Study of paradoxical response to chemotherapy in tuberculous pleural effusion.

BACKGROUND: Paradoxical worsening of disease, in spite of effective chemotherapy for tuberculosis, has been reported to occur in cases of intracranial tuberculoma, lymph node, and pulmonary tuberculosis. However, only rare case reports describe such paradoxical response in tuberculosis pleurisy. METHODS: Sixty-one patients with proven tuberculous pleural effusion were retrospectively screened in Riyadh, Saudi Arabia, in three major hospitals to look systematically at the incidence and features of paradoxical response. RESULTS: Paradoxical increase in the size of the effusion was detected in 10 of 61 patients. In six patients, the effusion became massive with worsening of dyspnoea requiring the use of corticosteroids in five patients and therapeutic aspiration in all six. However, complete resolution occurred in all 10 patients within 1-3 months. Three out of the 10 patients developed residual pleural thickening. CONCLUSION: An incidence of 16% (10/61) paradoxical worsening of tuberculous effusion following the start of anti-tuberculous treatment has been documented. This resulted in respiratory distress necessitating therapeutic re-aspiration in six of 10 patients.

Allergic bronchopulmonary mycosis in patients with asthma: period prevalence at a university hospital in Saudi Arabia.

Allergic bronchopulmonary mycosis (ABPM) is a known complication of asthma and can result in progressive lung damage, respiratory failure and death. Asthma is a common disease in Saudi Arabia and until now the prevalence of ABPM has not been investigated. The aim of this study was to estimate the period prevalence of ABPM due to Aspergillus and Candida in patients with asthma. The setting was an outpatient pulmonary clinic at a university hospital in the central region of Saudi Arabia. Two hundred and sixty-four consecutive patients with asthma (150 or 57% females) were evaluated. All patients were screened for ABPM with skin prick test (SPT) using a panel of fungal antigens. Those with positive skin reactions had further clinical, immunological, respiratory and radiological assessment. ABPM was diagnosed by the presence of a minimum of five of the major criteria suggested by Rosenberg in 1977. Of the 264 patients, 62 (23%) had a positive SPT for at least one fungal allergen, of whom 44 (71%) were females (P=0.01). Seven patients (six females) were diagnosed with ABPM due to Aspergillus and (or) Candida species. Therefore, we estimate the period prevalence of ABPM to be 2.7% (95% confidence interval 1.3-5.4%). A. niger was the commonest fungal species isolated in our group. In conclusion, ABPM is not uncommon in Saudi Arabia and females seem to be more at risk. Because asthma is common, physicians need to have high index of suspicion for this disease and pursue the diagnosis with the appropriate tests.

Overlooked inhaled foreign bodies: late sequelae and the likelihood of recovery.

The present paper describes eight patients (two teenagers and six adults) who had chronic symptoms (haemoptysis, cough, recurrent pneumonia) caused by foreign body (FB) inhalation which went undetected for 3 months to 25 yr. None of the patients had the usual predisposing conditions like mental retardation, seizures or brain tumour. The diagnosis of FB was made by radiography in one patient only. Computerized tomography visualized one FB (a beef bone), and bronchoscopy identified FB in another two patients. The remaining four cases were diagnosed at thoracotomy. Removal of FB was curative in three of five cases who required surgical resection for irreversible bronchiectatic changes. The severity of pulmonary changes correlated with duration of symptoms. It is concluded that chronic, unexplained respiratory symptoms should warrant further investigation to exclude FB despite negative history and normal chest radiography. Finding of granulation tissue or cicatricial stenosis of the bronchus could be the only clue to the presence of a FB. Early diagnosis would avoid irreversible parenchymal changes which necessitate lung resection.

Tuberculosis is the commonest cause of pneumonia requiring hospitalization during Hajj (pilgrimage to Makkah).

