An adult case of cervico-mediastinal tuberculous lymphadenitis]

We reported a case of cervico-mediastinal tuberculous lymphadenitis followed by the development of pulmonary lesions and recurrent laryngeal nerve palsy. A 48-year-old man was admitted to our hospital due to fever, dry cough, and loss of body weight. He had no medical history of tuberculosis or other significant diseases. On admission, a right cervical tumor was palpable and chest X-ray films revealed widened superior mediastinum. Chest computed tomography showed multiple swollen mediastinal lymph nodes, including multiple low-density areas and contrast medium-enhanced septa and margins. Gallium-67 scintigraphy demonstrated abnormal uptake in the right cervix and mediastinum. A PPD skin test was strongly positive and ribosomal RNA of tubercle bacilli was detected in aspirated gastric juice. Although anti-tuberculous chemotherapy was initiated, fever and cough persisted, and hoarseness due to left recurrent laryngeal nerve palsy developed. One month later, chest X-ray films showed abnormal infiltration in the left upper lung field. The patient was sero-negative for HIV. To confirm the diagnosis, right supraclavicular lymph node biopsy was performed. Microscopic examination of the biopsy specimen revealed acid-fast bacilli and granuloma with central caseous necrosis surrounded by Langhans' giant cells and epithelioid cells. After 9 months of extended anti-tuberculous chemotherapy, the cervical and mediastinal masses receded and the abnormal chest X-ray shadows disappeared. Because the incidence of tuberculosis in Japan is gradually increasing among young people as well as the elderly, the differential diagnosis of this disease will become more necessary.     

Pulmonary coccidiomycosis in New Delhi, India

Coccidioidomycosis is an endemic disease of the western hemisphere. In cases occurring in non-endemic areas, eliciting a history of exposure as well as a high index of suspicion is imperative for timely and accurate diagnosis. In this case, a 65-year-old male presented to our hospital with fever, dry cough and malaise, and on X-ray chest, was found to have a lower lobe consolidation left lung with nodular lesions in both lungs and necrotic mediastinal lymphadenopathy. He lived in Arizona, USA, for 6?months before admission. Pulmonary coccidioidomycosis was confirmed by the isolation of Coccidioides spp. in pure culture from both broncho-alveolar lavage and lung biopsy specimens. The identity of the isolate was confirmed as C. posadasii by gene sequencing. The patient improved after being treated with fluconazole.     

Case of miliary tuberculosis with esophageal perforation and a tracheal inflammatory polyp secondary to mediastinal lymphadenitis causing massive hematemesis and hemosputum

A 62-year-old man with a history of left nephrectomy due to tuberculosis was referred to our hospital, because chest radiography showed diffuse miliary shadows in the bilateral lung fields, and acid-fast bacilli were detected from his hemosputum after steroid therapy for fever of unknown origin. Chest computed tomography showed mediastinal lymph node enlargement with partial calcification of these lymph nodes together with the presence of air. He was diagnosed with miliary tuberculosis and tuberculous mediastinal lymphadenitis and anti-tuberculosis drug therapy was started. Massive hematemesis occurred 11 days after the start of the treatment. Although gastroendoscopy was performed, the bleeding point could not be identified. The patient's symptoms improved after conservative therapy. Repeat gastroendoscopy showed a submucosal nodule with laceration of the esophageal mucosa, 30 days after admission for the examination of melena and progression of anemia. The episodes occurred because of esophageal perforation secondary to tuberculous mediastinal lymphadenitis. Bronchoscopic examination for hemosputum showed an inflammatory polypoid lesion in the left tracheal wall. These symptoms improved with anti-tuberculosis drug therapy. In our case, mediastinal lymphadenitis progressed to miliary tuberculosis because of endogenous reactivation. We report a rare case of esophageal perforation with a tracheal inflammatory polyp secondary to tuberculous mediastinal lymphadenitis. In cases of tuberculous mediastinal lymphadenitis, if hematemesis or hemosputum is observed, an endoscopic examination should be performed.     

