Presentations of chronic cavitary pulmonary histoplasmosis mimic infected cystic bronchiectasis in an immunocompetent host: A case report.

BACKGROUND: Chronic cavitary pulmonary disease and laryngeal involvement are unusual manifestations of Histoplasmosis capsulatum infection, particularly in patients who are not immunocompromised. The presence of fibro-cavitary lesions has been reported as a radiologic presentation of chronic histoplasmosis in patients with pre-existing lung disease. However, there have been few reports of extensive basal predominant cavitary lesions that mimic cystic-bronchiectasis. CASE PRESENTATION: A 65-year-old previously healthy Thai male presented with productive cough, hoarseness, low-grade fever, and weight loss for 6 months. There was no history of significant exposure to Histoplasmosis capsulatum. Tests for HIV and anti-IFN- γ antibody were negative. Chest CT revealed multifocal thick wall cavities, which were distributed in a peri-bronchial pattern, and some areas of consolidation in both basal lungs. Laryngoscopy revealed an ulcerative lesion of the false vocal cords. Histopathological study of false vocal cords and lung tissue showed granulomatous inflammation with mixed inflammatory cell infiltration and aggregation of histiocytes containing round intracytoplasmic organisms. GMS-staining was positive, but negative mucicarmine-staining was negative. A real-time PCR assay of the lung tissue was positive for Histoplasmosis capsulatum. The final diagnosis was chronic cavitary pulmonary histoplasmosis with laryngeal involvement. CONCLUSION: Chronic cavitary pulmonary histoplasmosis is rare, as is laryngeal involvement. However, there have been such cases in endemic areas, even in immunocompetent patients. Chronic histoplasmosis should be considered in patients who present with the extensive basal predominant cavitary-pulmonary lesions that mimic cystic bronchiectasis.

Proteomic analysis of infected primary human leucocytes revealed PSTK as potential treatment-monitoring marker for active and latent tuberculosis.

Markers for monitoring clearance of Mycobacterium tuberculosis (Mtb) infection during anti-TB drug treatment could facilitate management of tuberculosis (TB) treatment, but are lacking. We aimed to screen for Mtb clearance markers from in-vitro-infected leucocytes and to evaluate these markers in followed-up active TB (ATB) patients and latent TB (LTBI) cases after anti-TB drug treatment. Extracellular proteins from primary leucocytes infected with each of the Mtb lineages (East-Asian, Indo-Oceanic, Euro-American and the laboratory strain H37Rv) were screened as possible clearance markers. Leucocytes infected with Staphylococcus aureus acted as controls. The proteomic analysis was performed using GeLC-MS/MS. Several quantitative and qualitative candidate clearance markers were found. These proteins were suppressed during the infection stage of all Mtb lineages and re-expressed after bacillary clearance. PSTK, FKBP8 and MGMT were common clearance markers among the four Mtb lineages in our model. Only PSTK was a potential clearance marker based on western blot validation analysis from culture supernatants. The PSTK marker was further validated with western blot analysis using serum samples (n = 6) from ATB patients and LTBI cases during anti-TB drug treatment, and from healthy controls (n = 3). Time-dependent increase of PSTK was found both in ATB and LTBI patients during the course of anti-TB drug treatment, but not in healthy controls. We have demonstrated that PSTK is a potential treatment-monitoring marker for active and latent TB.

Multiple pulmonary nodules in granulomatous polyangiitis: A case series.

Granulomatous polyangiitis (GPA) is a multiple systemic necrotizing vasculitis. Diagnosis of pulmonary nodules in GPA is still challenging in clinical practice, however, other extrapulmonary manifestations, serology, and histopathology may help the diagnosis of GPA. This case series was of limed GPA with one of the largest pulmonary nodules which had a poor treatment response in contrast with previous literature.

Massive pleural effusion due to IgG-Kappa subtype multiple myeloma: A case report.

Multiple myeloma (MM) is a hematologic malignancy of plasma cell origin. Incidence of pleural effusion in multiple myeloma patients is approximately 6%. Myelomatous pleural effusions (MPE) are rare and occur in less than 1% of all MM cases. MPE is associated with advanced diseases, decreased survival time, and poor treatment response. In our case report, we describe a 59-year old man who presented with MPE at the initial diagnosis of MM. A diagnosis of MPE was reach through pleural fluid cytology and pleural tissue histology. The MPE had good response to initial dexamethasone without local therapy.

COMPARISON OF GeneXpert MTB/RIF ASSAY WITH CONVENTIONAL AFB SMEAR FOR DIAGNOSIS OF PULMONARY TUBERCULOSIS IN NORTHEASTERN THAILAND.

