Tuberculous constrictive pericarditis complicated with tuberculous mediastinitis - case report.

Constrictive pericarditis is a rare and severe disease. A 37-year-old patient was admitted in the hospital for dyspnea, precordial pain, right-sided cardiac failure. Chest X-ray showed cardiac enlargement and an opacity suggestive for pleural effusion. Echocardiography revealed an adhesive-effusive-constrictive pericarditis, a very thickened pericardium and bilateral pleural effusion. After a pericardiectomy done to restore cardiac compensation and to identify etiological factors, a tuberculous pericarditis (TBP) was diagnosed. After surgery and starting anti-TB treatment, the patient presented altered clinical status, dyspnea, dry cough, fever and delayed callus formation at sternum level. Thoracic scan revealed mediastinal air collections, pericarditis and pleurisy. Thus, the TBP diagnosis was extended to mediastinal TB and anti-TB therapy was continued. After four months of treatment, another thoracic scan showed disappearance of the mediastinal air-leakage bubbles, multiple new micronodules in both lungs and lymph nodes of up to 15 mm; also increasing pericardial and pleural effusions. This case was interpreted as a TB treatment failure situation. A retreatment regimen was started, resulting in a slow favorable outcome. Pericardial TB is a rare condition, usually with delayed diagnosis and poor treatment benefits. Whenever possible, earlier diagnostic can contribute to better management of these cases.

Efficacy and safety of oral solithromycin versus oral moxifloxacin for treatment of community-acquired bacterial pneumonia: a global, double-blind, multicentre, randomised, active-controlled, non-inferiority trial (SOLITAIRE-ORAL).

BACKGROUND: Community-acquired bacterial pneumonia (CABP) is a leading cause of morbidity and mortality, and treatment recommendations, each with specific limitations, vary globally. We aimed to compare the efficacy and safety of solithromycin, a novel macrolide, with moxifloxacin for treatment of CABP. METHODS: We did this global, double-blind, double-dummy, randomised, active-controlled, non-inferiority trial at 114 centres in North America, Latin America, Europe, and South Africa. Patients (aged ≥18 years) with clinically and radiographically confirmed pneumonia of Pneumonia Outcomes Research Team (PORT) risk class II, III, or IV were randomly assigned (1:1), via an internet-based central block randomisation procedure (block size of four), to receive either oral solithromycin (800 mg on day 1, 400 mg on days 2-5, placebo on days 6-7) or oral moxifloxacin (400 mg on days 1-7). Randomisation was stratified by geographical region, PORT risk class (II vs III or IV), and medical history of asthma or chronic obstructive pulmonary disease. The study sponsor, investigators, staff, and patients were masked to group allocation. The primary outcome was early clinical response, defined as an improvement in at least two of four symptoms (cough, chest pain, sputum production, dyspnoea) with no worsening in any symptom at 72 h after the first dose of study drug, with a 10% non-inferiority margin. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT-01756339. FINDINGS: Between Jan 3, 2013, and Sept 24, 2014, we randomly assigned 860 patients to receive solithromycin (n=426) or moxifloxacin (n=434). Patients were followed up to days 28-35 after first dose. Solithromycin was non-inferior to moxifloxacin in achievement of early clinical response: 333 (78·2%) patients had an early clinical response in the solithromycin group versus 338 (77·9%) patients in the moxifloxacin group (difference 0·29, 95% CI -5·5 to 6·1). Both drugs had a similar safety profile. 43 (10%) of 155 treatment-emergent adverse events in the solithromycin group and 54 (13%) of 154 such events in the moxifloxacin group were deemed to be related to study drug. The most common adverse events, mostly of mild severity, were gastrointestinal disorders, including diarrhoea (18 [4%] patients in the solithromycin group vs 28 [6%] patients in the moxifloxacin group), nausea (15 [4%] vs 17 [4%] patients) and vomiting (ten [2%] patients in each group); and nervous system disorders, including headache (19 [4%] vs 11 [3%] patients) and dizziness (nine [2%] vs seven [2%] patients). INTERPRETATION: Oral solithromycin was non-inferior to oral moxifloxacin for treatment of patients with CABP, showing the potential to restore macrolide monotherapy for this indication. FUNDING: Cempra.

