RESUMEN
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.
Asunto(s)
Anticuerpos Monoclonales/efectos adversos , Antineoplásicos Inmunológicos/efectos adversos , Puntos de Control del Ciclo Celular/inmunología , Granuloma/inducido químicamente , Inmunoterapia/efectos adversos , Neoplasias/terapia , Sarcoidosis/inducido químicamente , Anticuerpos Monoclonales/uso terapéutico , Antineoplásicos Inmunológicos/uso terapéutico , Granuloma/patología , Humanos , Inmunoterapia/métodos , Masculino , Enfermedades del Mediastino/inducido químicamente , Enfermedades del Mediastino/diagnóstico , Enfermedades del Mediastino/patología , Persona de Mediana Edad , Neoplasias/patología , Receptor de Muerte Celular Programada 1/inmunología , Sarcoidosis/patologíaAsunto(s)
Hepatitis Autoinmune/complicaciones , Inmunosupresores/efectos adversos , Lipomatosis/inducido químicamente , Cirrosis Hepática Biliar/complicaciones , Enfermedades del Mediastino/inducido químicamente , Prednisona/efectos adversos , Azatioprina/uso terapéutico , Hepatitis Autoinmune/tratamiento farmacológico , Humanos , Inmunosupresores/uso terapéutico , Ictericia Obstructiva/etiología , Lipomatosis/diagnóstico por imagen , Cirrosis Hepática Biliar/tratamiento farmacológico , Masculino , Enfermedades del Mediastino/diagnóstico por imagen , Persona de Mediana Edad , Prednisona/uso terapéutico , Tomografía Computarizada por Rayos XRESUMEN
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.
Asunto(s)
Corticoesteroides/efectos adversos , Lipomatosis/inducido químicamente , Enfermedades del Mediastino/inducido químicamente , Corticoesteroides/administración & dosificación , Femenino , Humanos , Lipomatosis/diagnóstico , Enfermedades del Mediastino/diagnóstico , Persona de Mediana Edad , Enfermedad Mixta del Tejido Conjuntivo/tratamiento farmacológicoRESUMEN
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.
Asunto(s)
Apéndice Atrial/diagnóstico por imagen , Ecocardiografía , Hematoma/diagnóstico por imagen , Enfermedades del Mediastino/diagnóstico por imagen , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Calcinosis/diagnóstico por imagen , Constricción Patológica , Diagnóstico Diferencial , Dilatación Patológica/diagnóstico por imagen , Hematoma/inducido químicamente , Hematoma/terapia , Hematoma Subdural/complicaciones , Hematoma Subdural/diagnóstico por imagen , Humanos , Cuidados a Largo Plazo , Imagen por Resonancia Magnética , Masculino , Enfermedades del Mediastino/inducido químicamente , Enfermedades del Mediastino/terapia , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/diagnóstico por imagen , Síncope/etiología , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/lesiones , Espera VigilanteRESUMEN
A 72-year-old man with a recent inferior-wall myocardial infarction complicated by continued ischemic cardiac pain underwent an intracoronary streptokinase infusion in an attempt to re-establish coronary perfusion. Although the cardiac catheterization and streptokinase infusion were technically uncomplicated, signs of an enlarging mediastinal mass associated with a drop in the hematocrit reading developed in the patient 12 hours after the procedure. Aortography showed no evidence of aortic dissection or laceration. The patient was believed to have a spontaneous mediastinal hemorrhage related to streptokinase infusion.
Asunto(s)
Enfermedad Coronaria/tratamiento farmacológico , Hemorragia/inducido químicamente , Enfermedades del Mediastino/inducido químicamente , Derrame Pleural/inducido químicamente , Estreptoquinasa/efectos adversos , Anciano , Humanos , Masculino , Derrame Pleural/diagnóstico por imagen , RadiografíaRESUMEN
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.
Asunto(s)
Anticuerpos Monoclonales Humanizados/efectos adversos , Antirreumáticos/efectos adversos , Artritis Reumatoide/tratamiento farmacológico , Fiebre Reumática/tratamiento farmacológico , Sarcoidosis/inducido químicamente , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Adalimumab , Anticuerpos Monoclonales Humanizados/uso terapéutico , Antirreumáticos/uso terapéutico , Femenino , Humanos , Enfermedades del Mediastino/inducido químicamente , Persona de Mediana Edad , Enfermedades de la Piel/inducido químicamenteRESUMEN
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.