Anterior mediastinal teratoma presenting as cardiac tamponade

Anterior mediastinal teratoma presenting clinically as cardiac tamponade is unusual. We report the case of a 58-year-old woman, with an unremarkable prior history, who was admitted with cardiac tamponade. Emergency pericardial aspiration showed a thick, yellow fluid. Computed tomography scan of the chest was suggestive of anterior mediastinal teratoma rupturing into the pericardium. Within 24 hours, just before the planned surgery could be performed, it re-ruptured, warranting emergency surgery. Histopathology confirmed the diagnosis of a teratoma. Early surgery is recommended for even asymptomatic benign mediastinal teratomas to avoid this potentially lethal complication of rupture into the pericardial cavity, and cardiac tamponade.     

Familial outbreak of psittacosis

Three familial cases of psittacosis are reported. The first case was a 46-year-old woman, the second case, her 18-year-old daughter. Both of them often visited the house of the third case, a 49-year-old women, who was the elder sister of case 1 and who took care of the chick of a budgerigar which she kept in the house. Case 1 came to our hospital with abrupt onset of fever, headache, nausea and general malaise. Because she was suspected to have meningitis, she was admitted to the Department of Neurology. On admission, her chest X-ray film showed bilateral ground glass shadows. She also had hypoxemia and liver dysfunction. On learning of her history of contact with the chick, psittacosis was suspected. Case 2 suffered from fever and headache. Her chest X-ray film revealed opaque infiltration in the right lower lung field. Case 3 complained of fever, headache and vomiting. Her chest X-ray film showed fan-shaped faint shadows in the left upper, middle and lower lung fields. We interpreted these findings as showing psittacosis based on anamnesis. The result of the complement fixation (CF) antibody titer against chlamydia was 1:32 in cases 2 and 3, enabling a serological diagnosis of psittacosis. The corresponding result was 1:16 in case 1. Although the CF antibody titer showed no increase, we diagnosed the case clinically as psittacosis. It is difficult to correctly diagnose psittacosis only from the physical findings and chest X-ray films. Detailed anamnesis, in particular taking a history of exposure to birds, is an important clue for diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of Beh?et disease with multiple nodular shadows and aneurysm of the brachiocephalic trunk caused by necrotizing vasculitis]

A 36-year-old man was admitted to our hospital in 1994 because of fever, and abdominal CT showed multiple low-density areas in the liver. Although granulomas were found in a liver biopsy specimen, a definitive diagnosis could not be established. With complaints of oral and genital ulcerations and erythema nodosum, Beh?et disease was diagnosed in 1995 and he was treated with colchicine and cyclosporin. In May 1997 he had fever, leg edema, and proteinuria, and a renal biopsy revealed secondary amyloidosis. Cavitary lesions were found on a chest X-ray for the first time, but these later disappeared spontaneously. In October 2002, nodular shadows, cavitary lesions, and a mediastinal tumor appeared on a chest X-ray film. The nodular shadows in the lung fields had transformed into cavity lesions, resulting in the disappearance of the shadows. Specimens obtained from an open lung biopsy showed necrotizing granulomas and destructive vasculitis of the lung, and aneurysm of the brachiocephalic trunk caused by destructive vasculitis. Because multiple nodular shadows with cavitary lesions in Beh?et disease, as in this case, have never been reported, we think this is a rare case.     

A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.     

Aortitis syndrome associated with ulcerative colitis, preceded by pulmonary infarction involvement]

A 21-year-old woman with a 6-year history of ulcerative colitis admitted to our hospital with chest pain, cough and fever of unknown origin in August 1998. On admission, laboratory data showed positive inflammatory signs. A chest radiograph and chest computed tomogram (CT) revealed nodular shadows in the right upper lung field. Fifty days after admission, hypertension developed and a bruit was audible in the neck and the upper abdomen. Digital subtraction angiography showed stenosis in carotid, renal and right upper pulmonary arteries. On the basis of these results, a diagnosis of aortitis syndrome was made. Moreover, these findings indicated pulmonary infarction in the right upper lobe due to aortitis syndrome. Aortitis syndrome preceded by pulmonary infarction involvement is very rare. Autoimmune disorders may have been involved in this case because of the association with ulcerative colitis.     

