Autochtonal case of chronic, unifocal, pulmonary paracoccidioidomycosis with methotrexate use, in Salvador ‒ Brazil.

We report an autochthonous case of mild unifocal chronic pulmonary paracoccidioidomycosis in a 48-year-old previously healthy woman with no history of possible environmental exposures in endemic rural areas, supposedly resulting from reactivation of a latent pulmonary focus secondary to the use of methotrexate for the control of Chikungunya arthropathy. Laboratory investigation ruled out other immunosuppression. Her only symptoms were a dry cough and chest pain. Diagnosis confirmed by needle lung biopsy. There were no abnormalities on physical examination nor evidence of central nervous system involvement. MRI of the total abdomen showed no involvement of other organs. Computed chest tomography showed a favorable evolution under the use of itraconazole (200 mg/day). Different tomographic presentations findings are highlighted when performed before and after treatment. CONCLUSIONS: PCM should be considered even in a woman without a history of consistent environmental exposure and in a non-endemic geographic area.

Autochtonal case of chronic, unifocal, pulmonary paracoccidioidomycosis with methotrexate use, in Salvador ‒ Brazil

Abstract Summary We report an autochthonous case of mild unifocal chronic pulmonary paracoccidioidomycosis in a 48-year-old previously healthy woman with no history of possible environmental exposures in endemic rural areas, supposedly resulting from reactivation of a latent pulmonary focus secondary to the use of methotrexate for the control of Chikungunya arthropathy. Laboratory investigation ruled out other immunosuppression. Her only symptoms were a dry cough and chest pain. Diagnosis confirmed by needle lung biopsy. There were no abnormalities on physical examination nor evidence of central nervous system involvement. MRI of the total abdomen showed no involvement of other organs. Computed chest tomography showed a favorable evolution under the use of itraconazole (200 mg/day). Different tomographic presentations findings are highlighted when performed before and after treatment. Conclusions PCM should be considered even in a woman without a history of consistent environmental exposure and in a non-endemic geographic area.

Revisiting the Rich's formula: an update about granulomas in human tuberculosis

The formula proposed by Rich in 1951 explained the formation in a tuberculous lesion in a period that was unknown cellular functions, cytokines and other immunological aspects involved in granuloma formation by tuberculosis; its components are assembled conceptually to explain the pathogenic mechanisms involved in the granulomatous lesion in tuberculosis. In this manuscript, we report an update of Rich's formula based on the new and old concepts about pathogenic mechanisms involved in the granulomatous lesion in tuberculosis. Current knowledge allows us to conclude that the balance between the characteristics of the bacillus and host protective response is necessary to indicate the outcome of pathogenesis, infection or active disease and the necrosis degree of the tuberculosis lesion.

Revisiting the Rich's formula: an update about granulomas in human tuberculosis.

The formula proposed by Rich in 1951 explained the formation in a tuberculous lesion in a period that was unknown cellular functions, cytokines and other immunological aspects involved in granuloma formation by tuberculosis; its components are assembled conceptually to explain the pathogenic mechanisms involved in the granulomatous lesion in tuberculosis. In this manuscript, we report an update of Rich's formula based on the new and old concepts about pathogenic mechanisms involved in the granulomatous lesion in tuberculosis. Current knowledge allows us to conclude that the balance between the characteristics of the bacillus and host protective response is necessary to indicate the outcome of pathogenesis, infection or active disease and the necrosis degree of the tuberculosis lesion.

Is tuberculosis difficult to diagnose in childhood and adolescence?

OBJECTIVE: To determine the sensitivity of the scoring system proposed by the Brazilian National Ministry of Health in 2002 for the diagnosis of tuberculosis in children and adolescents suspected of having the disease. METHODS: This was a retrospective study of 316 children and adolescents (0-14 years of age) diagnosed with pulmonary tuberculosis between 1997 and 2007 at the Brazilian Institute for Tuberculosis Research, located in the city of Salvador, Brazil. After reviewing the medical charts and chest X-rays of the patients, we calculated the tuberculosis scores. RESULTS: The majority of the subjects (80.4%) had a history of close household contact with an AFB-positive adult within the last two years. The tuberculin test was negative in 11 subjects (3.5%). According to the scoring system, 251 (79.4%) were very likely to have tuberculosis (score, > 40), 63 (19.9%) were moderately likely to have tuberculosis (score, 30-35), and 2 (0.7%) were unlikely to have tuberculosis (score, < 25). When a cut-off score of 30 was used, the sensitivity of this scoring system was 99.3%. CONCLUSIONS: In our sample, the sensitivity of this scoring system was high when the selected cut-off score was employed. If a cut-off score of 40 had been used, 20% of the subjects would not have been treated. Therefore, scores between 30 and 35 are critical for diagnostic confirmation. Judicious clinical evaluation should prevail in the decision of treating these patients. When the cut-off score of 30 is used, 30% of individuals with other pathologies will be treated for tuberculosis. This highlights the need for improved diagnostic methods for tuberculosis.

