Coexistence of Cryptococcal Fungemia and Pneumocystis jirovecii Pneumonia in an HIV-Infected Patient: A Case Report.

INTRODUCTION: Opportunistic infections caused by bacteria and fungi are common in human immunodeficiency virus (HIV)-infected patients. Cryptococcus neoformans and Pneumocystis jirovecii are the most common opportunistic infections in immunosuppressed individuals, but their coexistence is rare. To our knowledge, this is the first case presented in Turkey involving the coexistence of C.neoformans fungemia and P.jirovecii pneumonia. CASE PRESENTATION: A 26-year-old male patient presented with a cachectic appearance, cough, sputum, weakness, shortness of breath, and a weight loss of 15 kg in the last three months. It was learned that the patient was diagnosed with HIV three years ago, did not go to follow-ups, and did not use the treatments. CD4 cell count was 7/mm3 (3.4%), CD8 cell count was 100 (54%) mm3, and HIV viral load was 5670 copies/mL. In thorax computed tomography (CT), increases in opacity in diffuse ground glass density in both lungs and fibroatelectasis in lower lobes were observed. With the prediagnosis of P. jiroveci pneumonia, the HIV-infected patient was given trimethoprim-- sulfamethoxazole 15 mg/kg/day intravenously (i.v.). On the 4th day of the patient's hospitalization, mutiplex PCR-based rapid syndromic Biofire (Film Array) blood culture identification 2 (BCID2) test (Biomerieux, France) was applied for rapid identification from blood culture. C. neoformans was detected in the blood culture panel. The treatment that the patient was taking with the diagnosis of C. neoformans fungemia was started at a dose of liposomal amphotericin B 5 mg/kg/- day + fluconazole 800 mg/day. CONCLUSION: While the incidence of opportunistic infections has decreased with antiretroviral therapy (ART), it remains a problem in patients who are unaware of being infected with HIV or who fail ART or refuse treatment. High fungal burden, advanced age, low CD4+ cell count, and being underweight are risk factors for mortality in HIV-positive patients. Our case was a cachectic patient with a CD4 count of 7 cells/mm3. Despite the early and effective treatment, the course was fatal.

Complete videothoracoscopic en-bloc resection of lung cancer invading the diaphragm.

Locally advanced non-small cell lung cancer invading the diaphragm is an infrequent clinical presentation. A 74-year-old male patient was operated using video-assisted thoracoscopic surgery in our clinic for a tumor originating from the right lower lobe. A right lower lobectomy with diaphragmatic resection was performed to the tumor with a diameter of 3 cm that invaded the diaphragm, and the resulting defect was repaired primarily with video-assisted thoracoscopic surgery. The patient did not develop complications in the postoperative period and was discharged on Day 6. In conclusion, patients with non-small cell lung cancer invasive to the diaphragm can be even safely operated with the video-assisted thoracoscopic surgery.

Comparison of Brock University, Mayo Clinic and Herder models for pretest probability of cancer in solid pulmonary nodules.

OBJECTIVE: Risk analysis models, which are used in the diagnostic algorithm of incidental pulmonary nodules, are based on patient data from developed countries. Mayo Clinic, Brock University and Herder are among the most known models. We aim to compare the reliability of these models in patients with indeterminate solid nodules and to investigate the contribution of the predictors used to the model. METHODS: We analysed 305 patients who performed transthoracic needle biopsy and positron emission tomography/computed tomography for solid nodules, retrospectively. For all three models, the malignancy risk probabilities of patients were calculated, and patients were classified as low (<5%), moderate (60%) and high (<60%) risk groups. Later, the malignancy rates of each model in three different risk groups were compared within each other and among the models. RESULTS: The malignancy rate is 73% in 305 patients. In the Mayo Clinic and Herder models, the difference in the low-, medium- and high-risk groups is significant (p < 0.001). In the medium-risk group, the rate of malignancy is 96.8% in the Brock model. In the high-risk group, the rate of malignancy in Herder is 88.3% and the rate of malignancy in Mayo Clinic is 28.8%. The optimal cutoff values for the Mayo Clinic, Brock University, and Herder were 29.6, 13.4 and 70 (AUC, respectively; 0.71, 0.67 and 0.73). Age, smoking, gender, size, emphysema and spiculation increase the likelihood of malignancy. CONCLUSION: Close results were obtained in all three models. In the high-risk group, the Herder model has the highest reliability rate (odds ratio 3.3, confidence interval [1.1, 10.2]). Upper lobe predilection is not a reliable predictor.