The diagnosis and treatment of pneumonia in mass gathering situations is a medical challenge, requiring prompt decision making and knowledge of the aetiology. We studied cases of pneumonia admitted to two hospitals during the 1994 pilgrimage (Hajj) season to Makkah. Sixty-four patients were enrolled in the study, of which 47 (75%) were men with a mean age of 63 years (range 21-91). Nearly all were from developing countries. Diagnosis was established in 46 patients (72%) with Mycobacterium tuberculosis being the commonest causative organism (20%), followed by gram-negative bacilli (18.8%). Streptococcus pneumoniae accounted for only 10%, with Legionella pneumophilia, Mycoplasma pneumoniae, and viruses accounting each for 6%. The main finding of this study is that M. tuberculosis is a common cause of pneumonia under these unusual "extreme circumstances". Its presentation was acute and indistinguishable from pyogenic pneumonia. Thirty-one per cent of tuberculous cases had upper lobe involvement, 54% lower lobe, and 15% multi-lobar. This was similar to the radiographic features in non-tuberculous pneumonia cases. All but one patient with tuberculosis recovered following the administration of first-line anti-tuberculous drugs. The total mortality was 17%. The preponderance of M. tuberculosis and Gram-negative bacteria over S. pneumoniae may reflect the prior use of amoxycillin and the effect of exhaustion, malnutrition, and old age.

Contribution of ventilation and perfusion lung imaging to the management of patients with bronchiectasis.

Sixty patients were studied with ventilation-perfusion (V-P) lung scans for suspected bronchiectasis. Bronchography showed bronchiectatic changes in 51 patients. Lobar and segmental matched defects were seen on V-P scans in 53 patients, of which only 46 were true positives (sensitivity 90%). V-P lung scans showed the site and extent of bronchiectatic lesions; 48 (72.7%) in the left lung and 18 (27.3%) in the right lung. Detection of associated chronic obstructive airway disease by V-P scans in 17 patients had prognostic value in postsurgery recovery time and improvement of symptoms. This may be a potential new application to the routine use of V-P lung scan in the presurgery work-up of patients with bronchiectasis. Our results showed that bronchography should not be performed on patients with preserved lung perfusion.

An outbreak of acute hepatitis A infection in rural Saudi Arabia.

In areas of hyperendemicity of hepatitis A virus (HAV) infection, acquisition of immunity occurs relatively early in life. In such populations epidemic outbreaks are rare. A recent HAV infection outbreak occurred in the Al-Dahnah district in Saudi Arabia. In thirty day period, 23 children and adolescents were diagnosed by clinical examination. 19 of these were positive for IgM anti-HAV. Concomitant acute infections with the Epstein Bar Virus (EBV) was documented in 4 of these patients. A limited epidemiological survey suggested that the source of infection might have been a contamination of one of the tankers which delivered water supplies to the various houses. In a transitional period of development the rapid improvement in socio economic status and standards of living may increase the susceptible pool. Therefore a greater surveillance is needed to identify and contain such possible outbreaks.

Clinical profile of sleep apnea syndrome. A study at a university hospital.

OBJECTIVES: To review a series of patients with sleep apnea syndrome, to promote more awareness and alert local health professionals to early diagnosis and treatment. METHODS: We studied, prospectively, 48 consecutive patients who were managed at the university hospital from 1992 to 1996. RESULTS: The male:female ratio was 1.4:1. The mean interval between onset of symptoms and the diagnosis was 5.5 years (range 0.25 to 30). In over half of the patients the diagnosis was not suspected upon referral. The mean body mass index was 42.8 kg/m2, (range 25 to 76). Daytime hypoxemia was present in 28 patients (58%), while 26 (54%) had Pa CO2 > 45 mmHg, mainly as a result of obesity-hypoventilation syndrome. Significant proportions had systemic and pulmonary hypertension (60% and 23%), and 32% had ischemic heart disease. All patients, but one, tolerated continuous positive airway pressure, but cost of the equipment led some to prefer surgical treatment that is offered free. CONCLUSION: This series shows a bias towards female sex and frequent association with obesity-hypoventilation syndrome. In many cases the diagnosis was not suspected suggesting poor recognition and awareness of sleep apnea syndrome. Monitoring pulse oximetry during sleep was helpful in the diagnosis and titration of continuous positive airway pressure. Ways of providing continuous positive airway pressure under the health system need to be studied.

Hypercalcemia in active pulmonary tuberculosis.