A tuberculose na infância e na adolescência é difícil de diagnosticar? / Is tuberculosis difficult to diagnose in childhood and adolescence?

OBJETIVO: Determinar a sensibilidade do sistema de escore proposto pelo Ministério da Saúde do Brasil em 2002 para o diagnóstico de crianças e adolescentes com suspeita de tuberculose. MÉTODOS: Entre 1997 e 2007, 316 crianças e adolescentes (0-14 anos de idade) com diagnóstico de tuberculose pulmonar no Instituto Brasileiro de Investigação da Tuberculose, em Salvador (BA), foram incluídos no presente estudo retrospectivo. Foram revisados os prontuários médicos e as radiografias de tórax dos pacientes, e os escores foram calculados. RESULTADOS: A maioria dos sujeitos (80,4 por cento) tinha história de contato domiciliar com adultos com BAAR positivo nos últimos dois anos. O teste tuberculínico foi negativo em 11 sujeitos (3,5 por cento). Conforme o sistema de escore, 251 (79,4 por cento) muito provavelmente tinham tuberculose (escores > 40), 63 (19,9 por cento) possivelmente tinham tuberculose (escores entre 30 e 35) e 2 (0,7 por cento) pouco provavelmente tinham tuberculose (escores < 25). A sensibilidade desse sistema de escore foi de 99,3 por cento, com um ponto de corte de 30. CONCLUSÕES: Em nossa amostra, a sensibilidade do sistema de escore foi alta para o ponto de corte selecionado. Com um ponto de corte de 40, 20 por cento dos sujeitos não teriam sido tratados. Portanto, escores entre 30 e 35 são críticos para a definição diagnóstica. Uma avaliação clínica judiciosa deve prevalecer para a decisão de tratar esses pacientes. Com um ponto de corte de 30, 30 por cento dos indivíduos com outras patologias seriam tratados para tuberculose. Isto enfatiza a necessidade de melhores métodos diagnósticos para a tuberculose.

OBJECTIVE: To determine the sensitivity of the scoring system proposed by the Brazilian National Ministry of Health in 2002 for the diagnosis of tuberculosis in children and adolescents suspected of having the disease. METHODS: This was a retrospective study of 316 children and adolescents (0-14 years of age) diagnosed with pulmonary tuberculosis between 1997 and 2007 at the Brazilian Institute for Tuberculosis Research, located in the city of Salvador, Brazil. After reviewing the medical charts and chest X-rays of the patients, we calculated the tuberculosis scores. RESULTS: The majority of the subjects (80.4 percent) had a history of close household contact with an AFB-positive adult within the last two years. The tuberculin test was negative in 11 subjects (3.5 percent). According to the scoring system, 251 (79.4 percent) were very likely to have tuberculosis (score, > 40), 63 (19.9 percent) were moderately likely to have tuberculosis (score, 30-35), and 2 (0.7 percent) were unlikely to have tuberculosis (score, < 25). When a cut-off score of 30 was used, the sensitivity of this scoring system was 99.3 percent. CONCLUSIONS: In our sample, the sensitivity of this scoring system was high when the selected cut-off score was employed. If a cut-off score of 40 had been used, 20 percent of the subjects would not have been treated. Therefore, scores between 30 and 35 are critical for diagnostic confirmation. Judicious clinical evaluation should prevail in the decision of treating these patients. When the cut-off score of 30 is used, 30 percent of individuals with other pathologies will be treated for tuberculosis. This highlights the need for improved diagnostic methods for tuberculosis.

Pseudotumoral form of primary progressive tuberculosis: a diagnosis to be considered.

The diversity of clinical presentations of primary progressive tuberculosis (TB) and the difficulty in establishing the diagnosis of paucibacillary forms is the subject of painstaking research, as well as a cause of delay in therapy. We report the case of a 10-year-old black child who presented with chest pain and progressive widening of the upper mediastinum. Computerized tomography of the chest revealed multiple calcifications that were not identified with X-rays. Biopsy through mediastinoscopy was compatible with a diagnosis of tuberculosis. Despite exhaustive investigation that included direct examination, culture for mycobacteria and PCR (Polymerase Chain Reaction) of tissue samples, the etiologic agent was not revealed. Tuberculin conversion was observed during the follow-up and resolution period of the lesion, after administration of isoniazid, rifampicin and pyrazinamide. The nodal pseudotumoral form of tuberculosis is rare in immunocompetent children and it may simulate neoplastic disease; therefore, it should be included in the list of differential diagnoses of masses located in the anterosuperior mediastinum.

