Granulomatous Pneumocystis jiroveci Pneumonia in an HIV-Positive Patient on Antiretroviral Therapy: A Diagnostic Challenge.

Human Immunodeficiency Virus (HIV)-related Opportunistic Infections (OI), including Pneumocystis jiroveci pneumonia (PCP), have become much less commonplace with anti-retroviral therapy (ART). Despite this, OIs are still common and it is important to remain vigilant for their presence and be aware of how ART and OI chemoprophylaxis may lead to atypical disease presentations. We present the case of a 51-year-old woman with HIV and CD4+ T helper lymphocytes cell count > 200 cells/ul on both ART and trimethoprim/sulfamethoxazole prophylaxis who presented with cavitating lung masses, mediastinal lymphadenopathy and pleural effusions. Negative bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) prompted a second diagnostic procedure with a transthoracic core needle biopsy; the final diagnosis was granulomatous PCP. This case showcases a very rare presentation of PCP, with both large cavitating lung masses on imaging and granulomatous reaction on pathology, as well as the challenge of a potentially missed diagnosis with negative BAL and TBBx requiring transthoracic core needle biopsy for a final diagnosis.

Nested Variant of Urothelial Carcinoma Is a Luminal Bladder Tumor With Distinct Coexpression of the Basal Marker Cytokeratin 5/6.

OBJECTIVES: The nested variant of urothelial carcinoma (NVUC) is a rare bladder tumor that may possess a luminal molecular phenotype. We sought to determine whether a small immunohistochemical (IHC) panel using common surrogates for molecular phenotypes would reliably classify a cohort of pure NVUC cases. METHODS: IHC staining with a panel composed of markers for basal subtypes (CK5/6, CK14) and luminal subtypes (FOXA1, GATA3) was performed on pure small NVUC cases (n = 23) and 5 large NVUC cases (n = 5). Scoring of IHC stains was performed semiquantitatively. Individual cases were analyzed using previously reported IHC-based surrogates for molecular subtype. RESULTS: The phenotype of NVUC was classified as luminal from 60.1% (FOXA1+/CK5/6-) to 100% (GATA3+/CK14-) of cases using composite phenotypes. No cases possessed a basal or squamous cell carcinoma-like phenotype. The majority of small NVUC cases (69.5%) showed subset CK5/6 expression distinctly localized to the basal layers of tumor cell nests. Intratumoral heterogeneity was also noted in CK5/6 (21.7% of small NVUC cases) but no other markers. CONCLUSIONS: NVUC appears to express markers of both basal and luminal bladder tumors. Definitive gene expression profiling may be valuable to further characterize this unique histologic variant.

Chirality of Topological Gap Solitons in Bosonic Dimer Chains.

We study gap solitons which appear in the topological gap of 1D bosonic dimer chains within the mean-field approximation. We find that such solitons have a nontrivial texture of the sublattice pseudospin. We reveal their chiral nature by demonstrating the anisotropy of their behavior in the presence of a localized energy potential.

Symptomatology and chest roentgenographic changes of pulmonary tuberculosis among diabetics.

Symptoms and chest x-ray findings in 28 diabetics and 38 non diabetics with pulmonary tuberculosis were compared. The two groups of patients were age and sex-matched. There was no statistical difference in respiratory or constitutional symptoms between the two groups. Distribution of chest x-ray involvement including cavitary disease was again similar in the two groups of patients. These findings are contrary to previous reports and beliefs that diabetics were less symptomatic and that x-ray findings were more frequent in lower lung fields.

Bronchial carcinoid tumours in southern Saudi Arabia.

Clinical presentation, pathology, surgical management and follow-up of ten bronchial carcinoid tumour (BCT) patients are described. There were five male and five female patients with age range between 5 to 85 years (mean 39.2 +/- 21.5, SD). Pathology revealed BCT on the right side in seven and on left side in three patients. The tumour was an incidental finding in four while the other six had respiratory symptoms. Cough was present in all of the later group and hemoptysis was present in four patients. Recurrent chest infections were seen in two patients. Symptoms ranged from 1 week to 15 years. Successful surgical resection was done in nine with the longest follow-up of 80 months (mean: 23 months +/- 26.3, SD) without recurrence or metastasis. Histopathological examination of these tumours revealed classical morphological features in all but one case. Grimelius stain positivity for argyrophilia confirmed the diagnosis in all the patients in this study. Electron microscopic examination was done in patient no. 9 which showed atypical morphological features and neurosecretory granules. BCT may present like pneumonias or bronchial asthma. Although BCTs have low-grade malignancy, early diagnosis and surgical resection yield curative results almost in all cases.

