[Extrapulmonary tuberculosis: a difficult therapeutic approach]. / Extrapulmonale Tuberkulose: Therapie mit Hindernissen.

HISTORY: The 37 year old patient was admitted to hospital with persisting fever for 4 weeks. He had a history of weight loss, night sweat and cough. Antipyretic treatment with Paracetamol and up to ineffectiveness therapy with Ibuprofen was taken by the patient. FINDINGS AND DIAGNOSIS: Fever and poor general condition were obvious on time of admission. The ECG showed tachycardia. Liver values were increased. X-ray of the chest showed a central mass on the right site. On computed tomography there was a finding of a possibly necrotic tumour close to central vessels. The patient developed a prolonged thrombocytopenia and bleeding on several sites. Further diagnostic approaches were difficult to perform. After puncture of the central mediastinal mass and bone marrow we diagnosed an extensive extrapulmonary tuberculosis. Toxic hepatitis was getting worse under medical treatment of tuberculosis. In addition, with thrombocytopenia patient condition reached a critical state. THERAPY AND COURSE: After initiation of prednisolone-treatment up to suspicion of drug- induced thrombocytopenia (D-ITP) and switch of the anti- Tb-regimen the general condition improved. There was repetitive need for transfusion of thrombocytes. CONCLUSIONS: Toxic hepatitis is a possible severe complication of anti-Tb-treatment. A critical evaluation of patients' medication and soon initiation of anti -Tb-treatment is necessary. Especially in patients coming from high tb-incidence regions with history of poor general condition and persisting fever the diagnosis of extrapulmonary tuberculosis and bone marrow infiltration should be taken into account.

Decreased apoptosis of pulmonary PMN in COPD patients with community-acquired pneumonia.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) predisposes for the acquisition of community-acquired pneumonia (CAP). OBJECTIVE/METHODS: To assess clinically and scientifically suggested disorders in innate immune response during acute phrase and resolution CAP (T2), we evaluated peripheral and pulmonary polymorphnuclear neutrophils (PMN), recovered by induced sputum, from CAP patients with and without COPD with regard to cell activation, interleukin-8 (CXCL-8) and CXCL-8 receptor expression, and apoptosis rate. RESULTS: At T1, COPD patients displayed significantly lower pulmonary PMN apoptosis rates, while total cell count, the amount of macrophages, and vital and necrotic neutrophils in sputum samples were similar between study groups. At T2, there were no differences between study groups or between pulmonary and peripheral compartment. While under systemic steroid treatment apoptosis rates of peripheral and pulmonary PMN at T1 were slightly decreased, there were no significant differences in intrapulmonary CXCL-8 levels. Regarding cell activation, no significant differences could be seen, neither in comparing study groups nor in pulmonary to peripheral PMN. CONCLUSION: Elucidating the pathology of suspected disorder in innate immune response, we found decreased apoptosis rates of pulmonary neutrophils in COPD at the peak of CAP indicating an increased inflammatory response, which is independent from anti-apoptotic cytokines such as CXCL-8, severity of disease and isolation of bacteria from sputum cultures.