Pseudotumoral form of primary progressive tuberculosis: a diagnosis to be considered

The diversity of clinical presentations of primary progressive tuberculosis (TB) and the difficulty in establishing the diagnosis of paucibacillary forms is the subject of painstaking research, as well as a cause of delay in therapy. We report the case of a 10-year-old black child who presented with chest pain and progressive widening of the upper mediastinum. Computerized tomography of the chest revealed multiple calcifications that were not identified with X-rays. Biopsy through mediastinoscopy was compatible with a diagnosis of tuberculosis. Despite exhaustive investigation that included direct examination, culture for mycobacteria and PCR (Polymerase Chain Reaction) of tissue samples, the etiologic agent was not revealed. Tuberculin conversion was observed during the follow-up and resolution period of the lesion, after administration of isoniazid, rifampicin and pyrazinamide. The nodal pseudotumoral form of tuberculosis is rare in immunocompetent children and it may simulate neoplastic disease; therefore, it should be included in the list of differential diagnoses of masses located in the anterosuperior mediastinum

Histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis) in an HIV-positive patient.

Histiocytic necrotizing lymphadenitis, or Kikuchi's lymphadenitis (KL), is an unusual form of lymphadenitis, generally with self-limited clinical course. KL has been reported in rare patients infected with the human immunodeficiency virus (HIV). Pathogenesis of the lesion is probably related to an impaired immune function. The purpose of the present article is to report on one case in which KL was diagnosed in an HIV-infected patient. Histomorphology and immunophenotype were similar to previous reports, but a focus of activated CD30+ macrophages was seen, what might be due to the immunological status of the patient. EBV was not detected on the sections using the in situ hybridization technique. Although rare, the occurrence of KL in HIV-infected subjects must be emphasized, because of the potential misdiagnosis of malignancy, especially in the presence of CD30+ cells.

Histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis) in an HIV-positive patient

Histiocytic necrotizing lymphadenitis, or Kikuchi's lymphadenitis (KL), is an unusual form of lymphadenitis, generally with self-limited clinical course. KL has been reported in rare patients infected with the human immunodeficiency virus (HIV). Pathogenesis of the lesion is probably related to an impaired immune function. The purpose of the present article is to report on one case in which KL was diagnosed in an HIV-infected patient. Histomorphology and immunophenotype were similar to previous reports, but a focus of activated CD30+ macrophages was seen, what might be due to the immunological status of the patient. EBV was not detected on the sections using the in situ hybridization technique. Although rare, the occurrence of KL in HIV-infected subjects must be emphasized, because of the potential misdiagnosis of malignancy, especially in the presence of CD30+ cells

Pulmonary cavities colonized by actinomycetes: report of six cases

Seis casos de bola pulmonar intracavitária formada por Actinomycetes säo descritos. Eles foram observados no Estado da Bahia, Brasil. Todos os pacientes queixavam-se de tosse e hemoptise e o estudo histopatológico mostrou bronquiectasias e pequenas cavidades no tecido pulmonar. Tais lesöes eram ocupadas por microcolônias de Actinomyces, identificados morfologicamente através de propriedades tintoriais e cultura em dois casos (meio de tioglicolato). Nos seis pacientes, a doença estava limitada aos pulmöes. Em um paciente gräos foram encontrados, próximo à cavidade colonizada, dentro de microabscesso no interior do parênquima. Provavelmente a invasäo ocorreu devido à ulceraçäo da mucosa brônquica que estava coberta por tecido de granulaçäo. O autor sugere que à semelhança da nocardiose, o espectro da actinomicose deve ter uma forma invasiva, uma saprofítica, podendo apresentar uma terceira, como colonizador de cavidades pulmonares pré-existentes

Mediastinal and pulmonary entomophthoromycosis with superior vena cava syndrome: case report

O primeiro caso de entomoftoromicose mediastinal e pulmonar com síndrome de veia cava superior, é descrito. A paciente apresentou-se com história de edema facial, cervical e de membros superiores, bem como circulaçäo colateral na parede anterior do tórax. O estudo histopatológico do tecido do mediastino, próximo a veia cava, revelou reaçäo granulomatosa com microabscessos, circundados por material amorfo, eosinfílico e com hifas largas no centro. Cultura näo foi realizada porque o diagnóstico clínico foi de doença de Hodkin ou de um linfoma näo Hodgkin. Correçäo cirúrgica da área obstruida foi realizada e a paciente tratada com iodeto de potássio, nas doses preconizadas, obtendo-se sucesso. Os autores propöem que a entomoftoromicose mediastinal deva ser considerada no diagnóstico diferencial de doença causando síndrome de veia cava superior em regiöes tropicais e sub tropicais. Este caso aumenta o espectrum de manifestaçöes clínicas das zigomicoses causadas por Entomophthoraceae