ALK, ROS1 and EGFR status of lung cancers in the Aegean Region of Turkey.

Background/Aims: As targeted therapies are promising in the treatment of lung cancer (LC), it is important to identify the genetic variations in tumors. The present research aimed to determine the regional prevalence of alterations in ALK, ROS1, and EGFR genes. Materials and. Methods: ALK rearrangement in 1152, ROS1 rearrangement in 390, and EGFR mutations in 1054 cases with LC were evaluated. Results: Alteration rates of ALK, ROS1, and epidermal growth factor receptor (EGFR) genes were 3.5%, 0.4%, and 11.2% in the samples, respectively. ALK rearrangements were mainly detected in young patients (P < 0.01) and in females (P < 0.01). Females were also more often inflicted by EGFR variations, especially from the exon 19 deletion. Exon 21 L858R mutations were more frequently found in men. However, any statistical significance between EGFR alterations and gender or age was not discovered. Conclusion: In this study, molecular changes were less frequent than expected. We thought that this low rate confirmed the aphorism of "smokes like a Turk, " which could be because almost all patients were active or passive smokers.

The relation between distant metastasis and genetic change type in stage IV lung adenocarcinoma patients at diagnosis.

INTRODUCTION: Brain metastasis prevalence is higher in patients with positive epidermal growth factor receptor (EGFR) mutation, anaplastic lymphoma kinase (ALK) and C-ROS oncogene 1 (ROS-1) fusion change in lung adenocarcinoma. OBJECTIVES: The purpose of our study is to investigate the relation between the genetic change type and the initial distant metastasis in stage IV lung adenocarcinoma patients with genetic changes. METHODS: The study was conducted between January 2007 and December 2018 in a retrospective fashion with patients who had lung cancer diagnosed as stage IV adenocarcinoma. The relation between genetic mutation change (EGFR, ALK or ROS-1) and distant metastasis was analysed. RESULTS: A total of 845 patients were included in the study. The median age was 62 (28-88). It was determined that lung and pleura metastases were more frequent at a significant level in patients with positive EGFR mutation (P = 0.032, P = 0.004, respectively). In patients with positive ALK fusion change, pleura metastasis was determined to be more frequent (P = 0.001). Multiple metastases were determined to be significantly more in patients with positive ALK fusion change than single metastasis (P = 0.02). CONCLUSION: In patients with EGFR mutant lung adenocarcinoma, lung and pleura metastasis is more frequent and pleura metastasis is more frequent in ALK positive adenocarcinoma. Additionally, multiple organ metastases are higher in ALK positive lung adenocarcinoma.

Diagnostic success of transthoracic needle biopsy and PET-CT for 1 to 2 cm solid indeterminate pulmonary nodules.

OBJECTIVES: Among the nodule types, the most controversial group are indeterminate solid nodules from 1 to 2 cm in size with the first choice being transthoracic needle biopsy (TTNB) or positron emission tomography (PET-CT) or both methods together. However, no single diagnostic algorithm could be applied to all cases. This research discusses the diagnostic success of PET-CT and TTNB. MATERIALS AND METHODS: 407 Patients who referred to our hospital for any reason, with solid nodules with the size from 1 to 2 cmincidentally identified on the thoracic CT tests were investigated. Among the patients who underwent biopsy, 312 cases had PET-CT, and maximum SUV (SUVmax) values of the nodules were examined. Values of ≥2.5 were accepted as hypermetabolic. RESULTS: The mean age of the patients was 61 ± 10.8 years. 84 patients were female (20.6%) and 323 were male (79.4%). For TTNB; sensitivity, specificity and accuracy rates of all cases, who were correctly diagnosed, were 76.9%, 83.3% and 78.9%, respectively (P < .001). The 2.5 SUVmax cutoff value had sensitivity of 91%, specificity of 35.6%, accuracy of 75% (P = .034). The cutoff value of 49 years of age, nodule size of 16.4 mm, gender and 2.5 SUVmax value had high accuracy for benign-malignant differentiation. No statistically significant difference was found in the upper lobe localization of nodule. CONCLUSION: A positive result from TTNB is a reliable finding; however, a negative result is not definitive. The high negative predictive value of PET-CT is effective in preventing the unnecessary biopsies and surgical procedures.