In a retrospective review of 241 patients with active pulmonary tuberculosis, hypercalcemia was found in 62 (26%). It was detected on presentation in 48 patients and developed in 14 patients 4 to 6 weeks aftr the start of antituberculous therapy. The mean (+/- SD) serum calcium level in those cases was 2.78 (+/- 0.137) mmol/L. The majority of cases (67.6%) had a mild rise in the calcium level that remained below 2.8 mmol/L but 35% had a level that ranged between 2.8 and 3.0 mmol/L. Only 2.4% had serum level higher than 3.0 mmol/L, which could explain the predominant absence of hypercalcemia-related symptoms. Hypercalcemia was more common in patients older than 50 years (P<0.05), but this did not correlate with the extent of the tuberculosis shown on radiological evaluation. Spontaneous return to normocalcemia occurred in all 42 patients who underwent serial assessments of their serum calcium concentration, 6 to 8 weeks after the start of chemotherapy. Saudi Arabia is known to have a high prevalence of vitamin D deficiency, but none of our patients were immobilized or had received vitamin D supplements or multivitamins. This supports the view that vitamin D intake does not play a major role in inducing hypercalcemia in cases of active pulmonary tuberculosis, as has been suspected.

Pulmonary tuberculosis in diabetic patients.

In a retrospective study of 1566 cases of pulmonary tuberculosis, 136 were found to have diabetes mellitus for a prevalence of 8.7%. There were 100 males and 36 females, and the average age patient age was 52 years. Saudis accounted for 94 (69%) of the cases. The prevalence of diabetes was 13% for Saudi patients as compared with 5% for non-Saudis (P < 0.005). Sputum conversion took an average of 46 days. There was a 19% prevalence of lower lung field lesions. Ninety-three (68.4%) patients were on insulin therapy, 25 (18.9%) were on oral hypoglycemics, and 18 (13.2%) were managed on diet alone. Of 104 patients who were sputum positive, 100 showed conversion after treatment with first-line antitubercular drugs. There was no statistically significant difference in the sputum conversion between diabetic and nondiabetic patients.

Prescribing for asthma in the outpatient clinics in Riyadh: Does it follow the guidelines?

In order to reduce the significant morbidity and mortality associated with asthma, current guidelines recommend the use of anti-inflammatory therapy in a step-wise approach. To obtain information on how physicians are treating asthma, we evaluated prospectively 243 newly seen asthmatics in the outpatient clinics in four hospitals in Riyadh. The patients were assessed by five pulmonologists who confirmed the diagnosis, established the severity, recorded the medications patients were taking, and the specialty of the prescribing physician. The inhaler technique was checked and changes made in the treatment were also recorded. The medications prescribed were ss agonists (inhaled 69%, oral 25%0, steroids (inhaled 33%, systemic 8%), cough mixtures (30%), antibiotics (26%), theophylline (21%), and miscellaneous 16%. Over half of the patients (55%) were taking ss agonists regularly. The most frequent changes made were as follows: adding steroids (inhaled 56%, systemic 27%, or increasing the inhaled dose 16%), starting inhaled ss agonists (28%) and discontinuining theophylline (9%). The GPs were the group least inclined to prescribe inhaled steroids (P < 0.0001). The inhaler technique was poor in 53% of the patients. We conclude that in treating asthma, physicians are still relying more on bronchodilator and symptomatic therapy rather than anti-inflammatory therapy. There is also evidence to suggest overuse of antibiotics. Wide dissemination of the guidelines may alter the prescribing habits, and as many asthamtics are managed by GPs, this group in particular should be targeted.

Pulmonary tuberculosis in Saudi Arabia: A retrospective study of 1566 patients.

A review was conducted of 1566 cases of pulmonary tuberculosis admitted to Sahary Chest Hospital in Riyadh between July 1983 and August 1987. The medical records, chest rafiographs, and sputum results were studied. The 21 to 30 year age group represented 40.7% of all patients, which indicates the need for improving measures for the control of tuberculosis in young adults, whose protection may have waned despite BCG vaccination in infancy. Non-Saudi males patients constituted more than half of the admission which raises the question of the efficacy of the current pulmonary tuberculosis screening policy for individuals entering the Kingdom. The four-drug regimen of rifampicin, isoniazid, pyrazinamide, and ethambutol, when properly supervised, was very effective in achieving early sputum conversion. Based on results of this study, decentralizing tuberculosis services and attaching them to other local and general hospitals appears to be recommended.

Establishment of a normal reference range for adenosine deaminase in plasma of healthy Saudis using the continuous spectrophotometric method.