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.

Tracheomalacia in children and adults--not so rare as expected.

Tracheomalacia remains a special entity present also in children and adults. Tracheomalacia refers to a weakness of the trachea. Bronchoscopy is the "golden standard" for diagnosis. Differential diagnosis includes foreign body aspiration, difficult controlled asthma and other diseases. This disease may be congenital or it may be acquired. Acquired tracheomalacia can be treated. The main symptoms in tracheomalacia are: dyspnea, sputum production, hemoptysis and cough in adults and expiratory stridor and cough in children. Tracheomalacia could be progressive in some patients. We want to bring to your attention the tools for diagnosis and different methods of treatment. Tracheomalacia is not a rare disease and therefore we need to consider it.

Fatal paradoxical cryptic miliary tuberculosis and immune reconstitution disease in a young non-HIV immunocompromised male patient: case report with autopsy findings.

Non-HIV immunocompromised patients may develop immune reconstitution inflammatory syndrome (IRIS) as an abnormal response to invading microorganisms, such as Mycobacterium tuberculosis (MTB). IRIS consists in a sudden change in the dominant T-helper responses to inflammation, which is not balanced by anti-inflammatory response, playing a critical role in microbial pathogenesis. A patient with restoration of host immunity during anti-tuberculosis treatment can become gravely ill with a paradoxical severe form of tuberculosis (TB) disease named TB immune reconstitution disease (IRD).The diagnosis of acute cryptic miliary TB is difficult and requires an accurate histopathology. We report a fatal association between a generalized lymphadenitis tuberculosis and IRD in a 34-year-old male patient, non-smoker, non-HIV immunocompromised, but with a previously co-morbid diabetes mellitus (DM) type I. The purpose of this report is to describe an unusual and rare case of a progressive extrapulmonary TB disease to a liver involvement, mimicking a hepatotoxicity secondary to anti-tuberculosis therapy. The diagnosis of disseminated miliary TB with cryptic pulmonary was confirmed later after performing necropsy. Formalin-fixed paraffin-embedded pulmonary and extrapulmonary miliary foci were processed for histology and stained with Hematoxylin and Eosin. This rare entity of cryptic miliary involvement of the lungs is described more in elderly than in young individuals. In the reported case, IRD induced a paradoxical progressive dissemination of TB lesions leading to death in a patient with an apparent uncomplicated form of lymphadenitis TB.

Disseminated tuberculosis presenting as febrile seizures with fatal evolution in an infant.

Disseminated tuberculosis with the involvement of brain, liver and gut is a rare disease in immunocompetent infant. Early diagnostic and instauration of anti-tuberculosis therapy is capital because the outcome is poor. Here, we report the case of an 11-month-old boy with disseminated tuberculosis of brain, liver abdominal lymph nodes, small bowel and lung, which presented with fever, generalized tonic-clonic seizure, hemodynamic instability and a history of recurrent respiratory tract infections. His father was diagnosed with active pulmonary tuberculosis six month ago and family members completed an anti-tuberculosis chemoprophylaxis regimen.

Lung Involvement in Multiple Myeloma - Case Study.

INTRODUCTION: Mutiple mieloma (MM) cells are rarely found in extramedullary sites. The sites of extramedullary dissemination reported in the literature are spleen, liver, lymph nodes, kidneys, thyroid gland, adrenal gland, ovary, tests, lung, pleura, pericardium, intestinal tract and skin. We report a case in which the myeloma was diagnosed after we discovered the presence of monoclonal plasma cells in the bronchoalveolar lavage fluid (BAL). Matherial and method: a case in which diagnosis was established from bronchoalveolar lavage (BAL) fluid demonstrating the presence of monoclonal plasma cells in Craiova Pneumology Departament. RESULTS: Analysis of BAL fluid for the presence of plasma cells and for cytoplasmic immunoglobulin DNA provides a noninvasive means of establishing the diagnosis. CONCLUSIONS: Pulmonary parenchyma is an uncommon site of extramedullary involvement in multiple myeloma. Interstitial lung disease as pulmonary manifestation of multiple myeloma is even rarer; only isolated cases with histological proofs have been reported in the literature.

