Adenopatías mediastínicas y tos en paciente con enfermedad de Crohn y psoriasis. Un reto diagnóstico / Intrathoracic lymph nodes and cough in a patient with Crohn’s disease and psoriasis. A diagnostic challenge

La mesalazina está aprobada como tratamiento de primera línea para inducción y mantenimiento a largo plazo en enfermedad inflamatoria intestinal de leve a moderadamente activa. Las reacciones adversas pulmonares documentadas en ensayos clínicos se consideran muy raras (< 1/10.000 pacientes), sin embargo, existen numerosos casos publicados que relacionan el fármaco con toxicidad pulmonar. La relación temporal entre el inicio del tratamiento y la aparición de síntomas respiratorios no siempre es evidente, si bien en la mayoría de publicaciones va desde 3 a 15 meses. Realizar un diagnóstico correcto y suspender precozmente el fármaco es fundamental para evitar que la afectación pulmonar subaguda y tratable progrese a crónica con hallazgos de fibrosis irreversibles. Se presenta el caso de un paciente de 26 años con enfermedad de Crohn y psoriasis, que desarrolla neumonitis por hipersensibilidad subaguda de forma secundaria al tratamiento con mesalazina, debutando los primeros síntomas tras 31 meses de tratamiento

Mesalamine is approved as a first line treatment for induction and long term maintenance for patients with mild to moderately active inflammatory bowel disease. Pulmonary adverse reactions documented in clinical trials are considered very rare (< 1/10,000 patients), however, there are numerous published cases that relate the drug to pulmonary toxicity. The temporal relationship between the onset of treatment and the onset of respiratory symptoms is not always evident, although in most publications it goes from 3 to 15 months. Making a correct diagnosis and stopping the drug early is essential to prevent subacute and treatable pulmonary involvement from progressing to chronic with irreversible fibrosis findings. We report the case of a 26-year-old patient with Crohn’s disease and psoriasis, who develops subacute hypersensitivity pneumonitis secondary to treatment with mesalamine, starting the first symptoms after 31 months of treatment

[Sarcoid-like granulomatosis in cancer patients treated with immune checkpoints inhibitors]. / Granulomatose sarcoïdosique survenant sous inhibiteurs de point de contrôle immunitaire.

INTRODUCTION: Immune checkpoint inhibitors are becoming a standard treatment for many different cancers. Their toxicities are variable and include organ-specific dysimmune injuries and the development of systemic diseases. CASE REPORT: We report 3 cases of sarcoid-like granulomatosis that occurred during treatment of various types of primary cancer by immune checkpoint inhibitors: lung adenocarcinoma, small cell lung cancer and melanoma. The clinical presentation, radiologic pattern and severity of this toxicity were variable. The diagnosis was made on biopsy with pathological examination and exclusion of differential diagnoses, particularly infection. In such cases, immunotherapy should be discontinued and subsequent rechallenge discussed later. Systemic corticosteroids should be considered depending on the severity of symptoms. CONCLUSIONS: Knowledge of this toxicity is crucial as the clinical signs and radiological patterns may suggest tumour progression.

[Massive intraatrial mass?] / Panique dans l'oreillette.

Posterior mediastinal hematoma in a rare and potentially lethal disease and is frequently consecutive to a traumatism. We report the original case of a 88-year-old male admitted to our department for lipothymia and syncope related to a severe compression of the left atrium by an important mediastinal hematoma mimicking in transthoracic echocardiography an obstructive intraatrial mass.

Dapsone hypersensitivity syndrome-related lung injury without eosinophilia in the bronchoalveolar lavage fluid.

A 73-year-old man was admitted in respiratory failure that had subacutely progressed after five weeks of dapsone treatment for a skin rash. He also presented with fever, systemic erythroderma and liver dysfunction. Chest computed tomography showed diffuse reticular shadows with ground-glass opacity and bilateral mediastinal lymphadenopathy. Lymphocytes, but not eosinophils, were increased in the bronchoalveolar lavage fluid. Moreover, reactivation of human herpes virus-6 was confirmed on a paired serum test. Finally, we diagnosed the patient with dapsone hypersensitivity syndrome (DHS), a rare adverse event of this drug. Lung injury unaccompanied by eosinophilia in the bronchoalveolar lavage fluid is even more rare as a DHS-related lung manifestation.

[Sarcoidosis after adalimumab treatment in inflammatory rheumatic diseases: a report of two cases and literature review]. / Sarcoïdose survenant chez des patients traités par adalimumab pour un rhumatisme inflammatoire: à propos de deux cas et revue de la littérature.

CONTEXT: TNF α antagonists (anti-TNF α) are widely used in inflammatory rheumatic diseases: rheumatoid arthritis (RA) and spondylarthropathy (SpA). The efficacy of the anti-TNF α monoclonal antibodies was also observed in unresponsive sarcoidosis to conventional therapy. In contrast, sarcoidosis in patients with inflammatory rheumatic disease treated with anti-TNF α keep on growing, with a suspected role of anti-TNF α in this pathological process. METHODS: We presented here two cases of sarcoidosis developing while the patient was on adalimumab (ADA) therapy for inflammatory rheumatic disease. In one case, the reintroduction of ADA led to increase in symptomatology. We also analyzed the 16 other cases of sarcoidosis developing under ADA treatment published in literature, mostly in RA patients. RESULTS: These cases show a possible paradoxical effect of ADA in sarcoidosis development in patients treated with anti-TNFα monoclonal antibodies. The iatrogenic mechanism remains unclear. These cases underline the importance of a drug-induced etiology survey facing any symptomatology suggesting the development of sarcoidosis in patients treated with anti-TNF α for an inflammatory rheumatic disease.