The effects of steroidal and non-steroidal anti-inflammatory drugs on tracheal wound healing in an experimental rat model.

OBJECTIVES: The effect of non-steroidal anti-inflammatory drugs (NSAID), mostly used for postoperative analgesic purposes for wound healing, is still a matter of debate. Our goal was to evaluate the effects of the most widely used NSAID and corticosteroids after surgical operations on tracheal wound healing in an experimental rat model. METHODS: Thirty-nine male Wistar albino rats were included in this study. Tracheotomy was performed in 32 rats; then they were divided into 3 groups. After the first day, the animals in group 1 were treated with an NSAID (diclofenac 10 mg/kg/day) (NSAID, n = 12) for 7 days; the animals in group 2 were treated with a corticosteroid (dexamethasone, 2 × 0.1 mg/kg/day) (steroid, n = 10) for 7 days; the animals in group 3 (control, n = 10) were not given any medications. For a fourth group (histological control, n = 7), in order to evaluate normal morphological and histological characteristics, neither surgery nor medication was used. Five rats were eliminated from the study (2 rats in the NSAID group died and 3 rats in the steroid group developed local wound infections). The drop-out rate was 12.8%. Histological characteristics, inflammation, fibrosis, necrosis, neochondrogenesis, neovascularization and epithelization were evaluated in 34 rats. Non-parametric tests were used for statistical analysis. RESULTS: Inflammation, vascularization and number of fibroblasts and chondrocytes were significantly higher in the control group than in the histological control group. There was some reduction in all parameters except vascularization in the NSAID group (P > 0.05). When the steroid group was compared to the NSAID group, inflammation (P < 0.05), vascularization and number of chondrocytes (P > 0.05) were more suppressed in the steroid group. The number of fibroblasts increased in the steroid group (P > 0.05). CONCLUSIONS: Steroids and NSAID may have negative effects on tracheal wound healing, probably by suppressing inflammation and fibroblast proliferation. NSAID was mostly used postoperatively for analgesic purposes and should be avoided.

Multiple endobronchial hamartoma.

BACKGROUND AND AIMS: Pulmonary hamartomas appear as parenchymal or endobronchial lesions, the latter representing '1.4 to 11%' of the total number of pulmonary hamartomas. Endobronchial hamartomas usually emerge as a single mass. As they are accepted as benign tumors, endobronchial treatments are recommended today. 45 year-old male patient admitted with cough, phlegm and fever. A lesion totally obstructing the right main bronchus was found in CT. METHODS: In his brochoscopy, a mobile, smooth-surfaced lesion obstructing right main bronchus was seen. Its histopathology was reported as 'hamartoma.' RESULTS: The lesion was removed by using argon plasma coagulation and electrocotery. After the removal of the lesion in right main bronchus, another lesion with similar characteristics was seen in the intermedius bronchus and this lesion which histopathology was reported as 'hamartoma' was excised by using electrocauter snare. There was no recurrence in the 24 month follow-up. CONCLUSION: Reports of multiple endobronchial hamartomas are rare in the literature, and the awareness of this form of benign disease is important in the differential diagnosis of pulmonary diseases.

Prognostic factors affecting survival in malignant pleural mesothelioma: analysis of 125 subjects.

AIM OF THE STUDY: Determining the pre-treatment prognostic factors in malignant pleural mesothelioma is important in terms of estimating the course of the disease and selecting patients who are candidate for multimodal therapy. The aim of the study was to determine the prognostic factors affecting survival in patients with malignant pleural mesothelioma. STUDY DESIGN: One hundred and twenty-five patients who had been diagnosed histologically as having malignant pleural mesothelioma over the past 5 years were evaluated retrospectively. Relationships of survival of the patients with their age, gender, exposure to asbestos, smoking history, platelet, hemoglobin, leukocyte (WBC) and serum LDH values, histology, performance score and stage of disease were examined. RESULTS: Advanced clinical stage, N2 nodal involvement and the presence of distant metastasis were found to be related to survival. Sarcomatous histology was found to be a poor prognostic factor independently of other factors. CONCLUSIONS: We showed that histological subtype and stage of disease were the most important parameters in planning the treatment, especially in determining the patients who were candidate for multimodal treatment and in estimating the prognosis.

