Multiple pleural nodules without effusion--a rare presentation of tuberculous pleurisy.

We report a rare case of tuberculous pleurisy presenting with multiple pleural nodules without associated effusion or parenchymal lung lesions. A 62-year-old man had multiple discrete pleural nodules in the right hemithorax on chest radiography without any clinical symptoms. Thoracoscopic biopsy of the pleural nodules revealed a caseous granuloma with acid-fast bacilli. The patient received antituberculous therapy, with resolution of tuberculomas on chest film within 2 months. To our knowledge, only two similar cases have been previously reported in the English literature, and our observation should lead to broadening of the spectrum of the differential diagnosis of multiple pleural nodules.

Pulmonary strongyloidiasis--case report of 2 cases.

Strongyloidiasis is a benign gastrointestinal infection. It can pass through the lungs and induce pulmonary strongyloidiasis. The suspicion of pulmonary involvement begins with clinical and chest radiographic features in the patients at risk. They are as follows: chronic lung diseases, age was 65 years, altered cellular immunity, and use of corticosteroids. Definitive diagnosis is made by identification of strongyloides in the secretion or tissue of the respiratory tract. We present 2 patients with pulmonary strongyloidiasis in this research. These 2 cases were patients with chronic obstructive pulmonary disease; both patients were more than 65 years old. They had the risk factors for severe strongyloides infection (advanced age, use of corticosteroids, an high serum cortisol level), worsening of pulmonary symptoms (e.g., dyspnea, cough, sputum production) and abnormal radiographic findings. Strongyloides stercoralis was found in the sputum and stool, and pulmonary strongyloidiasis was diagnosed. Mebendazole 100 mg twice daily was used and this eliminated the parasite from the stool in case 1, and from the sputum in case 2. Unfortunately, there was a relapse of parasite infection in case 1 and it also induced pulmonary strongyloidiasis. Finally, he died of respiratory failure. Since this disorder has a high relapse rate (15%), serial follow-up of stool and sputum is very important.

The acting site of bronchodilator, methacholine and upper respiratory tract infection on airways.

BACKGROUND: The bronchodilator agent is an important drug for patients with chronic obstructive pulmonary disease. Methacholine is a popular bronchial provocative agent. Although the major acting site of bronchodilator, methacholine and upper respiratory tract infection (URI) has been evaluated in some studies, the sites are still in debate. This study investigated the exact major acting sites. METHODS: Thirty subjects participated in this study. Episodes of URI were identified by a questionnaire. Spirometry, bronchial provocative test with methacholine, and five minutes' inhalation of a mixture of helium and oxygen (HeO2) were done on day one. Spirometry, bronchodilator test, with five minutes' inhalation of HeO2 and expiratory flow-volume (F-V) curve were performed on another day. The change of pre- and post-HeO2 VEMax50 was calculated as delta VEMax50. The pre- and post-bronchodilator VEMax50 and delta VEMax50 differences were counted to decide the acting site of bronchodilator. After bronchial provocative test with methacholine, the volume of isoflow (VisoV) was estimated from pre- and post-HeO2 F-V curve to establish the acting site of methacholine. RESULTS: This study indicated that small airways are the major acting sites of bronchodilators, large airways are the major acting sites of methacholine and URI affects mainly large airways. Although airway hyperresponsiveness is more severe in subjects with positive methacholine response, the recovery of spirometry values is not significantly different between the methacholine-positive and -negative groups. CONCLUSIONS: The major acting sites of the bronchodilator, methacholine, and URI are the small, large and large airways, respectively. Bronchial hyperresponsiveness is not a cause of quick restoration of spirometry values in subjects with positive methacholine response.

Digital ischemia associated with lung cancer: a case report.

Digital ischemia or necrosis has unusually been associated with neoplasm. The occurrence of cryoglobulinemia and lung cancer with digital ischemia has been extremely rare in the past. This report concerns a case with adenocarcinoma of the lung associated with cryoglobulinemia, with rapidly developing digital ischemia of the tips of fingers and toes. Following concurrent chemoradiotherapy, there was improvement in digital ischemia and disappearance of serum cryoglobulin. The mechanisms of neoplasm-associated digital ischemia are complex; however, the cryoglobulinemia and probable arteritis may have played important roles in producing the ischemic symptoms in this case.