Unexpected Cause of Pericarditis: Chest Teratoma

Mediastinal teratoma rarely causes pericarditis. We report a case of a 22-year-old young female admitted to the emergency department for inspiratory chest pain and fever with severe pericardial effusion, unexepectable the cause of pericarditis was a mediastinal teratoma.     

A case of salazosulfapyridine-induced pneumonitis presenting with multiple pulmonary nodules and lymphadenopathy]

We report a rare case of drug-induced pneumonitis, probably caused by salazosulfapyridine, showing a radiographic pattern of multiple pulmonary nodules and lymphadenopathy. An 18-year-old woman was admitted to our hospital because of fever, skin rash, dry cough and dyspnea on exertion. She had been given salazosulfapyridine for two weeks to treat Crohn's disease. A chest radiograph and computed tomographic scan showed multiple nodular shadows in both lung fields, mediastinal lymphadenopathy, and bilateral pleural effusions. Cessation of salazosulfapyridine followed by corticosteroid therapy led to an immediate symptomatic improvement. The drug-induced lymphocyte stimulation test for salazosulfapyridine was negative. The same symptoms reappeared with rechallenge of SASP, however, which led to diagnosis as salazosulfapyridine-induced pneumonitis. This is apparently the first case report of salazosulfapyridine-induced pneumonitis with a radiographic pattern of multiple pulmonary nodules; accumulation of similar case reports are needed to confirm the association.     

Mediastinoscopy in the case of recurrent uveitis

INTRODUCTION: The authors report the case of a patient who presented for 4 years recurrent anterior uveitis accompanied by asymptomatic tuberculous mediastinal lymphadenitis. EXEGESIS: CT scan of the chest showed the existence of mediastinal lymphadenopathy (< 1 cm). Mediastinoscopy with biopsy of the right laterotracheal lymph node was performed. The culture was positive for Mycobacterium tuberculosis, thus permitting the diagnosis of tuberculosis. CONCLUSION: This case report stresses the advantage of extensive etiological assessment when faced with unexplained uveitis; particularly it emphasizes the importance of investigating potential tuberculosis. The existence of granulomatous uveitis, a positive skin test, the ethnic origin, and mostly results of chest CT scan, were the rationale for the use of mediastinoscopy with lymph node biopsy to help guide diagnosis.     

Development of interferon induced sarcoidosis in a patient with familial mediterranean fever

A 42-year-old male patient, who had been on colchicine therapy for familial mediterranean fever admitted with dyspnea on exertion. He had a history of interferon-alpha (IFN-alpha) administration. The chest X-ray showed diffuse distribution of reticulonodular opacities in both lungs. A computerized tomography scan of the lungs revealed mediastinal and bilateral hilar lymphadenopathies, translucent densities, consolidations, reticular opacities and subpleural milimetric cystic spaces. Pulmonary-function studies demonstrated defects in diffusing and vital capacity. Histopathological evaluation was compatible with granulomatous lymphadenitis. The patient was diagnosed as having pulmonary sarcoidosis. He reflects the characteristics of IFN-induced sarcoidosis, but the duration between the cessation of IFN therapy and the development of symptoms is 42 months, which is longer than usually expected. In this case, history of IFN-alpha administration led us to suspect sarcoidosis because of a possible association between IFN therapy and the development of sarcoidosis.     

An unusual case of mediastinal mass due to Fonsecaea pedrosoi.

Phaeohyphomycosis is a disease caused by dematiaceous fungi. Here, the first culture-proven case of mediastinal mass due to Fonsecaea pedrosoi is reported. The patient was a 40-yr-old male who had presented with history of dyspnoea and dysphagia. Computed tomography of the chest disclosed a mediastinal mass. Cultures of a specimen from the mediastinum grew Fonsecaea pedrosoi. The patient received amphotericin B and itraconazole and showed a remarkable recovery. Repeat computed tomography revealed a reduction in the mediastinal mass. The case highlights the need for a high degree of clinical suspicion and appropriate histopathological and mycological examination of clinical specimens.     