Asunto(s)
Antiinfecciosos/efectos adversos , Dapsona/efectos adversos , Síndrome de Hipersensibilidad a Medicamentos/etiología , Insuficiencia Respiratoria/inducido químicamente , Lesión Pulmonar Aguda/inducido químicamente , Anciano , Líquido del Lavado Bronquioalveolar/citología , Diagnóstico Diferencial , Síndrome de Hipersensibilidad a Medicamentos/diagnóstico , Eosinofilia/diagnóstico , Eosinófilos/fisiología , Fiebre/inducido químicamente , Humanos , Síndrome Inflamatorio de Reconstitución Inmune/inducido químicamente , Recuento de Leucocitos , Enfermedades Linfáticas/inducido químicamente , Linfocitos/fisiología , Linfocitosis/inducido químicamente , Masculino , Enfermedades del Mediastino/inducido químicamente , Prurito/tratamiento farmacológico , Infecciones por Roseolovirus/inducido químicamente , Tomografía Computarizada por Rayos XRESUMEN
Corticosteroid-induced mediastinal widening with simulated focal lymphadenopathy was found in a patient having myasthenia gravis. To my knowledge, this is the first report of such changes occurring in a patient having myasthenia gravis. As the use of corticosteroids in the treatment of myasthenia gravis becomes more common, this association can be expected to occur more often. Reemphasis of this phenomenon should help to avoid unnecessary surgical intervention in these patients.
Asunto(s)
Enfermedades del Mediastino/inducido químicamente , Miastenia Gravis/complicaciones , Prednisona/efectos adversos , Humanos , Lipomatosis/inducido químicamente , Masculino , Enfermedades del Mediastino/diagnóstico por imagen , Neoplasias del Mediastino/inducido químicamente , Mediastino/diagnóstico por imagen , Persona de Mediana Edad , Miastenia Gravis/tratamiento farmacológico , Prednisona/uso terapéutico , RadiografíaRESUMEN
Spontaneous hemomediastinum is a rare event, occurring in association with bleeding disorders, intratumoral bleeding, or following an abrupt increase in intrathoracic pressure. We report the case of a patient with systemic lupus erythematosus, nephrotic syndrome, and renal failure, in whom mediastinal lipomatosis (ML) developed following increased corticosteroid therapy. Anticoagulant therapy likely precipitated a massive spontaneous hemomediastinum secondary to diffuse hemorrhage of mediastinal fat, which required emergency decompressive surgery. Steroid-induced ML is common and usually well tolerated, but clinicians should be aware of its potential risk of bleeding when associated with anticoagulant therapy. This case further emphasizes the bleeding complications of treatment with low-molecular-weight heparin in patients with renal failure.
Asunto(s)
Anticoagulantes/efectos adversos , Glucocorticoides/efectos adversos , Hemorragia/inducido químicamente , Heparina de Bajo-Peso-Molecular/efectos adversos , Lipomatosis/inducido químicamente , Enfermedades del Mediastino/inducido químicamente , Prednisona/efectos adversos , Adulto , Femenino , HumanosRESUMEN
To evaluate the potential effect of aspirin, a platelet inhibitory agent, on postoperative bleeding complications after coronary artery bypass graft surgery, we compared each of nine patients who had taken aspirin within 7 days prior to operation to one or two control subjects (total 16 patients) matched for age, sex, extent of coronary disease, number of grafts placed total operative time, bypass time, and preoperative use of propranolol. Preoperative prothrombin time, partial thromboplastin time, and platelet counts were normal for all patients. Mean mediastinal blood loss was significantly greater in the aspirin group (919 +/- 164 ml., S.E.) than in the control group (437 +/- 61 ml., p less than 0.001). The degree of mediastinal blood loss did not correlate with patient age, total operative time, bypass time, number of vessels diseased, or grafts placed. In addition, compared to controls the aspirin group required prolonged chest tube drainage (33 +/- 5 hours versus 19 +/- 1 hour, p less than 0.001).
