Severe Pulmonary Tuberculosis With Organizing Pneumonia: A Diagnostic Ambiguity

@#Pulmonary TB may present insidiously and ambiguously, leaving clinicians with a diagnostic dilemma. A 30-year-old lady with underlying spinocerebellar ataxia presented with progressive shortness of breath, prolonged cough with whitish sputum, loss of appetite and weight loss of 1-year duration. Physical examination showed a cachectic, tachypnoeic female with finger clubbing and coarse crepitations on lung auscultation. Chest radiograph showed bilateral air space opacities relatively sparing the upper zone. Contrast-enhanced CT thorax revealed bilateral cavitary necrotising consolidations, multiple scattered lung nodules with surrounding ground-glass opacities. After exclusion of alternative diagnoses, cryptogenic organizing pneumonia diagnosis was made. She had a rapid clinic improvement once steroid was started. TB polymerase chain reaction (PCR) from bronchoscopic bronchial washing eventually was positive. Anti-TB treatment was started, and oral steroid was slowly tapered down. Organizing pneumonia (OP) may complicate pulmonary TB. Diagnosing OP without lung biopsy requires a multi-disciplinary approach, taking into consideration all available evidences. Early steroid therapy is lifesaving and should be considered after thorough exclusion of alternative diseases.

A mysterious clavicular swelling

@#The clavicle or collarbone is a horizontal-axis bony structure located between the neck and thoracic area. Tumour metastasis at the clavicle is very rare. Due to its location at the border of the neck and chest area, a primary tumour could originate from both areas. We report the case of a 39-year-old man who presented with a painful right sternal-end clavicular mass and intermittent fever. Chest radiography was normal. Musculoskeletal ultrasound of the clavicle revealed a mass. Computed tomography (CT) thorax further identified a mass at the upper lobe of the right lung. CT-guided tissue biopsy confirmed that it was a lung adenocarcinoma. This case shows an atypical presentation of lung carcinoma and how musculoskeletal ultrasound helped in the diagnosis when other features and investigations were inconclusive.

Elevated serum rheumatoid factor, anti-citrullinated protein antibodies and active rheumatoid arthritis disease are not associated with chronic periodontitis

@#Introduction: Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease of the joints with the involvement of other systems. Previous studies have demonstrated its association with chronic periodontitis (CP), a chronic inflammatory disease of tooth-supporting tissues. Positive rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) in RA patients have been found to be associated with CP. The aim of this study is to determine the prevalence of CP in RA patients, and to investigate the association of ACPA, RF status and RA disease activity with CP and non-CP RA patients. Materials and Methods: A comparative cross-sectional study involving 98 RA patients was conducted at Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia. Clinical oral examination was carried out to determine the CP status of RA patients. RF, ACPA and erythrocyte sedimentation rate (ESR) were measured, and the 28-joint Disease Activity Score (DAS-28) was assessed. Results: Forty-five patients (45.9%) were found to have CP (95% CI: 0.36-0.56). No significant difference was observed in the prevalence of positive RF (p=0.989) or ACPA (p=0.431) in CP and non-CP RA patients. There was also no significant association between active RA disease (DAS-28 score ≥3.2) and RF positivity in CP (p=0.927) and non-CP (p=0.431) RA patients as well as ACPA positivity in CP (p=0.780) and non-CP (p=0.611) RA patients. Conclusion: In our cohort of RA patients, we did not find significant associations between elevated RF, ACPA, or active RA disease with the presence of CP. There were also no significant associations between elevated RF or ACPA with active RA disease.