A rare association of cutaneous leukocytoclastic angiitis (hypersensitivity vasculitis) and hypersensitivity pneumonia (extrinsic allergic alveolitis) in a pigeon breeder - case report and literature review.

Extrinsic allergic alveolitis is an occupational condition intensively studied and published about, unlike cutaneous leukocytoclastic angiitis. The coexistence of these two diseases is even more rare in the same patient with exposure to occupational pollutants of animal origin. We present the case of a 44-year-old man, a pigeon breeder admitted to hospital with a pruritic purpuric eruption and lower limb paresthesia, dyspnea on exertion, polymyalgia rheumatica, mixed polyarthralgias. Based on the clinical, paraclinical and laboratory investigations (electroneuromyography, plethysmography, computed tomography scan, musculocutaneous biopsy, current laboratory tests and immunoassays), the main diagnoses of extrinsic allergic alveolitis and leukocytoclastic vasculitis were determined. The patient underwent treatment with corticosteroids with a favorable outcome, but which becomes aggravated by the occurrence of necrotic skin lesions at the cessation of corticosteroid therapy on the patient's own initiative. After the resumption of the corticosteroid therapy, the lesions and symptoms improve. To our knowledge, this case report is the first one that describes an association of two major conditions, extrinsic allergic alveolitis and cutaneous leukocytoclastic angiitis, in the same clinical context of an occupational exposure to specific pollutants. Long-term corticosteroid therapy has proved to be useful in preventing relapses and improving the patient's clinical status with the association of cutaneous leukocytoclastic angiitis and extrinsic allergic alveolitis. Considering our findings in this case report, we may suggest the inclusion of systemic vasculitis on the list of recognized professional diseases.

Pulmonary Langerhans cell histiocytosis in a 26-year-old female: still a diagnostic challenge.

Langerhans cell histiocytosis (LCH) is a rare disorder caused by monoclonal Langerhans cells proliferation in bone, skin, lung, lymph nodes, liver, spleen, nervous or hematopoietic system. Pulmonary LCH is a diagnostic trap that is displayed on computed tomography (CT) as an interstitial disorder with honeycomb aspect. In this paper, we present an unusual case of a 26-year-old female that was hospitalized with progressive worsening dyspnea and history of recurrent pneumonia. Lung biopsy showed fibrosis of the interalveolar septa, architectural distortion and large cells with foamy cytoplasm and convoluted nuclei that were marked by CD68, S-100 and the specific antibody CD1a that allowed establishing the diagnosis of pulmonary LCH. The only extrapulmonary manifestations were femoral bone cysts that were radiologically seen 10 years before and were not modified along the years. The therapy consisted on smoking cessation and oral corticosteroids without significant improvement of the clinical symptoms and enlargement of the cystic spaces during six months of follow-up. This case highlights for a rare disorder of the lung that should be taken into account in young patients with progressive pulmonary fibrosis.

Smoking habits of pharmacy students attending the University of Medicine and Pharmacy in Targu Mures.

Smoking is common among health professional students. The aim of this study was to assess the smoking habits of the pharmacy students attending the University of Medicine and Pharmacy in Târgu Mureș (UMPh TM), Romania. Material and methods: Smoking habits and attitudes toward smoking among 414 pharmacy students attending UMPh TM (86% female) were evaluated using a self-completed questionnaire. Results: The rate of smoking increases during the time students attend the university (24.1% to 33.3% from 1st to 5th year) and males are significantly are more likely to smoke than females (41.4% vs. 27.3%, p=0.042). 36.9% of the smoking pharmacy students are tobacco-dependent, and 40.4% of smokers started daily smoking at the age of 16-19. We found significant differences between smoker and non-smoker pharmacy students regarding their attitudes toward smoking and tobacco control policies, with non-smokers being more supportive of smoke-free policies. Conclusions: Prevention programs and education have a very important role in decreasing the percentage of smokers and support for smokefree policies, but it is critical to begin such programs early in their university training.

Multimacronodular pulmonary tuberculosis (bacteriologically negative) confirmed histologically.