Diagnostic value of transbronchial lung biopsy under fluoroscopic guidance in solitary pulmonary nodule in an endemic area of tuberculosis.

In the endemic area of tuberculosis, there are many cases that present tuberculosis as a solitary pulmonary nodule (SPN) on chest radiographs. The objective of this study is to evaluate the diagnostic yield of transbronchial lung biopsy (TBLB) under fluoroscopic guidance in SPNs such as lung cancer or pulmonary tuberculoma in areas with high prevalence of tuberculosis. One hundred and seventy patients with SPNs on chest radiographs were included in the study; all had negative sputum smears for tubercle bacilli and no malignancy by sputum cytology before bronchoscopy. Transbronchial lung biopsy and brushing were performed, routinely, under fluoroscopic guidance. Of 170 patients, 120 (70.6%) had lung cancer (including three with metastatic cancer), 40 (23.5%) patients had pulmonary tuberculosis (Tb), and the remaining 10 (5.9%) patients had other benign pulmonary lesions. The overall diagnostic rate in SPNs was 62.4% (106 of 170). Transbronchial lung biopsy and brushing revealed a diagnostic sensitivity of 70.0% in lung cancer (84 of 120) and a sensitivity of 55% in Tb (22 of 40). In addition, TBLB and brushing also provided rapid microscopic identification of Tb in 18 of 40 patients (45%, including 15 by TBLB, one by brushing smear, and two by postbronchoscopic sputum). The percentage of positive diagnosis correlated with diameter of the SPN. Solitary pulmonary nodules with diameter less than 2 cm were diagnosed in only 35.3% of cases (6 of 17; cancer 40% vs. Tb 29%). In contrast, the diagnostic rates in SPNs with diameters 2-4 cm and greater than 4 cm were 64.5% (78 of 121; cancer 72.0% vs. Tb 62.5%) and 68.8% of cases (22 of 32), respectively. Diagnostic bronchoscopy under fluoroscopic guidance is a useful tool in evaluation of patients with a peripheral pulmonary nodule since it may provide additional information to minimize unnecessary thoracotomy and give way for proper medication as early as possible.

Elevated serum CK-MB and CK-BB isoenzymes in a patient with small cell lung cancer: a case report.

An increase in serum creatine kinase-MB (CK-MB) isoenzyme is regarded as a specific indication of acute myocardial infarction. Recently, increased concentrations of various types of creatine kinase isoenzymes (mostly CK-BB and macro CK type 2 isoenzymes) have been found in the blood of some patients with malignancies. However, highly elevated serum CK-MB isoenzyme associated with malignancy has rarely been reported previously. Herein a case of extensive small cell lung cancer is presented in which the elevated serum levels of CK were detected throughout the three weeks of hospitalization. Fractionation of its isoenzymes by gel electrophoresis displayed elevated CK-MB and CK-BB isoenzymes. The proportion of serum CK-MB and CK-BB isoenzyme activities was persistently above normal (CK-MB 50-53%, normal < 5%). Clinical examination showed no evidence of myocardial infarction or injury, or tumor involvement of the heart. The tumor was the probable source of most circulating CK-MB isoenzyme. In clinical practice, markedly elevated levels of CK-MB, or increased levels of CK-MB in combination with CK-BB may point away from a myocardial origin and toward the existence of a malignancy.

Arthrography-assisted intra-articular injection of steroids in treatment of adhesive capsulitis.

Following shoulder arthrography to establish the diagnosis of adhesive capsulitis, we injected steroids via the in situ arthrogram needle. Subsequent intraarticular steroids, if needed, were given at the outpatient clinic using landmarks established at the time of arthrography. Out of 18 patients treated, function sufficient to permit resumption of usual work and self-care activities returned to 16. In 11 patients, recovery was associated with painless total shoulder movement gather than a return to glenohumeral motion. This therapy appears perferable to other forms of intraarticular injection and is an alternative to surgery when physical therapy has failed.