Asunto(s)
Aspirina/efectos adversos , Puente de Arteria Coronaria , Hemorragia/inducido químicamente , Enfermedades del Mediastino/inducido químicamente , Adulto , Anciano , Aspirina/uso terapéutico , Drenaje , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Tromboembolia/prevención & control , Factores de TiempoRESUMEN
A case of testicular teratocarcinoma metastatic to a mediastinal lymph node and associated with a mediastinal lesion indistinguishable from an enteric cyst is presented. It is postulated that the mediastinal enteric cyst-like lesion resulted from histologic maturation of metastatic teratocarcinoma after intensive chemotherapy. The basis in the medical literature for this postulate is detailed.
Asunto(s)
Antineoplásicos/efectos adversos , Quistes/patología , Enfermedades Intestinales/patología , Enfermedades del Mediastino/patología , Teratoma/patología , Neoplasias Testiculares/patología , Adulto , Antineoplásicos/uso terapéutico , Quistes/inducido químicamente , Quistes/diagnóstico , Diagnóstico Diferencial , Humanos , Enfermedades Intestinales/inducido químicamente , Enfermedades Intestinales/diagnóstico , Metástasis Linfática , Masculino , Enfermedades del Mediastino/inducido químicamente , Enfermedades del Mediastino/diagnóstico , Teratoma/diagnóstico , Teratoma/tratamiento farmacológico , Neoplasias Testiculares/diagnóstico , Neoplasias Testiculares/tratamiento farmacológicoRESUMEN
Most patients undergoing open heart operations have had exposure to heparin for diagnostic and/or therapeutic procedures. Heparin antibody formation and heparin-induced thrombocytopenia with repeat heparin administration can cause high morbidity and mortality from thrombotic complications, especially when delay in diagnosis occurs. From 1981 to 1991, heparin-induced thrombocytopenia was diagnosed in 82 of 4,261 open heart surgical patients (1.9%). Platelet counts less than 100 x 10(9)/L (100,000/microL) or new or recurring thrombotic events prompted suspicion of heparin-induced thrombocytopenia. Heparin-dependent antibody was diagnosed preoperatively in 12 patients (group I) and postoperatively in 70 patients (group II). Heparin was not given postoperatively in group I patients, and complications in this group were limited to bleeding in 3 patients. There were no thromboembolic events and all patients survived. Group II patients had late recognition of heparin-dependent antibody postoperatively, and heparin exposure was continued for varying periods postoperatively. Thirty-seven group II patients (53%) had bleeding complications and 31 (44%) had thromboembolic complications. These complications led to death in 23 group II patients (33%). Heparin-dependent antibody may occur in patients having open heart operations and is a major cause of morbidity and mortality if not diagnosed early with cessation of heparin therapy.
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Anticuerpos/análisis , Procedimientos Quirúrgicos Cardíacos/mortalidad , Heparina/efectos adversos , Trombocitopenia/inducido químicamente , Lesión Renal Aguda/etiología , Adulto , Anciano , Transfusión Sanguínea , Causas de Muerte , Trastornos Cerebrovasculares/epidemiología , Transfusión de Eritrocitos , Femenino , Hemorragia Gastrointestinal/inducido químicamente , Hemorragia Gastrointestinal/terapia , Hemorragia/inducido químicamente , Hemorragia/terapia , Heparina/inmunología , Humanos , Incidencia , Masculino , Enfermedades del Mediastino/inducido químicamente , Enfermedades del Mediastino/terapia , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Recuento de Plaquetas/efectos de los fármacos , Embolia Pulmonar/mortalidad , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
A case report describing persistent paratracheal lymphadenopathy after doxorubicin, bleomycin, vinblastin, and dacarbazine (ABVD) chemotherapy for a patient with Hodgkin's disease (HD) is presented. Mediastinoscopy and biopsy of the paratracheal lymph nodes showed non-caseating granulomas characteristic of sarcoidosis. The authors discuss the relationship between sarcoidosis and HD and hypothesize that the development or progression of sarcoidosis in a patient with HD is a potential consequence of chemotherapy. Two possible mechanisms are proposed. The first includes the immunosuppressive effect of chemotherapy and the second implicates the influence of a specific chemotherapy agent, bleomycin, which is known to have relatively higher lymph node, skin and lung tissue concentrations than other agents included in the ABVD regimen, and a predilection for those tissues that are prone for the development of sarcoidosis. With the incidence of sarcoidosis exceeding that of HD for the general population, the authors emphasize the importance of considering the presence of sarcoidosis in the differential diagnosis of patients who do not respond radiographically to HD chemotherapy.