Background: Pulmonary tuberculosis can be confirmed by positive bacteriology of sputum, bronchial aspirate or by biopsies (microscopy and/ or culture) or by histopathological examination highlighting specific tuberculous granulomas. When microscopy is repeatedly negative during noninvasive methods, lung biopsy by thoracoscopy is needed for confirmation and differential diagnosis. Case presentation: A 40-year-old female patient (nonsmoker, diabetic, with previous exposure to chemicals) was admitted to the hospital for weight loss, dry cough, loss of appetite, pallor, and fatigue. Chest-X-ray and thoracic CT revealed multiple irregular macronodules with various shapes, randomly spread across the lungs. Bacteriology for acid fast bacilli (AFB) from six spontaneous sputum was negative. Bronchoscopy showed an acute bronchitis. Bronchial aspirate was negative for tumor cells and AFB. Several biopsies from bronchial wall showed unspecific changes. The molecular biology tests for specific nucleic acids detection (Polymerase Chain Reaction) or positron-emission-tomography (to differentiate benign nodules from malign ones) were not accessible. Multiple biopsies from lung parenchyma and pleura were obtained using thoracoscopy. Histopathology revealed multiple specific tuberculous granulomas. The complex antituberculous treatment (9 months) has led to the total cure of the disease and resorption of the nodules. The patient's last visit (after 2 years) showed no clinical/imagistic or bacteriologic relapse of the disease. Conclusion: Tuberculosis may present in the form of multiple macronodules spread randomly across the lung parenchyma. Thoracoscopy coupled with multiple large lung biopsies are recommended for diagnosis of multinodular lung lesions, especially when common bacteriology/cytology from bronchoscopic aspiration failed to achieve diagnosis. Histological exam from thoracoscopic biopsies allows differential diagnosis between entities that have macronodular features: tuberculosis, primitive lung cancer, lymphomas, metastatic disease or invasive fungal disease.

Advanced Sarcoidosis with Apparent Onset by Respiratory Failure.

We present the case of a 14 years-old male (with poor living condition, non-smoker) hospitalized for a sudden onset of a rest dyspnea, mucopurulent cough. We found bronchial sibilant rales, wheezing, cyanosis, peripheral adenopathies, hepatosplenomegaly, purulent tonsillitis. the chest-x-ray revealed bilateral mediastinal lymphadenopathy and bilateral lung infiltrations. Spirometry: severe mixed ventilator dysfunction without reversibility. Sputum: negative microscopy and culture for Koch bacillus. Stool examination: cysts of Lamblia giardia. The patient refused bronchoscopy and mediastinoscopy, so it was performed axillary lymph node biopsy which confirmed sarcoidosis (non-caseating epithelioid granulomas). The treatment included antibiotics, antiparasites, oral and inhaled corticosteroids (CS), bronchodilators, oxygen, with clinical/functional improvement after 3 months. CS was followed 1.5 years with poor compliance. A relapse occurred after 3 years and the CS were reinserted. The computerized tomography (CT) scan revealed a diffuse interstitial fibrosis with bronchiectasis. The case particularity relies on the atypical early onset of the sarcoidosis, with respiratory failure and progression to lung fibrosis despite CS treatment. The association of proinflammatory risk factors such as multiple infections needs to be noted.

Tuberculosis of the oral cavity.

Tuberculosis (TB) of the tongue is not a common finding diagnosis, even if consider endemic areas. Tuberculosis of the tongue sometimes can mimic lingual neoplasm. Oral tuberculosis is rarely primary as mechanism, and frequently secondary to pulmonary tuberculosis. There are many suspect lesions that can be classified as tuberculosis, such as tumor mass, ulcerative lesion or fissure. It is very important for diagnosis to perform histopathological examination of the biopsy. We present here the case of a 74-year-old man who developed lingual tuberculosis with a tumor aspect concomitant with pulmonary tuberculosis. Histopathological and immunohistochemical examinations established the diagnosis of lingual tuberculosis.

Neuroendocrine pancreatic tumor - diagnosis circumstances, staging and treatment: a case report.

Neuroendocrine neoplasms (NENs) of the pancreas are rare and frequently malignant. Our presentation of a pancreatic NEN analyzes the diagnosis circumstances, staging, treatment, one-year evolution and disease particularities. A 39-year-old nonsmoker patient was admitted in the Clinic of Pulmonology, Tirgu Mures, Romania with a pneumonia suspicion (fever, thoracic pain irradiated below the diaphragm, mild dyspnea). The chest X-ray showed a rise of the left diaphragm. Abdominal ultrasound revealed a large pancreas-related tumor. Computerized tomography (CT) scan with contrast confirmed a well-vascularized pancreatic tumor, which invades spleen, collateral circulation of the splenic vein, enlarged liver without secondary lesions and no retroperitoneal adenopathies. The patient was referred to the surgery where there was performed total tumor resection, spleen resection, and large lymphadenectomy. Histopathology and immunohistochemistry revealed the pancreatic NEN G2 grade, T3N1M0 and allowed accurate treatment. 2010 World Health Organization (WHO) NENs classification recommends further treatment-related biomarkers determination only in selected cases. Our case evolution after one year was favorable without local tumor relapse or metastases. The close survey of the patient (by clinical exam, imaging and biological markers) is ongoing. The onset of asymptomatic pancreatic tumor may have atypical respiratory symptoms. Imaging methods (ultrasound, contrast CT) are recommended in borderline symptomatology. Radical surgical resection of the tumor with lymphadenectomy, histopathology with immuno-histochemistry play an essential role in the correct diagnostic, grading, staging and treatment of pancreatic NENs. Close survey of the clinical, imagistic and biological markers is recommended.