Progressive intraparenchymal lung nodules dissemination in a heavy smoker and seropositive rheumatoid arthritis suspected of tuberculosis relapse.

Anthony Caplan first described rheumatoid lung nodules associated with pneumoconiosis in coal-miners (Caplan, 1953). Intraparenchymal lung nodules were later described in rheumatoid arthritis (RA) patients who were never exposed to coal dust and/or without pneumoconiosis. Rheumatoid lung nodules are usually detected in unselected patients: 0.2% in chest radiography and 4% in high-resolution computed tomography (Nannini et al., 2008). Patients could be reluctant to perform surgical lung biopsy for an accurate histopathological diagnosis. We present a peculiar association between a seropositive RA and a presumptive active tuberculosis (TB) disease in a 59-year-old male patient, ex-smoker with a previously healed pulmonary TB disease. The purpose of this report is to describe an unusual case of a presumptive relapse of the nodular TB disease, which progressed to an extensive nodular bilateral dissemination under anti-tuberculosis therapy, mimicking a metastatic carcinoma. The diagnosis of rheumatoid necrobiotic lung nodules was confirmed after open biopsy left pulmonary was performed. Formalin-fixed paraffin-embedded pulmonary rheumatoid nodules were processed for histology and stained with Masson's trichrome. Central structure of the removed pulmonary nodules is typical of a rheumatoid nodule with central necrosis surrounded by a palisade of macrophages. The accumulation of anthracotic pigment was noticed inside the pulmonary nodules in a RA patient without professional exposure to coal or mineral dust. This rare entity is an appearance of the rheumatoid nodules lung syndrome and anthracosis in a heavy tobacco former smoker.

Histological changes of gingival epithelium in diabetic patients with periodontal disease.

UNLABELLED: The pathogenesis of the periodontal disease is complex, because it derives from the initiation and maintenance of the chronic inflammatory process by the plenty microbial flora and its numerous bacterial products. The purpose of our study was to make evidence of the histopathological changes occurring in the gingival epithelium in patients with both diabetes mellitus and periodontal disease. MATERIALS AND METHODS: Our study was carried out on gingival tissue from 68 diabetic patients with specific symptoms of periodontitis. The preparations were processed by Hematoxylin-Eosin staining technique and trichromic staining after the Goldner-Szekely method. RESULTS: Although non-specific, since they have been generally found in chronic gingival inflammation, the noticed changes were significant and some of them had specific aspects for the diabetic patients: gingival epithelium changes like acanthosis type; the presence of inflammatory cells such as polymorphonuclear leukocytes and/or lymphocytes among the cells of the stratified squamous epithelium; surface ulceration areas covered by hematic and fibrino-leukocytary detritus; the epitheliocytes keratinization in the superficial layers. CONCLUSIONS: The diabetic patients with periodontitis frequently associate hypertrophy changes of the gingival epithelium with the epithelial permeability alteration and the presence of the intraepithelial inflammatory cells, subsequently leading to degenerative lesions and epithelial ulceration.

Tuberculosis mesenteric adenopathy and polyserositis.

A 41-year-old female patient was admitted into Surgery Clinic accusing abdominal pain, diarrhea, fever and chills. Based on clinical, biological and imaging data, it was established a diagnosis of pelviperitonitis and it was initiated an antibiotic and anti-inflammatory treatment. As fever and abdominal pain continued, it was decided to go on with surgery that revealed suppurated and perforated mesenteric adenopathy. Pus was sampled for bacteriological exam and also biopsy was performed for pathological exam. The result of pathological exam was suggestive for a specific granulomatous lesion (TB lesion). It was established diagnosis of TB mesenteric adenopathy and it was initiated specific anti-TB treatment according to WHO guidelines. After three, respectively five months of treatment, patient developed a right laterocervical adenopathy that fistulized in both cases, despite the correct treatment administered. No resistant TB strain and no atypical mycobacteria was discovered.

