On the fence: Combining multimodal imaging and laparoscopy for diagnosing tuberculous peritonitis.

Tuberculous peritonitis (TB peritonitis) is one of the most challenging forms of extrapulmonary TB to diagnose. While tumor markers can be elevated in patients with TB peritonitis, FDG-PET/CT can aid in distinguishing TB peritonitis from malignancies, if an apron-like omentum pattern is seen. Laparoscopy is crucial for accurate and early diagnosis.

[PULMONARY TUBERCULOSIS AND TUBERCULOUS PLEURISY COMPLICATED WITH RIFAMPICIN-INDUCED HYPOTHYROIDISM: A CASE REPORT].

Rifampicin can induce hypothyroidism. We report a case of pulmonary tuberculosis and tuberculous pleurisy that was complicated by rifampicin-induced hypothyroidism. The patient received rifampicin-based tuberculosis treatment and experienced persistent appetite loss, which led us to pro- vide concomitant hypothyroidism treatment. An 85-year-old woman with no underlying thyroid-related disease presented to her local hospital with a 3-month history of appetite and weight loss. A chest radiograph revealed pleural effusions and infiltrative shadows in the lower fields of both lungs, and we also detected high levels of lympho- cytes and adenosine deaminase levels (49.6 IU/1) in the pleu- ral effusion, with positive results from a polymerase chain reaction assay of a sputum sample. Thus, we diagnosed the patient with pulmonary tuberculosis and tuberculous pleurisy, and initiated treatment using isoniazid, rifampicin, etham- butol, and pyrazinamide. Her clinical course was good and her anorexia was improved. However, she subsequently experienced recurrent appetite loss, malaise, and bilateral lower-leg edema. Follow-up laboratory testing revealed that she had developed hypothyroidism. We started treatment using levothyroxine without interrupting the tuberculosis treatment. The loss of appetite and other thyroid-related symptoms were improved. The patient's thyroid function had been normal at her admission, and there were no findings of Hashimoto's thyroiditis or other thyroid conditions. Based on the clinical course, we conclude that the rifampicin induced the hypothyroidism. Therefore, rifampicin-induced hypothyroidism should be considered in cases with persistent appetite loss, even if the patient appears to be experiencing anorexia as an adverse drug reaction.

A 38-year-old man with pulmonary hypertension, who had undergone atrial septal closure 26 years previously.

The patient was a 38-year-old man. He underwent atrial septal closure at the age of 12 years at Yokohama City University Hospital, when he already had pulmonary vascular change and reduced left-to-right shunt with Qp/Qs of 1.55 and pulmonary artery pressure (PA) of 56/22 mmHg. Thereafter, he enjoyed running and skiing without any symptoms up until 32 years of age, when he developed syncope due to severe pulmonary hypertension and atrial flutter. PA was 116/57 mmHg and mRA was 13 mmHg on cardiac catheterization. He developed right heart failure and was referred to Keio University Hospital on May 12th, 2001. Home intravenous prostacyclin infusion therapy was introduced in addition to treatment for right heart failure. Echocardiography revealed a residual interatrial shunt (from right to left). He recovered and was discharged. His condition worsened again and he was readmitted to our hospital with chief complaint of visual disturbance due to digoxin intoxication, in addition to right heart failure. Despite aggressive treatment, he died of severe pulmonary hypertension, right heart failure and congestive hepatic failure on December 10th, 2001. The differential diagnosis, pathophysiology and necessary treatment of pulmonary hypertension are discussed in this paper. The clinical diagnosis was Eisenmenger syndrome due to atrial septal defect, and the pathological findings were compatible with this.