The level of adenosine deaminase (EC. 3.5.4.4), was estimated in plasma of 389 healthy males and 493 healthy females in order to establish a normal reference range for Saudis. Using the continuous spectrophotometric method, the reference ranges were calculated in two ways using the mean +/- 2 SD and the 2.5th - 97.5th percentile value methods. In both methods of calculation, a slightly higher range was observed for children as compared to adults. The method of 2.5th - 97.5th percentile values brought almost all of our subjects within the recommended range of 11.5 - 25 U/l. In the current study, the normal range for adenosine deaminase totalled 15.0 - 23.2, 14.8 - 23.6, 15.0 - 23.0 and 16.7 - 24.6 U/l for the overall population, all males, females, and children, respectively. The ranges are discussed in the light of significantly different results obtained by the two calculation methods and recommendation of an appropriate method for healthy Saudis, namely the 2.5th - 97.5th percentile values. The choice of the Ellis and Goldberg kinetic continous monitoring method for the estimation of plasma ADA levels in the current investigation is also hereby justified.

Lepromatous leprosy in Saudi female from central region.

Leprosy is an uncommon disease in Saudi population. Lepromatous leprosy is a most contagious form of leprosy. Erythema nodosum leprosum is an unusual complication of leprosy. We report an unusual case of leprosy from the central region of Saudi Arabia presenting as erythema nodosum leprosum.

The effect of henna paste on oxygen saturation reading obtained by pulse oximetry.

A controlled study was designed to examine the effect of red and black henna on the measurement of oxygen saturation by pulse oximetry. Fifty adult normal female volunteers had their left thumb coloured with red henna (40) or black henna (10). The uncoloured right thumb was used as a control. All measurements were done under room temperature, and the same pulse oximeter was used in all volunteers. In the red henna group there was no difference on oximetry reading between right and left thumb. In contrast, the thumb coloured with black henna gave no reading when compared to the uncoloured right thumb. On the basis of this study, pulse oximetry is not limited by red henna while black henna has a potential of causing major error in the measurement of oxygen saturation by pulse oximetry. In these cases we recommend to use ear oximetry for accurate measurement of oxygen saturation.

Schistosomiasis associated with a mediastinal mass: case report and review of the literature.

A 13-year-old girl presented with fever, night sweat, weight loss, abdominal pain, haematuria and hepatosplenomegaly. Urinalysis revealed many Schistosoma haematobium ova, but rectal snip examination was negative for schistosomal ova. X-ray and CT scan of the chest revealed enlargement of the anterior, superior, mediastinal and left suprahilar lymph node with an adjacent left pulmonary parenchymal opacity and small peripheral lesions on the right side. A bone marrow aspiration and biopsy was normal. The patient was treated with Praziquantel for her urinary schistosomiasis. Because of her clinical and radiological chest findings, the possibilities of lymphoma and tuberculosis were considered. Therefore, she underwent a thoracotomy and biopsy of her thoracic lesions. The histopathology revealed pulmonary granulomas surrounding schistosoma ova with reactive mediastinal lymph adenitis.

Removal of endobronchial mucormycosis lesion through a rigid bronchoscope.

A 44 year old man with poorly controlled diabetes mellitus developed endobronchial mucormycosis, which totally obstructed the right lower lobe bronchus. The lesion was removed through a rigid bronchoscope. Two weeks later the bronchus was free of mucormycosis histologically and on culture.

Changes in total lung capacity during acute spontaneous asthma.

An increased TLC has been reported during exacerbations of asthma, but the methods used (helium, dilution, plethysmography) have been subsequently found unreliable in the assessment of lung volumes in patients with obstructive lung disease. To address this problem, we measured TLC (TLC-XR) from posteroanterior and lateral chest roentgenograms obtained during exacerbations (E) of asthma and after recovery (R) using planimetry in 12 asthmatic subjects. At recovery, TLC was also measured by plethysmography or by helium dilution for comparison with the radiographic measurement. The plethysmographic measurements were made with a panting frequency less than 1 Hz to allow for airway obstruction. A chest radiologist also used independent radiologic measurements of hyperinflation (lung height, diaphragmatic arc height, rib counts) to assess lung volumes. Mean FEV1 during E was 1.43 +/- 0.38 L, and significant improvement occurred at R (FEV1 = 2.81 +/- 0.58 L, p less than 0.05). Of the independent radiologic variables measured, only an increase in lung height distinguished the two sets of radiographs. Mean TLC-XR (E) (6.01 +/- 1.62 L) was significantly greater than mean TLC-XR (R) (5.44 +/- 1.17 L, p less than 0.05). TLC measured radiographically at recovery was strongly correlated (r = 0.94) with TLC measured by plethysmography or helium dilution. We conclude that acute reversible increases in TLC do occur during exacerbations of asthma and that these changes are only readily detected by formal planimetry.