Lack of mediastinal shift as a clue to delayed postpneumonectomy empyema.

Delayed postpneumonectomy empyema is uncommon. The condition is usually elusive and diagnosed late in the course of the disease, leading to increased morbidity. New air-fluid level on chest x-ray film or appearance of empyema necessitatis may enhance the index of suspicion and lead to early diagnosis, but in many cases no clinical or laboratory clues are apparent. We describe the case of a 60-year-old man with high fever and dyspnea 3(1/2) years after pneumonectomy. Diagnosis of postpneumonectomy empyema was delayed and finally suggested by the lack of expected mediastinal shift on chest film. Computed tomography (CT) of the chest showed a large quantity of fluid, which later proved to be empyema. The patient was treated successfully by continuous cavity irrigation with neomycin and systemic antibiotics. We conclude that in postpneumonectomy patients with septic fever, the only clue to diagnosis of delayed postpneumonectomy empyema may be hemithorax opacification without mediastinal shift, confirmed by CT-guided thoracocentesis. Therapy with cavity irrigation and systemic antibiotics seems appropriate.

Chronic eosinophilic pneumonia associated with cutaneous T-cell lymphoma.

Cutaneous T-cell lymphomas (CTCL) are diseases characterized by cutaneous infiltrates of malignant clonally expanded T cells. CTCL cells exhibit a cytokine profile consistent with T helper-2 type (TH2) cells. Eosinophilic pneumonias are individual syndromes characterized by eosinophilic pulmonary infiltrates and commonly peripheral blood eosinophilia. CTCL and chronic eosinophilic pneumonia are rare clinical entities. We report a patient with the association of CTCL and chronic eosinophilic pneumonia. To understand the mechanism leading to the eosinophilia, we examined the patient's cytokine profile. This was consistent with a high TH2 activity. Her interleukin (IL) 5, 6, and 10 levels were extremely high, while her IL-2 and interferon-gamma (IFN-gamma) levels (TH1 profile) were low. We believe that eosinophilic pneumonia in this patient is probably secondary to high TH2 cytokine levels induced by tumor cells. We suggest that eosinophilic pneumonia should be considered as a possible diagnosis in patients with CTCL who have respiratory complaints.

Role of down-regulated CHIF mRNA in the pathophysiology of hyperkalemia of acute tubular necrosis.

Acute tubular necrosis (ATN) is associated with hyperkalemia. We have shown that the medulla is the main site of impaired sodium (Na+)/potassium (K+) pump activity in ATN. CHIF, a gene that evokes K+ conductance in oocytes, is regulated in the colon by aldosterone and in the kidney by K+ intake. It is assumed that CHIF has a role in K+ homeostasis. To characterize the impaired K+ handling in ATN, the effect of impaired renal function on CHIF mRNA expression in the kidney and colon was studied. Three groups of rats with glycerol-induced ATN were studied: (1) control group, (2) moderate-ATN group, and (3) severe-ATN group. Serum creatinine levels in the control group were 45+/-2.1 micromol/L; in the moderate-ATN group, 224.8+/-16.9 micromol/L; and in the severe-ATN group, 376.5+/-15.9 micromol/L. In the group with severe ATN, significant hyperkalemia (P < 0.001 v control group) was noted. The expression of CHIF mRNA in relative units (percentage of control) in the moderate-ATN group, in the medulla, papilla, and colon, was 16.3%+/-5.6% (P < 0.001), 94.2%+/-9.3% (P=not significant ), and 165.9%+/-11.1% (P < 0.001); and in the severe-ATN group was 11.1%+/-6.4% (P < 0.001), 73.7%+/-4% (P < 0.001), and 310.8%+/-27.3% (P < 0.001), respectively. These results show that (1) in both moderate and severe ATN, CHIF mRNA is dramatically reduced in the medulla, (2) in severe ATN, CHIF mRNA expression decreases in the papilla, and (3) CHIF mRNA is upregulated in direct relationship to the severity of ATN and to the levels of aldosterone in the colon. These results suggest that the hyperkalemia that occurs in severe ATN stems at least in part from the downregulation of CHIF mRNA in the kidney medulla and papilla. The compensatory increase in colonic CHIF mRNA is not sufficient to maintain normal serum K+ levels.

Talc granuloma of the uterus.

A 40-year-old woman presented with acute obstructive lung disease. She was treated with steroids and achieved a good response. However, she had two previous pelvic operations with histological findings of uterine serosal caseating granulomas presenting in the latter operation. Antituberculosis (TB) prophylaxis was suggested due to the suspicion of TB reactivation under steroid management. Investigation for TB infection or exposure was negative while revision of the histological slides disclosed talc granulomas. Although talc granuloma is reported in starch powder gloves which should not contain talc, it is still very uncommon.