The role of the tissue culture in granulomatous mediastinal lymphadenitis: tuberculosis or not.

AIM: To evaluate the role of the tissue culture via mediastinoscopic biopsy in granulomatous mediastinal lymphadenitis. METHODS: The dossier data of 92 cases with mediastinal lymphadenitis showing granulomatous lymphadenitis features by cervical mediastinoscopy and whose clinical, radiological and bacteriological definitive diagnosis is tuberculosis and sarcoidosis were examined retrospectively. The rate of the positive tissue culture of mediastynoscopic biopsy in the diagnosis of granulomatous lymphadenitis was calculated. RESULTS: There were 65 (71%) females and 27 (29%) males. The mean age of the patients was 42.5 (range 15-75) years. Non necrotizing granulomatous lymphadenitis was detected in 58 (63 %) cases while necrotizing granulomatous lymphadenitis was seen in 34 (37%) cases. There were 29 cases diagnosed with tuberculosis. Acid resistant bacilli culture positive rate was 38% (in 11 cases). There were 21 (62%) cases of necrotizing granulomatous lymphadenitis and eight (14%) cases of non-necrotizing granulomatous lymphadenitis diagnosed with tuberculosis. Culture positivity was identified in two (25%) of eight cases whose differential diagnosis could not be made histopathologically as tuberculosis/sarcoidosis. CONCLUSIONS: In addition to clinical, radiological and histopathological diagnosis, the study aims to highlight the importance of tissue culture in definitive diagnosis, especially undetermined incidents.

[A case of CD20 positive mediastinal rhabdomyosarcoma]. / B Lenfosit Belirleyicisi Cd20 Pozitif Mediastinal Rabdomyosarkom Olgusu.

We present the case of a 16-year-old boy admitted with a large mediastinal mass. Both in the mediastinal tru-cut biopsy and the bone marrow biopsy, a malignant small round cell tumor was determined. The clinical diagnosis was leukemia or lymphoma. The cytoplasmic CD20 expression was shown on the tumor cells of the mediastinal tru-cut biopsy. Rhabdomyosarcoma was diagnosed by the flow cytometric analysis and immunohistochemical demonstration of muscle markers. Rhabdomyosarcomas are traditionally distinguished from lymphomas by their absence of lymphoid markers such as CD20. But in this case we have encountered CD20 expression in the tumor cells. This finding lead us to conclude that the presence of a lymphoid phenotype does not absolutely exclude the diagnosis of rhabdomyosarcoma.

A case of Churg-Strauss syndrome treated with montelukast.

OBJECTIVE: To report a case of Churg-Strauss syndrome who had asthma and allergic rhinitis treated with montelukast. CLINICAL PRESENTATION AND INTERVENTION: A nonsmoking 59-year-old woman presented with fever, hemoptysis and dyspnea. Past medical history included allergic rhinitis and asthma which were diagnosed 18 years ago. The asthma was treated successfully with inhaled salmeterol and beclamethasone. She also received montelukast (10 mg/day) for 3 years. Although her chest X-ray was normal a week earlier, she had widespread bilateral pulmonary infiltrates on admission. She had leukocytosis (12.5 × 10(9)/l) with eosinophilia (15.6%). Her total IgE count was 550 U/ml. Testing for protoplasmic-staining antineutrophil cytoplasmic antibodies was positive. Bronchoalveolar lavage could not be performed due to bronchospasm and severe hypoxemia; however, mucosal biopsies were obtained, which revealed eosinophil leukocytes in the lumen and walls of small vessels. She was diagnosed to have Churg-Strauss syndrome and had remarkable clinical improvement on day 5 with high-dose of oral prednisolone (50 mg/day). Radiological improvement was detected at the end of the second week. CONCLUSION: This case shows the importance of being aware that leukotriene receptor antagonists could cause Churg-Strauss syndrome, in spite of the uncertainty about its mechanism.