Fludeoxyglucose positron emission tomography in the diagnosis of giant cell arteritis

We describe a case in which fludeoxyglucose F 18 positron emission tomography (PET) led directly to the diagnosis of giant cell arteritis in an elderly woman with a fever of unknown origin.The patient presented with a 3-month history of fatigue, fever, headache, visual disturbance, jaw claudication, and anemia. A computed tomographic scan showed an anterior mediastinal mass that was suspected of being malignant. A fludeoxyglucose F 18 PET scan performed for preoperative evaluation identified striking uptake of fludeoxyglucose F 18 in the walls of the entire aorta, left main coronary artery, and subclavian, carotid, and common iliac arteries bilaterally, suggestive of an arteritis, a diagnosis subsequently confirmed by the findings of an arterial biopsy. Her erythrocyte sedimentation rate was 129 mm/h. There was normalizaton of the PET scan 2 weeks following treatment with prednisolone. This case suggests that fludeoxyglucose F 18 PET contributes to the noninvasive diagnosis of giant cell arteritis, as well as to the evaluation of the extent of disease, response to therapy, and disease recurrence.     

Rare chronic gastric volvulus associated with left atrial and mediastinal compression

We report a case of chronic gastric volvulus associated with left atrial compression in a 75-year-old woman who presented with chest pain, shortness of breath, and hypotension after elective hemiarthroplasty of the left hip. The patient's medical history included a paraesophageal hernia and gastric volvulus diagnosed in 1997 but left untreated. The present diagnosis of gastric volvulus was made on the basis of a chest radiograph and subsequent computed tomography. Echocardiography showed the volvulus compressing the left atrium. Surgery to repair the defect was successful, and there were no operative or postoperative complications. A review of the world medical literature revealed that gastric volvulus is rarely reported to cause hemodynamic compromise or compression of the heart and mediastinal structures.     

A case of cervical-mediastinal lymph node tuberculosis progressed to pulmonary lesion through a bronchial fistula]

The patient was a 25-year-old man who had been admitted to a local hospital due to fever and trachelophyma. Tubercle bacillus was detected in pus culture obtained by biopsy of the trachelophyma, but not in sputum culture. Because combined therapy with 3 antituberculous drugs (RFP, INH and SM) failed to reduce the fever or drainage from the biopsy region, the patient was transferred to our hospital. Chest X-ray films taken on admission revealed dilatation of the superior mediastinal shadow; chest CT images revealed cervical and mediastinal lymphadenopathy and an anterior mediastinal abscess, but no pulmonary lesion. About 2 months after admission, cough developed and Gaffky type 2 was detected in the patients sputum. Bronchoscopy and bronchography revealed a bronchomediastinal fistula. Forty days after the onset of cough, reticulogranular shadows were observed in the right upper lobe on chest X-ray films, and a diffuse centrilobular lesion was observed in the right upper lobe on chest CT images. From these clinical observations, the patient was given a diagnosis of cervical-mediastinal lymph node tuberculosis, which had progressed to pulmonary lesion through a bronchial fistula due to lymphadenitis.     