[Evaluation of COPD patients using CAT-COPD assessment test]. / CAT-COPD assessment test Testul de evaluare a BPOC.

INTRODUCTION: Purposes and objectives. CAT test is a simple questionnaire that quantifies the impact of COPD on patients and doctor-patient communication; it is a complex questionnaire that evaluates the lung function and the impact on quality of life. The score ranges from 0 to 40. The higher the score, the bigger the health problems are. This questionnaire can be used in any language and country, by all COPD patients. METHOD AND MATERIALS: We evaluated 71 COPD patients from Clinical Hospital "Victor Babes" Craiova between 2010-2011. These patients were included in a respiratory rehabilitation program of 16 sessions of physical exercises and education for 8 weeks. RESULTS AND DISCUSSIONS: The average final score was with 12.86% lower than baseline score. The average CAT score after rehabilitation for COPD stage I recorded the best decrease with 16.23%. The program of respiratory rehabilitation has a positive impact no matter BMI. CONCLUSIONS: CAT questionnaire is a sensitive test, easy to fill in that improves the doctor patient communication with a great impact on quality of life.

Gingival inflammatory infiltrate analysis in patients with chronic periodontitis and diabetes mellitus.

UNLABELLED: Diabetes mellitus and periodontal disease are two pathological entities that destructively emphasize each other. The aim of our study was the histological and immunohistochemical analyze of the inflammatory infiltrate in the gingival tissue at patients with diabetes mellitus (DM) and periodontal disease. MATERIALS AND METHODS: The study was achieved on gingival tissue from 40 patients with DM and specific symptoms of periodontal disease. We used Hematoxylin-Eosin and trichromic Goldner-Szekely staining and CD20cy and CD45RO antibodies. RESULTS: In patients with DM under 10 years, we found an intense periodontal lymphocyte inflammatory infiltrate and in patients with a DM evolution more than 10 years, the lymphocyte inflammatory infiltrate had a less intensity. The pattern was mostly diffuse in lamina propria. Many patients had a very abundant plasmocyte infiltrate. During immunohistochemical exam, 25 cases presented CD20 positive immunostaining. The intensity of the inflammatory infiltrate with B-lymphocytes was very low (score 1). All immunohistochemical analyzed cases presented CD45RO positive immunostaining, with a mixed pattern of the T-cell lymphocyte infiltrate. CONCLUSIONS: The nflammatory infiltrate in diabetic periodontal disease was polymorph, mostly with a diffuse pattern in gingival chorion. The intensity of the lymphocyte infiltrate was higher in patients with chronic periodontitis and DM less than 10 years. Positive CD45RO T-lymphocytes were more numerous compared to positive CD20 B-lymphocytes and they were present intra and under epithelial in the gingival of all the patients, no matter of the DM time evolution.

[Evolution of endemic tuberculosis in Olt county, Romania, between 1990 and 2008]. / Caracteristici ale evolutiei endemiei de tuberculoza în judetul Olt, în perioada 1990-2008.

A world-wide recrudescence of tuberculosis has been seen, due to the deterioration of the health state of the population from many areas of the world, because of increasing number of homeless persons, and also the immigrants from countries with TB epidemic. The present epidemiological context draw attention to the necessity of early detection of the disease and the beginning of early directly observed treatment, preferably ambulatory, if the sick person doesn't have other complications, isn't infected with multidrog resistant bacili and lives in a properly social environment for his support. For the evaluation of tuberculosis epidemic in Olt county, the authors realised a retrospective study on a period of over 15 years (1990-2008), based on the analysis of the main epidemiological indices of TB epidemic in this county compared with Romania: global incidence both in adults and children, for new cases nd relapses apart, incidence of MDR-TB (multidrug resistant-tuberculosis) cases, mortality through tuberculosis. Global incidence of TB in Olt county almost doubled between 1990-2008, reaching 147, 4 per hundred thousand, with much higher values compared with the national ones. Olt county presents constant values over the national ones between 1995-2008, due to the global incidence and also to the new cases and relapses. The incidence of new cases in children in 2008 (20,4 per hundred thousand) was below the national level (28 per hundred thousand). The risk of illness for the 0-14 years old children from Olt county was significantly lower in 2008 compared with the previous year, which, toghether with a number of MDR-TB cases under 15, signifies a regress of the epidemic.