Thoracic endometriosis with a long delay in diagnosis.

This paper describes a case of thoracic endometriosis in 36-year-old woman with a long delay in diagnosis. At the admission in the hospital, the patient had a medical history of persistent dysmenorrhea since the age of 13, infertility and an episode of total right pneumothorax two months ago successfully resolved by minimum pleurotomy of the right hemitorax. She came with moderate pain on right hemithorax and dyspnea, which occurred on the first day of menstruation but she did not have any other respiratory symptoms such as hemoptysis, cough. Radiological imaging (chest radiography and computer tomography) at the time of admission confirmed recurrence of the right pneumothorax. She underwent surgical treatment of the right pneumothorax using a single-port video-assisted approach. Intraoperative macroscopic lesions were found catamenial pneumothorax characteristic diagnosis and biopsy material taken (parietal pleura) for histopathology. Immuno-histochemical tests confirmed the diagnosis of thoracic endometriosis. The gonadotropin-releasing hormone analogue was received by the patient early after surgery and there was no clinical or radiological recurrence at a four months follow-up.

Basic thoracic ultrasound for the respiratory physician.

Thoracic ultrasound (TUS) evolved in the last ten years as the method of choice for evaluating pleural abnormalities and for guiding lung procedures. TUS can "see" almost all structures in the chest, including thoracic wall, pleura, pleural space, the heart, the great vessels and the peripheral layers of the lungs. However, there is still a great need to develop TUS services in respiratory departments in Romania. To facilitate this development we reviewed the literature and selected what we considered to be essential practical information for the beginner in TUS, including technique, normal findings, and common abnormalities. Moreover, we describe here a step-by-step scanning technique for chest physicians. Our aim is to raise awareness of TUS. Because TUS is rapid, accurate, noninvasive and can be applied in any ward, we recommend facilitating the training of all junior respiratory doctors in this technique, as it is likely to improve patient experience, clinical effectiveness and to reduce costs with chest radiographs or CT scans in the future.

[Gastroesophageal reflux and asthma--pathogenetic mechanisms and treatment]. / Refluxul gastroesofagian si astmul bronsic-- mecanismele fiziopatologice si managementul lor.

Gastroesophageal reflux and bronchial asthma are frequently encountered comorbidities that maintain an ambivalent relationship, generating a vicious circle where gastroesophageal reflux increases asthmatic symptoms or precipitates bronchial asthma and asthma can trigger or worsen gastroesophageal reflux disease. Pathogenetic mechanisms of these interrelation are imperfectly understood, despite intense concerns of specialists in both areas. There have been incriminated: eso-bronchial constrictor vagal mediated reflexes, bronchial hyperreactivity, neurogenic inflammation induced by hydrochloric acid penetration in the oesofagus, airways hydrochloric acid microaspiration with asthmatic trigger effects, increased bronchial resistance or increased immune response to antigens. Bronchial obstruction and some antiasthmatic medication can decrease lower esophageal sphincter pressure and thus triggering or aggravating gastroesophageal reflux. The diagnosis of the gastroesophageal reflux in asthmatics involves a careful clinical exam, digestive functional test (up to 24 hours monitoring esophageal pH) and esogastroscopy. Gastroesophageal reflux treatment in asthmatic patients claims elimination of both disease risk factors, diet, proton-pump inhibitors.

[Solitary pulmonary nodule: diagnosis criteria and management]. / Nodulul pulmonar solitar: criterii de diagnostic, management.

The solitary pulmonary nodule (SPN) is a frequent aspect on the chest X-ray and computed tomography (CT). The diagnosis and management of the SPN is not yet standardized. A high percentage of the SPNs is represented by the malignant lesions (primary lung cancer or metastasis of other extra pulmonary tumors). The first aim of the diagnosis is to evaluate the malignant or benign feature of the SPN using noninvasive techniques: this technique will guide the further diagnosis and treatment management. The noninvasive diagnosis tools are: clinical aspects (age, risk-factors - smoking history, exposure to toxic environment, history of previous tumors or tuberculosis), CT aspects (SPN size, growth rate, nodule's borders, calcifications, "bronchial sign", satellite nodules, invasion), positron emission tomography (PET) and PET-CT fusion, contrast PET-CT (high uptake in malignant processes). An initial high probability benign diagnosis will avoid invasive treatment (pulmonary resection); the initial diagnosis of a malignant process will recommend further invasive investigations (percutaneous or bronchoscopic transbronchial biopsies, thoracoscopy, thoracotomy) and an early appropriate treatment for radical cure with high-survival rate (SPN = stage IA for lung cancer).