False-positive rifampicin resistance on Xpert® MTB/RIF caused by a silent mutation in the rpoB gene.

The Xpert® MTB/RIF assay detects the presence of Mycobacterium tuberculosis and its resistance to rifampicin (RMP) directly in sputum samples. Discrepant results were observed in a case of smear-positive pulmonary tuberculosis that was Xpert-resistant but phenotypically susceptible to RMP. Complementary investigations (repeat Xpert, Genotype®MTBDRplus assay and sequencing of the rpoB gene) revealed the presence of a silent mutation in the rpoB gene, leading to the conclusion of a false-positive Xpert result. As misinterpretation of Xpert results may lead to inappropriate treatment, the presence of rpoB mutations should be confirmed by sequencing the rpoB gene.

Routine implementation of EGFR mutation testing in clinical practice in Flanders: 'HERMES' project.

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is the recommended first-line treatment in metastatic EGFR-mutation-positive non-small cell lung cancer (NSCLC) patients. Such a personalized treatment requires fast EGFR mutation testing. This study was performed to determine the turn around time (TAT) for EGFR mutation testing on tumour samples of NSCLC in the clinical care in the region of Antwerp (Belgium). The secondary aim was to determine the frequency of EGFR mutations in this Flemish population. Tumour tissue was prospectively obtained from lung cancer patients in participating hospitals and sent from the local pathology laboratory (lab) to two central laboratories (labs) where EGFR-mutation analysis was performed. Results were returned from the central labs to the clinicians and the local pathology lab. TAT was defined as the interval between the request from the oncologist and the result obtained by the oncologist. One hundred and seven specimens were analysed. The clinician got the result from the local lab in a median time of 10 days (3-37 days) and from the central lab in 9 days (3-29 days). We detected seven mutations (7%) in this study population, all occurring in tumours with an adenocarcinoma histology, four (57%) in men and five (71%) in (ex-)smokers. There were six exon 19 deletions and one L858R mutation. It is possible to implement EGFR-mutation testing with timely reporting of the EGFR-mutation status. EGFR-mutation occurs in 7% of Flemish patients with NSCLC. Patients with advanced non-squamous NSCLC should be tested for EGFR mutation regardless of their gender and smoking history.

Use of an Amplatzer Device for Endoscopic Closure of a Large Bronchopleural Fistula following Lobectomy for a Stage I Squamous Cell Carcinoma.

Bronchopleural fistulas can occur as a rare but severe complication after pulmonary resection. Established guidelines for the proper treatment of patients with bronchopleural fistulas do not exist. Apart from attempts to close the fistula, emphasis is placed on preventive measures, early treatment with antibiotics, drainage of the empyema and aggressive nutritional and rehabilitative support. For inoperable patients, endoscopic procedures are the only therapeutic option. Unfortunately, large (>8 mm) or central bronchopleural fistulas are usually not suitable for such endoscopic management. Recently, some groups have published a few case reports about a novel technique for the endobronchial closure of bronchopleural fistulas, using an Amplatzer device, originally designed for transcatheter closure of cardiac septal defects. We applied the same technique as a life-saving treatment in a ventilated patient who was considered inoperable due to a high oxygen need. The operation was successful. The patient could be weaned from ventilation and was eventually discharged from the hospital to a rehabilitation facility several weeks after the insertion of the device. Until now, endoscopic techniques have only been useful for the treatment of small, peripheral, bronchopleural fistulas and even then only as a bridge to surgery in high-risk surgical patients. In this case report, we demonstrate that the use of an Amplatzer device can expand the importance of endoscopic techniques in the treatment of bronchopleural fistulas. An Amplatzer device, for endobronchial closure, can indeed be administered for large and central bronchopleural fistulas. Moreover, it can be considered as a definite alternative to surgery in inoperable patients.

Long-term disease control of a non-operable neuroendocrine tumor of the lung with lanreotide: a case study.

Bronchopulmonary neuroendocrine tumors (NETs) are malignant tumors that represent approximately 20% of all lung cancers. The therapeutic option for advanced or metastatic bronchopulmonary NETs is mainly palliation of symptoms; options need to be individualized and, therefore, rely on the knowledge of multidisciplinary teams. Somatostatin analogs have been widely used in NETs for control of hormonal syndromes and are currently under evaluation for their antiproliferative activity. Here, we present a case of NET of the lung, for which we achieved long-term disease control with a treatment comprising the somatostatin analog lanreotide Autogel(®) in a patient with limited therapeutic options due to considerable comorbidity, while preserving his quality of life.

Hospital services for people with HIV infection in Flanders: patients' satisfaction.

Two questionnaire surveys about satisfaction with hospital services were carried out among HIV-infected people in Flanders. In a first survey (CIRCA '93 study) between 1993 and 1995, before highly active antiretroviral treatment (HAART) was available, questionnaires were distributed by HIV treatment centres, general practitioners and HIV support organizations: 315 people with HIV infection completed the questionnaire. The level of patient satisfaction was generally higher with services at university hospitals than at general hospitals. Most patients preferred to be hospitalized in a ward specialized in HIV care. Contact with other HIV-infected patients was generally experienced as supportive. The second survey included 34 patients with HIV-infection and 83 patients with lung disease. They were admitted to the same ward at the Antwerp University Hospital, between July 1996 and July 1997. Patients with HIV infections were expecting more services than patients with lung disease. Both studies showed that HIV-infected patients wanted to be actively involved in diagnostic and treatment decisions. The multidisciplinary approach, offered by the Antwerp University Hospital, was widely appreciated by patients and could be used as an example for organizing patient care for other diseases.

Multicentric Castleman's disease in 2 patients with HIV infection, unresponsive to antiviral therapy.

Two HIV infected patients with multicentric Castleman's disease (MCD) and Kaposi's sarcoma are reported. Both died despite combination antiretroviral therapy including protease inhibitors.

Obstructive nephropathy due to sulfa crystals in two HIV seropositive patients treated with sulfadiazine.

Two HIV seropositive patients receiving sulfadiazine for presumed cerebral toxoplasmosis who developed an obstructive nephropathy are described. Ultrasound examination showed respectively a bilateral hydro-ureteronephrosis in one patient and unilateral hydro-ureteronephrosis in the other. The obstructive nephropathy resolved in both patients with alkalic hydration and discontinuation of the sulfadiazine.

Two imported cases of Penicillium marneffei infection in Belgium.

Two imported cases of Penicillium marneffei infection in Belgium are reported. Both patients are Thai women co-infected with HIV. P. marneffei infection should be suspected in immunocompromised patients originating or travelling from South-East Asia with unexplained fever (> 38 degrees C), weight loss, a generalised lymphadenopathy, hepatomegaly, splenomegaly, skin lesions, cough and anaemia. Diagnosis is made by culture and/or histopathological examination. Mild to moderate infections are treated with itraconazole 400 mg/day as first choice. Amphotericin B parenteral therapy may be required for seriously ill patients. Maintenance therapy with itraconazole 200 mg/day is necessary to prevent relapses.

Splenic rupture as a complication of P. falciparum malaria after residence in the tropics. Report of two cases.

Splenic rupture is an uncommon complication of malaria, which requires urgent medical investigation, close follow-up and adequate treatment. Until present, this complication was reported more often in P. vivax infections than in infections with other species. Rupture can happen spontaneously or as a result of trauma, which may be minor and unnoticed. The diagnosis is made by physical examination, ultrasound and CT-scan. Especially in malaria endemic areas the management of splenic rupture in malaria should be focused on splenic preservation. We describe two cases of splenic rupture during a P. falciparum infection, both requiring finally splenectomy.