Among infectious agents, Mycobacterium tuberculosis remains one of the most significant causes of death worldwide. Rapid and accurate diagnosis of pulmonary tuberculosis (TB) remains a great challenge. GeneXpert MTB/RIF assay is a novel integrated diagnostic system for rapid diagnosis of TB and particularly of rifampicin-resistant strains. A study was conducted between January 2010 and December 2014 to compare the performance of the sputum GeneXpert MTB/RIF assay with the conventional sputum AFB smear for diagnosis of active pulmonary TB in Thailand, a country with a high burden of this disease. Of the 125 patients who had cough and/or prolonged fever together with abnormal chest radiograph, 63 were diagnosed as having pulmonary TB by mycobacterium culture assay, while the remaining subjects were considered of having TB-like conditions, viz non-tuberculous mycobacterium infection (NTM), bacterial pneumonia or bronchogenic carcinoma. Two-thirds of the patients had underlying diseases, eg, diabetes mellitus (19 patients), autoimmune diseases (14), and HIV (6). Among patients with positive diagnosis of M. tuberculosis infection, 30 were AFB smear positive and 53 by sputum GeneXpert MTB/RIF method; among patients negative for M. tuberculosis infection, 4 were AFB smear positive and 5 by GeneXpert MTB/ RIF assay. Sensitivity and specificity of the sputum AFB smear and GeneXpertMTB/ RIF assay test were 48% (95% CI: 35-61) and 84% (95% CI: 73-92), and 94% (95% CI: 84-98) and 92% (95% CI: 82-97), respectively. Diagnostic performance of the GeneXpert MTB/RIF assay among AFB smear positive patients was higher than among AFB smear negative patients (adjusted OR 6.7; 95% CI: 2.3-19.9). Earlier diagnosis of pulmonary TB using GeneXpert MTB/RIF assay will lead to earlier appropriate treatment and provide opportunities to interrupt TB transmission.

Etiology and treatment outcomes of massive hemoptysis.

Massive hemoptysis is a life-threatening condition and can lead to asphyxiation. This is a retrospective review of 101 patients hospitalized with massive hemoptysis at Srinagarind Hospital, Khon Kaen, Thailand, between January 1993 and December 2002. The male to female ratio was 2.1:1. The average age was 47.1 (SD 16.8) years. Half the subjects were farmers and three-fourths had an underlying disease; most notably old pulmonary tuberculosis (41.6%). The mean duration of massive hemoptysis was 3.2 (SD 3.7) days. An initial hematocrit < or = 30% was found in 34.6% of patients, and a prolonged prothrombin time in 4.0%, and thrombocytopenia in 2.0%. Chest radiographs revealed unilateral, bilateral lesions and normal lungs in 57.4, 40.6, and 2.0%, respectively. A chest CT was done in 14.8% of patients. Bronchoscopy localized the bleeding and diagnosed the etiology in 19.8%. The most common causes of massive hemoptysis were bronchiectasis (33.7%), active pulmonary tuberculosis (20.8%) and malignancy (10.9%). Patients were grouped by treatment: 1) conservative (88); 2) emergency bronchial artery embolization (7); and, 3) emergency surgery (6). Of the 88 patients in group 1, the bleeding was stopped in 71 (80.7%) and recurred in 4. Of the 7 patients undergoing emergency bronchial artery embolization, the bleeding was stopped in 6 (86%) and recurred in 1. In the 6 patients who underwent emergency surgery, the bleeding was stopped in all and recurred in 1. Recurrent hemoptysis usually arose within 7 days of the first episode and was well controlled with bronchial arterial embolization. The mortality rate was 17.8%. Of the discharged patients, 36.1% had recurrent hemoptysis. Most of them occurred within one month after discharge. We conclude that, the most common cause of massive hemoptysis is benign rahter than malignant disease. Intensive care with conservative treatment should be applied vigorously. Bronchial artery embolization is an excellent, non-surgical alternative to control bleeding, and should be done before specific surgical intervention.

Pulmonary melioidosis presenting with right paratracheal mass.

A rare case of pulmonary melioidosis is reported. The patient was a 62-year-old man presenting with subacute fever, dry cough, and significant weight loss. A chest x-ray revealed a right paratracheal mass. The findings from fiberoptic bronchoscopy were a blunt carina and normal tracheobronchial tree. The patient had an underlying disease of poorly controlled diabetes mellitus, heavy smoking, and heavy alcoholic drinking. One of the two cultured blood specimens grew B. pseudomallei. The pathological finding of transbronchial biopsy at the apical segment of the right upper lung showed lymphocytic infiltrates. He was treated with two weeks of intravenous ceftazidime plus cotrimoxazole followed by 5 months of oral doxycycline plus cotrimoxazole. Clinical symptoms significantly improved and the right paratracheal mass disappeared.

Etiology and outcome of superior vena cava (SVC) obstruction in adults.