Spontaneous pneumothorax: A retrospective study of twenty-five patients and literature review.

We present a retrospective study of 25 patients with spontaneous pneumothorax (three current), comprising 16 Saudis (nine males and seven females) and nine non-Saudis (eight males and one female), seen at the Asir Central Hospital, Abha, over a period of 45 months. Almost one-third of the patients (9/25) had no underlying cause discernible by our investigational facilities (chest x-ray, ultrasonography, computed tomographic scan, and flexible bronchofiberscopy). Underlying pneumonia (three patients), pulmonary tuberculosis (two patients), lung abscess (one patient), and congenital bullae (one patient) constituted the etiology in another third of the spontaneous pneumothorax patients. Other underlying pulmonary diseases precipitating spontaneous pneumothorax in the group included pulmonary fibrosis, metastatic mesothelioma, and immunosuppression in a medulloblastoma patient undergoing chemotherapy with the development of chickenpox. Closed thoracostomy tube drainage was the only method of treatment in 20 out of the 25 patients, with three failures of closed thoracostomy tube drainage needing thoracotomy and resection of blebs/bullae. The only complication was empyema in two of the patients. Two patients were successfully treated conservatively with observation alone.

Empyema thoracis in adults in Saudi Arabia.

Empyema thoracis in adults is an uncommon disease in the Asir region of Saudi Arabia. In a period of seven years (1988 to 1994), 24 patients were treated for empyema thoracis with a hospital incidence of about 23 patients in 100,000 admissions. The community acquired empyemas are more common and less aggressive in non-Saudi patients (six males and one female) as compared to Saudi patients (11 males and 6 females) whose empyemas are mostly nosocomial with an aggressive course. The peak age in both Saudi and non-Saudi patients is 45 years and 25 years respectively, and the right pleura is more commonly affected than the left pleura in both groups. Risk factors include diabetes mellitus, pulmonary tuberculosis, post-pneumonectomy infections, trauma and pneumonia. The commonest organisms grown are Pseudomonas aeruginosa, Klebsiella species and Staphylococcus aureus, although in almost 40% of the patients the empyemas were sterile. The commonest method of treatment was closed thoracostomy tube drainage.

Resolution of fever in patients on chemotherapy for pulmonary tuberculosis.

Thirty-nine febrile and 37 afebrile patients with pulmonary tuberculosis were compared. Fever was defined as oral temperature of more than 37.2_C. Afebrile status on chemotherapy was presumed to have been achieved if patients remained without fever for at least seven consecutive days. Both groups were given short-course supervised chemotherapy in hospital consisting of isoniazid (INH), rifampin, ethambutol and pyrazinamide for the first two months and INH and rifampicin for the next four months. The two groups did not differ demographically or by the presence of cavitary disease. However, more patients with fever had anemia and elevated erythrocyte sedimentation rate (ESR) than afebrile patients. Resolution of fever occurred in 92% by four weeks. However, two female patients had fever lasting more than 60 days even though almost 1/4th of patients were afebrile one day after the start of chemotherapy and 1/3rd after three days.

Symptoms of pulmonary tuberculosis in consecutive smear-positive cases treated in Ethiopia.

The purpose of the study was to define in detail the usually accepted respiratory and non-respiratory symptoms of newly discovered smear-positive pulmonary tuberculosis in a group of Ethiopians. There were 163 consecutive patients referred to the weekly Chest Clinic at the Tuberculosis Demonstration and Training Centre in Addis Ababa. The results showed that more than 5% of pulmonary tuberculosis cases had respiratory symptoms of less than 2 weeks. Some symptoms such as haemoptysis, chest pain and dyspnoea prompted early reporting while there was a delay in reporting other symptoms such as cough, in spite of cough being present in all patients. Most of the non-respiratory (constitutional) symptoms were reported fairly early. A history of tuberculosis contact was relevant in this group of patients. A negative Mantoux test was noted in 20% of patients.

Tuberculin reaction in pulmonary tuberculosis in the Asir Region of Saudi Arabia.

The Mantoux test was performed on 75 Saudi and Yemeni patients with pulmonary tuberculosis using 2TU of PPD-RT23; 82.7% of these patients had a positive skin test. It was also noted that, contrary to findings in the West, old age does not seem to affect the Mantoux reaction adversely. 9 patients had a non-significant reaction and using the 3-step 'boosting', 8 of the 9 (88.9%) non-reactors converted to positive. Despite the low number of patients included in our study, we recommend 3-step 'boosting' when doing tuberculin skin testing in Third World Countries in order to bring out the true tuberculin 'reactors'.