New-onset mediastinal and central nervous system sarcoidosis in a patient with metastatic melanoma undergoing CTLA4 monoclonal antibody treatment.

BACKGROUND: Ipilimumab, a cytotoxic monoclonal antibody that inhibits cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), has been established as an effective therapy in the management of advanced melanoma. Immune-mediated adverse events are a common side effect. CASE REPORT: A 37-year-old male patient was diagnosed with nodal and osseous metastatic melanoma 15 months after the initial surgical treatment for lower limb melanoma. Therapy with the anti-CTLA-4 antibody, ipilimumab, was started. Follow-up staging imaging after treatment initiation showed symmetrical bihilar adenopathy. Transbronchial biopsy showed sarcoidosis. The patient had associated systemic symptoms of fatigue, joint pains, anorexia and weight loss. Brain magnetic resonance imaging (MRI), which was performed for the investigation of headaches, showed abnormal enhancing tissue in the sella turcica and adjacent to the pituitary infundibulum, consistent with neurosarcoidosis. The condition was successfully treated with corticosteroids. CONCLUSIONS: We report a case of immunotherapy-induced mediastinal/hilar sarcoidosis, with pituitary involvement, mimicking tumour progression. This highlights the need for awareness amongst radiologists and oncologists of the mechanism of action and potential side effects of new immunotherapies.

Spontaneous mediastinal haematoma: a rare complication of warfarin therapy.

A 64-year-old woman presented with shortness of breath, right-sided pleuritic chest pain and dry cough. She was systemically anticoagulated with warfarin for a pulmonary embolism diagnosed 3 months previously, with an international normalised ratio (INR) of 3.0 on presentation. Chest radiograph demonstrated a new right paratracheal abnormality, and CT scan showed a large mediastinal mass not present 3 weeks earlier. MRI demonstrated an ovoid mass with a fluid/fluid level with high T2 and dark T1 signal consistent with a mediastinal haematoma. The patient's anticoagulation was emergently reversed and a temporary inferior vena cava filter was placed. The haematoma slowly resolved on serial follow-up with no additional intervention. Spontaneous mediastinal haematoma is a rare but life-threatening diagnosis that frequently presents with chest pain, dry cough and dysphagia. It is frequently associated with therapeutic anticoagulation and may potentially be caused by sudden, atraumatic rise in intrathoracic pressure (ie, cough or emesis).

Boerhaave's syndrome - rapidly evolving pleural effusion; a radiographic clue.

Boerhaave's syndrome is the rare and often fatal condition of spontaneous esophageal rupture. Meckler's triad of vomiting, pain and subcutaneous emphysema are characteristic features of Boerhaave's syndrome. When these symptoms are absent, diagnosis is frequently late and often occurs as the result of incidental investigation. This contributes to the observed high morbidity and mortality. Unless specifically considered in the differential diagnosis, this rare disease is frequently overlooked. The authors described the case of a patient in whom the diagnosis was made several days following presentation by observing that a large pleural effusion had evolved rapidly on chest radiographs. This uncommon radiological sign has relatively few causes and prompted a review of the history and diagnosis, followed by the initiation of additional investigations that confirmed Boerhaave's syndrome.

[Precocious mediastinal lipomatosis: a rare complication of systemic corticosteroid therapy]. / Lipomatose médiastinale précoce: une complication exceptionnelle de la corticothérapie generale.

BACKGROUND: Corticosteroid-induced lipomatosis results from hypertrophy within adipose tissue; the condition is frequently asymptomatic and its incidence is underestimated. We report a case of mediastinal lipomatosis that is rare in terms of both site and presenting symptoms. CASE REPORT: A 46-year-old woman with no disease history other than obesity with a weight of 90 kg had been treated since 2002 for mixed connective tissue disease (profound lupus and dermatomyositis). She had been treated with oral corti costeroids (1 mg/kg/d). Two months after the start of treatment, she presented chest pains, resting dyspnea particularly aggravated in dorsal decubitus, chest edema in the subclavicular space and jugular turgescence. Chest x-ray revealed widening of all levels of the mediastinum. The chest CT scan showed lipomatosis throughout the entire mediastinum with no associated chest abnormalities or pericardial effusion. Rapid downward dosage adjustment ofcorticosteroids to 10 mg/d coupled with synthetic antimalarials resulted in gradual reduction of symptoms. The chest scan performed two months later short stabilization of the patient's mediastinal lipomatosis. DISCUSSION: The effects of long-term of glucocorticosteroid therapy are well-known, in particular Cushing's syndrome. Lipomatosis has been described more recently and affects different axial regions. Mediastinal localization is seen in 15% of patients treated. This presentation is less common than orbital and epidural localizations. Although often asymptomatic, as in our own report, it may present with worrying symptoms that pose real diagnostic problems. The diagnostic examinations of choice are CT scan or MRI. Regression following discontinuation or reduction of corticosteroids is inconsistent and often gradual.

Anesthetic considerations in steroid-induced mediastinal lipomatosis.

UNLABELLED: Mediastinal lipomatosis (ML) is a benign condition characterized by circumscribed overgrowth of adipose tissue producing mediastinal widening that can cause errors in diagnosis on chest roentgenogram. We describe a case of steroid-induced ML leading to difficulty in central venous catheterization during surgery and its other implications for anesthesiologists. Because many patients receive long-term steroid administration and present for surgical intervention, it is essential that they undergo detailed preoperative evaluation to exclude Cushing's syndrome and various pressure effects. IMPLICATIONS: This case report highlights problems during right internal jugular vein cannulation resulting from high back pressure and flow from superior vena cava obstruction in steroid-induced mediastinal lipomatosis. Other anesthetic considerations in mediastinal lipomatosis are also discussed.