[Inhaled corticosteroids in COPD and the risk of pneumonia]. / Corticoterapia inhalatorie in BPOC si riscul pneumoniei.

Concern is continuing about increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD) who use inhaled corticosteroids. The aim of this work is to present a few results from the literature about this problem.

[Importance of diagnosis and treatment of obstructive sleep apnea to prevent postoperative complications]. / Importanta depistarii si tratamentului sindromului apneei obstructive de somn în prevenirea complicatiilor postoperatorii.

Sleep Apnea is a medical condition, frequently undiagnosed, that leads to significant morbidity and reduced quality of life. Patients with obstructive sleep apnea (OSA) are particularly vulnerable of developing postoperative complications when having surgery or other invasive interventions under general anesthesia; pulmonary and cardiac disorders increase the risk of perioperative complications. We propose in this article to present the importance of polysomnography in the preoperative diagnosis of patients with OSA, initiations of CPAP therapy, treatment of associated disorders for reducing peri-operatory risk of these patients.

[Evolution of the tuberculosis epidemic in Oltenia, between 1980-2006]. / Evolutia endemiei de tuberculoza in Oltenia, in perioada 1980-2006.

The analyze of TB epidemic in Romania and, particularly, in Oltenia, in the condition of national applying of WHO strategy of prevention and control of TB, as the only way of achieving as main objective, the cure of 85% of source cases, represents the main way able to bring the base for adopting optimal solutions for correcting deficiencies. For the evaluation of the tendencies of evolution of the tuberculosis epidemic in Oltenia, the authors carried out a retrospective study over a period of more than 25 years, by the analysis of the main epidemiological indices of tuberculosis epidemic in this Romanian region: global incidence both in adults and children, for new cases and relapses apart, incidence of new cases of pulmonary and extra-respiratory TB, mortality through tuberculosis. In 1980, the TB global incidence was 71.07%000 and doubled this value in 2006. The distribution of new cases on regions in 2005 reflects the fact that Oltenia was on the first place, with a rate of 132.45%000, compared with national value of 105.7%000 in the same year. The incidence of new cases in children in 2006 (33.45%000) was higher than national level (31.6%000). The improvement of the living level of the population, following of the correct application of directly observed treatment and efficient anti-tuberculosis actions can determine a decrease of the TB epidemic in Oltenia.

[Epidemiology of lung cancer]. / Situatia epidemiologica a cancerului pulmonar.

Lung cancer is nowadays the most spread cancer worldwide, being the main cause of death of all cancers. Lung cancer is the most important and frequent type of lung tumour, representing over 90% of all cases of primary malignant and benign lung tumours. The most deaths of lung cancer occur at 35-75 age group. In the eighties, lung cancer was estimated to be almost 16% of all cancers worldwide and almost 23% of all cancers in Europe. In 1999, lung cancer relative frequency in USA was on top, being followed by colonic cancer and breast cancer relative frequency. In the same year, relative frequency of lung cancer was higher in USA than in Romania both for men (33.97% to 28.4%) and for women (about three times higher in USA than in Romania). According to statistics, lung cancer mortality rate in Romania in 1999 was on the first place in men (comparative with mortality rate of other cancers) and on the third place in women (after breast cancer and uterine collum cancer mortality rate). Lung cancer mortality rate in Romania increased significantly in 1985-2003 period, from 24.9%000 in 1985, to 39.7%000 in 2003. In 2000 year, lung cancer incidence for men in Romania (67.1%000) was lower than in Yugoslavia, Croatia, Bosnia-Herzegovina and Bulgaria but higher than its corresponding value in Macedonia and Albania. Prospective statistic studies estimate that in 2020 year lung cancer incidence for men will be the highest in Greece, Spain and France and the lowest in Great Britain, Ireland, Finland and Sweden. For women, the highest lung cancer incidence is estimated to be in Holland, Denmark and Austria and the lowest in Spain, Ireland and Finland.