Endobronchial foreign body demonstrated by xerotomography.

A case of pneumonia secondary to aspirated foreign body is presented. Xerotomography was useful in detecting abnormalities of the tracheobronchial tree and in demonstrating endobronchial foreign bodies.

Diagnosis of rotator cuff tear on routine radiographs.

Routine shoulder radiographs were reviewed in 42 patients with proven rotator cuff tears and in 38 patients in whom a rotator cuff tear had been excluded by shoulder arthrography. Five radiographic findings were identified which were commonly associated with a rotator cuff tear. One or more of these findings were seen in 90.4% of those patients with a rotator cuff tear. These findings were not specific and were also seen in 64.3% of those patients with a frozen shoulder.

Angiographic and ultrasonic findings in infected simple cysts of the kidney.

This paper describes angiographic and ultrasonic findings in three patients with proven infected renal cyst. The clinical picture was that of inflammatory renal disease. B-mode ultrasonography showed the characteristic features of renal cyst; however, this technique cannot differentiate between infected and simple cysts. Selective renal angiography demonstrated the following, enabling differentiation from simple renal cyst; hypervascular rim, irregular inflammatory vessels, indistinct interface between cyst and adjacent parenchyma, and prominent capsular branches. Since percutaneous puncture of an infected renal cyst or abscess carries risk of infectious complications, angiography appears justified only for those patients with fever and flank pain who have cystic lesions in the kidney confirmed by echography.

Lung carcinoma superimposed on pulmonary tuberculosis.

Review of patients with active pulmonary tuberculosis over a three-year period showed an increased incidence of bronchogenic carcinoma (5%). There had been considerable delay in establishing diagnosis of coexistent carcinoma which was attributed to finding of acid-fast bacilli and relative ease of ascribing all findings to that cause. Suspicious roentgen signs are reviewed and the importance of sputum cytology is also stressed.

Xerotomography of peripheral lung lesions.

Xerotomography was compared to conventional tomography in 72 patients with peripheral lung lesions. The xerotomogram was superior to the conventional tomogram in 41 patients, and yielded no additional information in 31. Details of lesions were better displayed, especially the margins: cavitations, air bronchogram and bronchiectasis, and calcification. Differentiation between benign, inflammatory and malignant lesions was facilitated. The xerotomographic process improved the image detail of lesions due to the edge enhancement property and the greater recording latitude of contrast of the xeroradiographs. Xerotomography is recommended only in selected patients for a few tomographic cuts because of the high radiation dosage.

Shoulder arthrography in rheumatoid arthritis.

Arthrograms of the shoulder were evaluated in 10 patients with rheumatoid arthritis. The arthrographic findings common to all joints consisted of nodular filling defects, irregular capsular attachments, bursal filling defects and visualized lymphatic drainage. Findings unique to the shoulder joint consisted of rotator cuff tear, frozen shoulder, and biceps sheath dilatation. Since the agents used to treat patients with rheumatoid arthritis have profound side effects, it is important to exclude an associated rotator cuff tear and/or confirm the presence of glenohumeral rheumatoid involvement.

Xerotomographic diagnosis of central bronchogenic carcinoma.

Xerotomography was used to examine 14 patients with substantial pulmonary opacities, in whom the diagnosis of bronchogenic carcinoma had been suspected. Xerotomography was valuable because it provided excellent delineation of the tracheobronchial tree, which assisted in differentiation of benign from malignant lesions. Malignancy was suggested by: 1) amputation, 2) eccentric narrowing of the bronchus, 3)irregularity of the bronchial wall, 4)presence of an intraluminal mass. Mediastinal and hilar node enlargement could also be assessed. The use of these criteria allowed a correct preoperative diagnosis in 12 of 14 patients. Due to the high radiation dosage, this method is not suitable for use as a screening procedure.