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Enfermedad de Hodgkin/complicaciones , Sarcoidosis/inducido químicamente , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Bleomicina/administración & dosificación , Bleomicina/efectos adversos , Dacarbazina/administración & dosificación , Dacarbazina/efectos adversos , Doxorrubicina/administración & dosificación , Doxorrubicina/efectos adversos , Femenino , Enfermedad de Hodgkin/tratamiento farmacológico , Enfermedad de Hodgkin/patología , Enfermedad de Hodgkin/radioterapia , Humanos , Enfermedades del Mediastino/inducido químicamente , Enfermedades del Mediastino/diagnóstico por imagen , Enfermedades del Mediastino/inmunología , Enfermedades del Mediastino/patología , Modelos Biológicos , Sarcoidosis/diagnóstico por imagen , Sarcoidosis/inmunología , Sarcoidosis/patología , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada por Rayos X , Vinblastina , Vincristina/administración & dosificación , Vincristina/efectos adversosAsunto(s)
Hematoma/diagnóstico , Enfermedades del Mediastino/diagnóstico , Melanoma/diagnóstico , Neoplasias Cutáneas/patología , Anciano , Clopidogrel , Hematoma/inducido químicamente , Humanos , Imagen por Resonancia Magnética , Masculino , Enfermedades del Mediastino/inducido químicamente , Neoplasias del Mediastino/diagnóstico , Neoplasias del Mediastino/secundario , Melanoma/secundario , Regresión Neoplásica Espontánea , Inhibidores de Agregación Plaquetaria/efectos adversos , Ticlopidina/efectos adversos , Ticlopidina/análogos & derivadosRESUMEN
The full range of mediastinal and pleural toxic effects of various drugs is reviewed. The importance of clinical information in suggesting the diagnosis of drug-induced disorders is emphasized. A separate section on the pleural and mediastinal toxic effects of illicit drugs is included.
Asunto(s)
Enfermedades del Mediastino/inducido químicamente , Enfermedades Pleurales/inducido químicamente , Humanos , Enfermedades del Mediastino/diagnóstico , Enfermedades Pleurales/diagnósticoRESUMEN
An increasing number of drugs have been implicated in the pathogenesis of a broad spectrum of pulmonary diseases. The clinical and radiographic manifestations are often nonspecific, requiring a high index of suspicion by both the clinician and the radiologist. The review focuses on patterns of drug-induced pulmonary disease, including parenchymal disorders, pulmonary vascular disease, pleural processes, airway disease, mediastinal abnormalities, and neuromuscular disorders. In each category, the differential diagnosis, clinical assessment, and diagnostic evaluation are discussed.
Asunto(s)
Enfermedades Pulmonares/inducido químicamente , Hemorragia/inducido químicamente , Hemorragia/diagnóstico , Humanos , Hipertensión Pulmonar/inducido químicamente , Hipertensión Pulmonar/diagnóstico , Enfermedades Pulmonares/diagnóstico , Enfermedades del Mediastino/inducido químicamente , Enfermedades del Mediastino/diagnóstico , Enfermedades Pleurales/inducido químicamente , Enfermedades Pleurales/diagnóstico , Embolia Pulmonar/inducido químicamente , Embolia Pulmonar/diagnósticoRESUMEN
The full range of mediastinal and pleural effects of a variety of drugs both therapeutic and illicit has been reviewed. The importance of clinical information in making the diagnosis of these drug-induced disorders is emphasized.
Asunto(s)
Enfermedades del Mediastino/inducido químicamente , Enfermedades Pleurales/inducido químicamente , Diagnóstico por Imagen , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Humanos , Drogas Ilícitas/efectos adversos , Enfermedades del Mediastino/diagnóstico , Enfermedades Pleurales/diagnóstico , Derrame Pleural/inducido químicamente , Derrame Pleural/diagnósticoRESUMEN
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 Crohns disease and psoriasis, who develops subacute hypersensitivity pneumonitis secondary to treatment with mesalamine, starting the first symptoms after 31 months of treatment