Tumores carcinóides de pulmäo: estudo comparativo entre as variantes clássica e atípica com ênfase do seguimento clinico e aspectos morfológicos e imuno-histoquímicos / Carcinoid tumors of the lung: a histological, immunohistochemical and follow-up of atypical and typical variants

Dez casos de tumores carcinóide de pulmäo, tratados cirurgicamente entre 1977 e 1984, foram analisados à histologia e imuno-histoquímica. Compararam-se os padröes histológicos com os dados de seguimento clínico em nove deles. Seis mostraram histologicamente padräo em mosaico e trabecular. Houve um caso de padräo oncocitóide, um de fusiforme e dois foram diagnosticados como variantes atípicas. A imunohistoquímica, todos os casos mostraram reaçöes positivas, com variaçäo desde um padräo difuso com enolase e cromogranina até positividade focal com proteína S-100. No seguimento, os casos com atipia falecram respectivamente 16 e 26 meses após a cirurgia, com metástases sistêmicas. Um caso clássico desenvolveu metástase hepática e retrocular antes do 84§ mês de seguimento e o restante mostra-se assintomático. O diagnóstico diferencial entre a variante atípica e outras neoplasias pulmonares, como paragangliomas e carcinoma anaplásico de pequenas células, é discutido

Teratomas pulmonares benignos: relato de dois casos / Benign lung teratomas: report of 2 cases

Dois casos de teratomas pulmonares säo descritos, correspondendo 24§ e 25§ divulgados até entäo. O primeiro caso de uma mulher de 28 anos, com sintomatologia de pequenas hemoptises de repetiçäo e tosse, durante cinco anos. Radiologicamente a lesäo correspondia a consolidaçäo paracardíaca, no interior da qual esboçava-se cavidade com aparente conteúdo. Com este dado, a hipótese de bola fúngica intracavitária foi aventada. Na cirurgia verificou-se que a lesäo localizava-se no lobo médio, tendo entäo sido feita a ressecçäo. Histologicamente verificou-se que a lesäo continha elementos dos três folhetos embrionários, com ênfase a tecido tímico e pancreático. No brônquio que comunicava diretamente com a lesäo, observaram-se alteraçöes de metaplasia escamosa, displasia, até carcinoma in situ. Este tipo de associaçäo näo fora até entäo observada nos casos anteriores. Säo discutidos possíveis elementos envolvidos na gênese desta alteraçäo da mucosa brônquica, enfatizando-se os aspectos irritativos locais. O segundo caso, de um homem de 41 anos com sintomatologia de tosse, hemoptise e múltiplos episódios de eliminaçäo de pêlos através do escarro. O estudo radiológico mostrava massa de aspecto tumoral na zona média do hemitórax direito, com evidência ainda de espessamento pleural. Internado de urgência com hemoptise grave, seguida de choque hipovolêmico e óbito. A necrópsia revelou lesäo localizada na porçäo inferior do lobo superior e envolvendo ainda lobo inferior de pulmäo direito. Histologicamente a lesäo estava constituída de epiderme e anexos cutâneos, mas estando ainda presentes elementos derivados do mesoderma e endoderma, todos bem diferenciados

Hidatidose pulmonar - relato do primeiro caso autoctone na Bahia. / Pulmonary hydatidosis - report of the first autochthous case in Bahia

O primeiro caso autoctone de cisto hidatico roto de pulmao visto no Estado da Bahia e relatado. Os autores discutem os achados clinicos e radiologicos, pouco sugestivos desta entidade no presente caso. Alem dos aspectos epidemiologicos, analisam-se os dados anatomo-patologicos, dando-se enfase a tecnica de Grocott, pela impregnacao argentia dos fragmentos de extrato laminar da parede como do cisto. Esta tecnica de Grocott ate entao nao utilizada nesta zoonose, mostrou-se importante como mais um metodo para identificacao de fragmentos da parede cistica, em suas formas rotas

Fibrossarcoma e fibro-histiocitoma maligno do pulmao.Consideracoes acerca de quatro casos. / Malignant fibrosarcoma and histiocytoma of the lung: consideration upon 4 cases

Sao descritos aspectos anatomo-clinicos de quatro pacientes com sarcomas primitivos do pulmao (tres casos de fibrossarcoma e um fibro-histiocitoma maligno), dois dos quais foram submetidos a resseccoes cirurgicas em condicoes adequadas o indice mais fidedigno para avaliacao do prognostico nesta neoplasia foi a contagem de mitoses/ 10 campos de grande aumento (CGA), observando-se sobrevida pos-operatoria de quatro anos do paciente que exibia apenas 2 mitoses/10 CGA