肺放线菌病一例并文献复习

目的 提高对肺放线菌病发病机制、诊断、临床特点及治疗的认识.方法 报道2007年3月解放军总医院附属第一医院呼吸科收治的1例肺放线菌病病例并进行相关文献复习.结果 患者女,66岁.反复出现咳嗽、咳痰、低热4年,多次X线胸片均示右中叶肺炎,经支气管镜检查及病理诊断为肺放线菌病.经林可霉素联合磺胺甲嚼唑/甲氧苄啶治疗6个月后痊愈.结合本例并复习近20年国内外文献报道的187例肺放线菌病(国外162例,国内25例)资料,结果 显示本病男性多见,发病年龄为12～87岁;咳嗽、咳痰、胸痛为常见症状,咳黄色颗粒样物为典型表现,但并不多见.胸部CT可表现为实质团块影、片状影、实变影伴支气管充气征、空洞、纵隔淋巴结肿大、胸腔积液及胸膜增厚等.病变部位以左下叶及右中叶居多,与肺癌、肺结核易混淆.确诊主要依靠经支气管镜活检病理及手术病理检查,痰涂片及培养阳性率低.青霉素、四环素、红霉素、磺胺类或林可霉素等抗生素治疗及手术切除是主要的治疗手段.结论 肺放线菌病是一种少见病,早期诊断和治疗可获得良好疗效.     

A case of sarcoidosis manifesting as acute febrile polyarthritis following bronchoalveolar lavage]

A 32-year-old man was incidentally found to have abnormal shadows on a chest X-ray film and was admitted on May 2004. His chest images showed mediastinal and bilateral hilar lymphadenopathy. The serum level of angiotensin-converting enzyme was elevated. We also found non-caseating epithelioid cell granulomas in transbronchial lung biopsy specimens, and confirmed the diagnosis of sarcoidosis. We carried out bronchoalveolar lavage (BAL) for evaluation of disease activity of sarcoidosis. After BAL, he suffered high fever and polyarthralgia. Both ankles were extremely inflamed. We suspected infectious arthropathy caused by atypical pathogens and thus administered antibiotics, but they had no effect at all. Also, no findings suggesting collagen-vascular disorders, including rheumatoid arthritis, were detected. His symptoms improved after three-weeks of treatment with non-steroidal anti-inflammatory drugs. Thus, this case was diagnosed as having acute sarcoid polyarthritis. BAL may have influenced the onset of febrile arthritis in this patient This case indicates that sarcoidosis should be considered as a possible cause of acute febrile polyarthritis.     

Early diagnosis in an unusual presentation of tubercular pericarditis-A case report

Patients with tuberculosis sometimes may present with atypical, unusual features. The reported case is of 57 years male admitted with chief complaint of fever and breathlessness. Spiral CT chest revealed significant pericardial effusion all around heart, bilateral pleural effusion and multiple ill defined alveolar nodules scattered in both the lungs, more so in upper lobes. No significant mediastinal lymphadenopathy was seen. Pericardial fluid on Ziehl-Neelsen staining revealed acid fast bacilli. Subsequently sputum examination also showed acid fast bacilli. Hence pericardial fluid examination is helpful in the diagnosis of tubercular pericarditis. Tuberculosis can have protean manifestations as in this case with bilateral pleural effusion, pericardial effusion and mottling of lungs. Therefore clinician needs to keep complex presentation of tuberculosis in mind to manage the case at its earlier stage to avoid residual complications.     

A case of sarcoidosis and idiopathic thrombocytopenic purpura accompanied with invasive pulmonary aspergillosis]

A 54-year-old woman with a 21-year history of sarcoidosis was admitted to our hospital with dyspnea on exertion, weight loss, and the appearance of consolidation in chest radiographs. The serum level of soluble IL-2 receptor was high, and CT findings demonstrated mediastinal, hilar and abdominal lymphadenopathy. The histological findings of subpleural consolidation in a transbronchial lung biopsy of the left lung showed giant cells; and those of a CT-assisted biopsy of a retroperitoneal lymph node revealed non-caseous epithelioid cell granulomas. After the biopsy, severe thrombocytopenia (6,000/microliter) developed. With prednisolone treatment, the platelet count rose to normal and the subpleural consolidation on chest radiography was improved. Five weeks later, the had a productive cough with fever, rapidly progressive cavitary lesions and consolidation on chest radiography. Aspergillus fumigatus was detected in the sputum by PCR, and Aspergillus antigen was detected in the serum. She died of progressive respiratory failure, in spite of therapy with amphotericin B and itraconazole. We report a rare case of sarcoidosis and idiopathic thrombocytopenic purpura accompanied with invasive pulmonary aspergillosis.