous disease where excision sufficed. One patient with pulmonary cryptococcosis from immunosuppressants also developed a nocardial brain abscess. CONCLUSIONS: Our series of patients with sarcoidosis and cryptococcal infections is unique in Australia. Although an unusual infection, cryptococcosis should always be considered in patients with sarcoidosis as it may be overlooked particularly in the lungs and can be fatal if untreated. Further immune dysregulation through steroid use may contribute significantly to the disease manifestations. Understanding why cryptococcosis and not other infections is more common in patients with sarcoidosis may reveal more about the mechanisms of granuloma formation and the nature of sarcoidosis itself.

A prospective study of 32 patients with neurosarcoidosis.

BACKGROUND AND AIM: There are few published prospective studies of neurosarcoidosis. To establish the incidence of neurological involvement and the response to treatment in patients presenting with sarcoidosis. METHODS: From 1991 to 1994, 123 patients were studied prospectively at the Prince Charles Hospital using a purpose designed computerised database (1). Consecutive patients were referred for neurological and psychiatric assessment when clinically indicated. Nerve conduction studies were done to confirm the presence of peripheral neuropathy. RESULTS: Neurological involvement was identified in 32/123 patients (15 male, 17 female, all white), mean age 48 years, age range 21-80 years. Of the 32 patients, the following frequencies of abnormalities were observed: papilloedema (6%), cranial neuropathy (59%), peripheral neuropathy (47%), mononeuropathy (25%), myopathy (25%), psychiatric disorders (19%), cerebellar ataxia (13%), and hydrocephalus (6%). A neurological improvement was seen in 16/19 (84%) of our patients as a result of therapy, and in 5/13 (38%) who were untreated. Corticosteroid treatment was used in 19/32 patients, with 6/32 requiring pulse intravenous methylprednisolone for initial poor response. The most predictable response incurred in patients with peripheral neuropathy; 12/14 treated patients responding. Only 1/8 patients who remained untreated for this, improved spontaneously. CONCLUSION: Neurological involvement was found more commonly than previously reported (26%). Corticosteroid treatment was found to be effective, although the response was often slow. High dose intravenous methylprednisolone was useful in poor responders (2). Peripheral neuropathy responded predictably to treatment. A formal neurological examination is recommended in all patients with sarcoidosis as neurological involvement may be overlooked.

Apparent spontaneous complete regression of a multifocal malignant mesothelioma of the pleura.

A 61-year-old woman diagnosed with multifocal, poorly differentiated epithelial mesothelioma in September 2002 went into sustained spontaneous remission within months. She was completely disease-free within 6 months, and remained so 5 years later. This case demonstrates that this tumour may, very rarely, regress spontaneously, with no recurrence for many years. A greater knowledge of the underlying immune mechanisms would aid future management of this and other tumours.