Aspergilloma formation in cavitary sarcoidosis / Formação de uma aspergilloma em sarcoidose com cavitação

Pulmonary cavitation is rather uncommon in patients with sarcoidosis, and aspergilloma is even more uncommon in such cases. Here, we present the case of a 63-year-old female patient with cavitary lung disease who had been under treatment for TB for 9 months. A diagnosis of pulmonary sarcoidosis was established based on the fiberoptic bronchoscopy finding of noncaseating granuloma. Treatment with corticosteroids led to a dramatic improvement in symptoms. While under treatment for sarcoidosis, the patient developed an aspergilloma. She presented immediate skin test reactivity to Aspergillus fumigatus, as well as positivity for A. fumigatus serum precipitins. This is the first reported case of aspergilloma formation in a patient with cavitary sarcoidosis in India.

A cavitação pulmonar é rara em pacientes com sarcoidose, e o aspergiloma é ainda mais raro nestes casos. Apresentamos o caso de uma paciente de 63 anos com doença pulmonar cavitária em tratamento para a TB por 9 meses. Estabeleceu-se o diagnóstico de sarcoidose pulmonar com base nos achados de granuloma não-caseoso na fibrobroncoscopia. Houve grande melhora dos sintomas com o tratamento com corticosteroides. A paciente desenvolveu um aspergiloma durante o tratamento para a sarcoidose. Houve reação imediata ao teste cutâneo para Aspergillus fumigatus, assim como resultado positivo para precipitinas de A. fumigatus no soro. Este é o primeiro caso relatado de formação de aspergiloma em um paciente com sarcoidose com cavitação na Índia.

A 35-year old man with a non-resolving pleural effusion.

A thirty-five-year old male, a nonsmoker, was referred to us for evaluation of progressive pulmonary disease. His clinical course during the past 2 years was characterized by paroxysmal attacks of cough with scanty mucoid sputum. This was accompanied by intermittent fever and malaise. There was no history of wheezing, nasal symptoms or loss of weight. Eighteen months prior to referral, based on his symptomatic and roentgenologic profile, he was clinically diagnosed as a case of tuberculous mediastinal lymphadenitis. He was initiated on antituberculous therapy (ATT) comprising rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 800 mg once daily. Prednisolone (10 mg thrice daily) was added after 2 months when the patient did not experience any relief. He was however irregular with the oral steroids and stopped it after 1 month. One year prior to referral, while on ATT for 6 months, he had few episodes of blood-streaked sputum, episodic exertional dyspnoea, and rightsided chest pain that increased on coughing and deep breathing. This was diagnosed as right-sided pleural effusion, and the patient was initiated on second line ATT in the form of kanamycin 1gm intramuscularly, sparfloxacin 400 mg, prothionamide 750 mg, clofazamine 200 mg, clarithromycin 500 mg, thiacetazone 150 mg and isoniazid 300 mg once daily. Kanamycin was stopped after 6 months but the other drugs were continued for a period of 1 year. In spite of regular second line ATT for 1 year, the patient remained symptomatic and as the effusion persisted, he was referred to us for evaluation. Physical examination revealed a middle-aged male in no acute distress. There was no clubbing or cyanosis. Chest examination suggested a right-sided pleural effusion. Examination of other systems, including an ophthalmologic referral, did not detect any abnormality.

Isoniazid associated, painful, bilateral gynaecomastia.

Gynaecomastia is a rarely reported adverse drug reaction due to isoniazid therapy. We describe a 25-year-old, human immunodeficiency virus (HIV)--negative man, who was started on antituberculosis treatment (ATT) with isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) in the combination RHZE for the first two months and RH there on. After four months, while receiving RH, he developed painful bilateral gynaecomastia. ATT had to be stopped because of this adverse drug reaction. Gynaecomastia, however, persisted even after three months of cessation of therapy. A year later, the patient reported complete disappearance of pain and swelling, although right breast continued to appear larger than the left.