Between 1997 and 2002, 107 patients with symptoms of superior vena cava (SVC) obstruction presented at a university hospital in Northeast Thailand. Age averaged 50.7 years (range, 1 to 84). The male to female ratio was 5.7:1. Duration of symptoms before diagnosis was 29.4 days (range, 2 to 240), including facial swelling, cough, and chest discomfort. About 20% of cases developed respiratory failure and 11.2% died shortly after admission. The mean hospital stay was 23.7 days. Anteroposterior and lateral chest radiographs and computed chest tomography helped locate the lesion. Transbronchial biopsy through bronchoscopy, transthoracic needle biopsy under computed tomography, lymph node biopsy, pleural fluid cytology and/or biopsy were used for histopathologic sampling. High levels of alpha-fetoprotein and beta-HCG indicated an anterior mediastinal mass. The most common etiology of SVC obstruction was bronchogenic carcinoma (51.8%), followed by an anterior mediastinal mass (14.5%), lymphoma (13.6%--with an LDH of 262 to 1459 U/l), metastatic cancer (9.1%), and acute lymphoblastic leukemia (1.8%). Benign SVC thrombosis was found in four patients with Behcet's disease or some other idiopathy. Mediastinal fibrosis from melioidosis occurred in three patients, which is rare, has not been previouly reported. Most patients (63.6%) received a combination of radiotherapy and corticosteroid and this helped 55.2% improve.

Diagnostic yield of adenosine deaminase in bronchoalveolar lavage.

Adenosine deaminase (ADA) activity rises in various body fluids in patients with tuberculosis. A prospective study was conducted to determine the diagnostic value of ADA activity in bronchoalveolar lavage. Between March 2001 and February 2003, 148 patients were enrolled in our study, mean age 55.6 years (SD 14.6), and a male to female ratio of 2.4:1. The mean duration of symptoms was 66.2 days. All patients were either sputum-smear negative for AFB or failed to produce sputum. The final diagnosis resulted in three patient groups: 43 with pulmonary tuberculosis, 70 malignancy, and 35 miscellaneous causes. The mean ADA activity in the bronchoalveolar lavage for the pulmonary tuberculosis, malignancy, and miscellaneous causes groups was 8.98 (95% CI, 3.79-14.17), 7.63 (95% CI, 4.12-11.14), and 11.61 U/l (95% CI, 3.59-19.62), respectively. No difference was detected in the ADA level in the pulmonary tuberculosis vs other groups (p=0.56, one-way ANOVA). A high level of ADA activity was found in non-tuberculous conditions such as bronchogenic carcinoma, pulmonary hemosiderosis, chronic pneumonia with empyema thoracis and chronic myeloid leukemia. We concluded that ADA activity in the bronchoalveolar lavage was not clearly diagnostic of smear-negative pulmonary tuberculosis. Early diagnosis required histopathology of biopsied transbronchial specimens obtained by fiberoptic bronchoscopy.

Eosinophilic pleural effusion in adults at Srinagarind Hospital.

The presence of pleural eosinophilia remains a controversy in etiology and prognosis. We conducted this study to evaluate the etiology of eosinophilic pleural effusion and to define the factors that determine malignancy in eosinophilic pleural effusion. Between 1 August 1994 and 1 July 2000, 50 patients were diagnosed with eosinophilic pleural effusion; 35 men and 15 women averaging 56.4 years of age. Most (96%) had exudative pleural effusion. Malignancy was the most common (46%) established cause followed by tuberculosis (10%), parapneumonic effusion (8%), and empyema thoracis (2%). We encountered only one case of pneumothorax and parasitic pleural effusion (from Strongyloides stercoralis). Unknown causes constituted 22% of cases. The etiology of those who had previously undergone thoracocentesis did not differ from those having their first thoracocentesis. Patients with malignant pleural effusion had significant longer duration of clinical symptoms (> or = 1 month) and weight loss than benign pleural effusion. The median duration of symptoms in benign pleural effusion was 14 days. Fever was more characteristic in patients with benign than in those with malignant pleural effusion. The percentage of eosinophils in pleural fluid and blood did not differ between the two groups. Pleural fluid eosinophils in malignant vs benign pleural effusion were 26.6% (range 10% to 63%), and 30.6% (range 10% to 93%), respectively. We concluded that, pleural eosinophilia did not indicate benign conditions which would spontaneously resolve. Malignant pleural effusion should be considered especially in areas malignancy is prevalent.

Bronchial adenoma presenting with chronic asthma and obstructive pneumonia: a case report.

A rare case of primary pulmonary neoplasm is reported. The patient was a 38-year-old woman presenting with obstructive pneumonia. Fiberoptic bronchoscopy revealed an endobronchial mass obstructing the left main bronchus: a reddish polypoid mass which bled on contract that was suggestive of bronchial adenoma. The patient also had a long-standing history of bronchial asthma and hemoptysis and the delay in establishing the eventured diagnosis was caused by the minor symptoms mimicking those of asthma. A persistent restrictive lung and the presentation of obstructive pneumonia were important clues which warranted further investigation by computed tomography (CT) scan and bronchoscopy. The patient underwent rigid bronchoscopy with CO2-laser ablation under general anesthesia. Histopathology confirmed a bronchial adenoma. The clinical response was excellent. Bronchial adenoma should be considered in young patients presenting with asthma, hemoptysis and obstructive pneumonia. Bronchoscopic CO2-laser ablation is an effective treatment and provides an alternative to aggressive thoracotomy.