Humoral immunodeficiency in T-cell chronic lymphocytic leukemia. An immunologic assessment.

The humoral antibody immunodeficiency in two patients with T-cell chronic lymphocytic leukemia (T-CLL) appeared to be the result of immunoregulatory abnormalities in the leukemic T-cell populations. Both patients had CD4+ CD45R+ "virgin" or suppressor-inducer T-CLL, but Patient 1 had hypogammaglobulinemia and Patient 2, immunoglobulin (Ig) M hypergammaglobulinemia. Although, CD25+ interleukin-2 (IL-2) receptors were present on leukemic T-cells of both patient, OKT9+ (CD71) transferrin receptors and OKT10 (CD38) activation antigens were found only on Patient 2's cells. Highly elevated amounts of IL-2 was secreted from phytohemagglutinin-stimulated and concanavalin A-stimulated T-cells in both patients. In Patient 1 with hypogammaglobulinemia, immune defects involve T-cells, first an intense suppressor activity on B-cell-induced IgM and IgG synthesis and, second, deficient production of B-cell growth factor (BCGF) and B-cell differentiation factor (BCDF). In Patient 2, highly elevated BCGF and IgM-specific BCDF was secreted by T-cells, a mechanism leading to IgM hypergammaglobulinemia in this patient. These studies stress the importance of BCGF and BCDF activity of leukemic T-cells in humoral antibody immunodeficiency disorders in T-CLL cases.

Severe T lymphocyte immunodeficiency associated with hypogammaglobulinemia: defective lymphokine secretion but enhanced autologous mixed lymphocyte reaction.

The multiparameter immunologic study of T cells of a patient with acquired hypogammaglobulinemia was investigated, since he had a normal B-cell number and function. His peripheral blood lymphocytes were found to contain predominant CD4+ CD45R+ T cells with a clear deficiency of CD4+ CDw29+ as well as CD8+ T cells. His T cells proliferated in response to phytohemagglutinin (PHA) and pokeweed mitogen (PWM), but no immunoglobulin was secreted in PWM-induced patient's T-cell and normal B-cell differentiations. His T cells were also found to possess concanavalin A (Con A)-induced suppressor function when cocultured with normal T cells, as well as IgG-, IgA-, and IgM-specific suppressor function on PWM-induced normal T- and B-cell differentiations. The patient's T cells were found to secrete elevated amounts of interleukin-2 but failed to secrete two important B-cell stimulating factors, B-cell growth factor and B-cell differentiation factor, in response to PHA. An investigation of immunoregulatory T-cell function in the autologous mixed lymphocyte reaction (AMLR) and allogeneic mixed lymphocyte reaction (MLR) indicated that the patient's T cells produced an enhanced AMLR but were deficient in MLR. These results suggest that the abnormalities we have identified in this patient with hypogammaglobulinemia reflect an intrinsic defect of T cells in the humoral immune response to produce three major immunoglobulins.

The use of sputum cultures in the evaluation of immigrants classified as tuberculosis suspects.

Because of possible deficiencies in the evaluation, based on symptoms and chest roentgenogram review, of new immigrants classified during the visa application process as tuberculosis suspects, a prospective (cohort) and a retrospective (case control) study were done to test the usefulness of routinely obtaining sputum specimens for culture in that setting. In the prospective study, 249 consecutive classified immigrants who were considered on the basis of clinical and roentgenographic findings to have nonprogressive tuberculosis submitted at least two sputums for culture: 13 (5.2%) had at least one culture positive for M. tuberculosis. Immigrants younger than 50 yr of age and refugees from Kampuchea and Laos had a fivefold to tenfold elevated risk of having a positive sputum culture. The cost per case detected of obtaining and processing sputum cultures was estimated to be +1,996 to +2,994. In the case-control study, 37 classified immigrants evaluated from 1981 through 1986 who had sputum cultures positive for M. tuberculosis even though they fulfilled clinical and roentgenographic criteria for nonprogressive tuberculosis served as control subjects. Several demographic, clinical, and roentgenographic factors were associated with an increased risk of being culture-positive: age younger than 50 yr, a positive tuberculin test, report of a cough, and a cavitary lesion on chest roentgenogram. The history of prior receipt of antituberculosis drugs was associated with having a negative culture, including a marked dose-response effect.