[Prognostic value of epithelial growth factor receptor, vascular endothelial growth factor, E-cadherin, and p120 catenin in resected non-small cell lung carcinoma]. / Valor pronóstico del receptor del factor de crecimiento epitelial, factor de crecimiento endotelial vascular, E-cadherina, y p120 catenina en el carcinoma de pulmón no microcítico resecado.

INTRODUCTION: Several markers have been investigated to predict the prognosis of lung cancer. In the present study, the prognostic values of epithelial growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), E-cadherin, and p120 catenin expression were investigated by immunohistochemistry in patients with a surgically resected non-small cell lung carcinoma (NSCLC). PATIENTS AND METHOD: EGFR, VEGF, E-cadherin, and p120 catenin expression were prospectively determined in resected specimens from patients with NSCLC who had undergone surgery between 2003 and 2007. Patients' and disease-related general characteristics and survival rate were recorded. RESULTS: One hundred seventeen patients with a mean age of 61.3 years were included in the study. After a mean follow-up of 27.5 months, the median survival was determined to be 44.0 months and the 5-year survival was 46.2%. The 5-year survival in negative and positive staining groups were as follows; 32% and 66.7% for EGFR (p = 0.02), 37.8% and 50.7% for VEGF (p = 0.5), 41% and 66% for E-cadherin (p = 0.19), 46% and 50% for p120 catenin (p = 0.27). The differentiation, N status, stage and EGFR staining were variables significantly affecting survival (p = 0.001, 0.006, 0.03 and 0.02 respectively). In multivariate Cox analysis, the EGFR staining level and N status were variables those significantly affecting survival (p = 0.021 and p = 0.010). CONCLUSIONS: While negative staining of EGFR was related with poor survival, staining of VEGF, E-cadherin, and p120 catenin were not related with survival in patients with resected NSCLC.

Seven years experience of bronchogenic cysts.

OBJECTIVE: To reveal the clinical, radiological, and surgical results of bronchogenic cysts. METHODS: Patients that underwent surgical procedure between January 2000 and June 2007, at Izmir Dr. Suat Seren Chest Disease and Thoracic Surgery Training Hospital, Izmir, Turkey with a radiological diagnosis of bronchogenic cyst were assessed retrospectively. Patients with confirmed histopathologically bronchogenic cyst (n=28) were evaluated for age, gender, symptoms, clinical and radiological signs, procedure of surgical treatment, and post-operative complications. RESULTS: There were 12 females, 16 males, and the mean age was 45.3 (25-73) years. Cysts were located at the pulmonary parenchyma in 53.5%, at the mediastinum in 43%, and at the intrathoracic extrapulmonary in 3.5%. There was no relation between localization and gender (p=0.276), and localization and the presence of symptoms (p=0.409). Frequently seen symptoms were dyspnea and chest pain. Cysts were infected in 11%, and intact in 89%. The average diameter of the cysts was 6.18 cm (2-12). Surgical complete resection was performed via thoracotomy in all patients. Mean follow-up time was 36 months, and there was no death. Minor postoperative complications occurred in 3 patients. CONCLUSION: Radiology alone may not be enough for diagnosis of bronchogenic cysts in all patients. Early surgical intervention is suggested for the exact diagnosis and prevention of operative difficulties and complications.

Inflammatory myofibroblastic tumor presenting as a large mass and a spontaneously resolving nodule in the lung.

A 21-year-old woman presented with nausea, vomiting, decrease in appetite, and weight loss of 6 months and right chest pain of 5 days' duration. Earlier diagnostic work-ups had been inconclusive, and she was referred for the evaluation of the bilateral lung lesions as seen on her chest x-ray. Thoracic computed tomography scan showed a 6-cm mass in the right lower lobe, a minimal right pleural effusion, and a peripheral 2-cm cavitary nodule in the inferior lingular segment. Ultrasonography-guided transthoracic cutting needle biopsy of the right-sided mass and following right lower lobectomy both yielded benign specimens pathologically assessed as "inflammatory myofibroblastic tumor." The chest x-ray and thoracic computed tomography scans obtained 1 month following the thoracotomy showed spontaneous and almost complete resolution of the left-sided nodule. In follow-up 1 year after the surgery, no clinical, laboratory, or radiologic recurrence was detected. She is being closely followed as an outpatient.