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The aim of the study was to determine the aetiology of large and symptomatic pericardial effusions and to review the management and subsequent outcome. A survey was done on a consecutive cases of patients who had undergone percutaneous pericardiocentesis over a 10 year period in a city centre general hospital serving a multiethnic catchment population. In all, 46 patients (24 male, 22 female; age range 16 to 90 years, mean 54 years) underwent a total of 51 pericardial drainage procedures (or attempted pericardiocentesis) between 1989 and 1998. Malignancy (44%), tuberculosis (26%), idiopathic (11%), and post-cardiac surgery (9%) were the most common causes of pericardial effusion. The most common presenting symptoms were breathlessness (90%), chest pain (74%), cough (70%), abdominal pain (61%) (presumed to be related to hepatic congestion), and unexplained fever (28%). In the 12 cases of tuberculous pericarditis, nine occurred in patients of Indo-Asian origin, and three in patients of Afro-Caribbean origin. Fever, night sweats, and weight loss were common among these patients, occurring in over 80% of cases of tuberculous pericarditis. Pulsus paradoxus was the most specific sign (100%) for the presence of echocardiographic features of tamponade, with strongest positive predictive value (100%). Although malignancy remains the most common cause in developed countries, tuberculous disease should be considered in patients from areas where tuberculosis is endemic. Percutaneous pericardiocentesis remains an effective measure for the immediate relief of symptoms in patients with cardiac tamponade, although its diagnostic yield in tuberculous pericarditis is relatively low.
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PMID:Management of pericardial effusion by drainage: a survey of 10 years' experience in a city centre general hospital serving a multiracial population. 1108 87

Coccidioides immitis is a dimorphic fungus primarily found in the soil in a limited region of the southwestern United States. When this fungus causes an infection (coccidioidomycosis), it is due to the spores being inhaled and causing an inflammation of the respiratory tract. In most cases, the infection is self-limiting and is controlled by cell-mediated immunity. In HIV-infected patients, it is thought that the infection may be newly acquired, or reactivated, from a former incident. Patients with a CD4 count under 250 are at highest risk for becoming infected, and may present with pneumonia, fever, weight loss, night sweats, cough, and dyspnea. The infection can also become disseminated, and upon autopsy, widespread disease is found in the majority of patients that die of coccidioidomycosis. Chest x-rays show a diffuse reticulonodular infiltrate, then diagnosis is made by culturing the organism. The treatment of choice for disseminated disease is amphotericin B and alternative therapies including itraconazole and fluconazole, with possible lifelong treatment necessary. There is no current evidence that coccidioidomycosis can be prevented by any of these drugs.
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PMID:Coccidioidomycosis. 1136 25

The use of anthrax as a weapon of biological terrorism has moved from theory to reality in recent weeks. Following processing of a letter containing anthrax spores that had been mailed to a US senator, 5 cases of inhalational anthrax have occurred among postal workers employed at a major postal facility in Washington, DC. This report details the clinical presentation, diagnostic workup, and initial therapy of 2 of these patients. The clinical course is in some ways different from what has been described as the classic pattern for inhalational anthrax. One patient developed low-grade fever, chills, cough, and malaise 3 days prior to admission, and then progressive dyspnea and cough productive of blood-tinged sputum on the day of admission. The other patient developed progressively worsening headache of 3 days' duration, along with nausea, chills, and night sweats, but no respiratory symptoms, on the day of admission. Both patients had abnormal findings on chest radiographs. Non-contrast-enhanced computed tomography of the chest showing mediastinal adenopathy led to a presumptive diagnosis of inhalational anthrax in both cases. The diagnoses were confirmed by blood cultures and polymerase chain reaction testing. Treatment with antibiotics, including intravenous ciprofloxacin, rifampin, and clindamycin, and supportive therapy appears to have slowed the progression of inhalational anthrax and has resulted to date in survival.
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PMID:Clinical presentation of inhalational anthrax following bioterrorism exposure: report of 2 surviving patients. 1172 75

A 73-year-old African American female presented to our clinic with painful lower extremity lesions of 2 weeks duration. She was in her usual state of health until 3 months prior to presentation when she reported symptoms of fatigue and weakness. She also noticed an enlarging mass on the left side of her neck. She denied fevers, chills, night sweats or cough. Her symptoms were unresponsive to a course of oral dicloxacillin. The neck mass enlarged over 8 weeks and she was referred to our institution for evaluation. CT scan of the neck showed an enlarged lymph node. Ten days prior to her presentation in dermatology, a fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas. Tissue was sent for routine mycobacterial and fungal cultures. Routine blood work, chest radiograph, and a tuberculin skin test were also performed. At the time of her dermatology visit she described the development of multiple new painful, non-pruritic lesions, bilaterally on the lower extremities. She also reported a red crusted area that appeared at the site of her tuberculin test that was placed subsequent to the development of her lower extremity lesions. Her past medical history was significant for Parkinson's disease, hypothyroidism and hypertension. Her current medications included l-thyroxine, estrogen and diltiazem. Her travel history was only remarkable for a trip to Jamaica the previous spring. She was born and raised in Haiti. She reported a history of a positive tuberculin skin test 20 years ago, but received no therapy. Physical examination revealed a 2 x 3 centimeter firm, nontender left lateral neck mass (Fig. 1). Her right forearm revealed an erythematous, ulcerated, indurated plaque 1.5 cm in diameter (Fig. 2.). Her lower extremities revealed tender 0.5 to 1 cm erythematous nodules below the knees bilaterally (Fig. 3). A punch biopsy of a lower extremity nodule revealed a mild pervisacular dermal infiltrate. Within the subcutaneous tissue there was septal widening. There was also a lymphohistiocytic infiltrate with a slight admixture of neutrophils within the septa of the fat lobules. There was no evidence of necrotizing vasculitis or collagen necrosis. An acid-fast stain was not performed. The histologic findings were consistent with a diagnosis of erythema nodosum. Her laboratory evaluation including CBC, electrolytes, thyroid studies, angiotensin converting enzyme level and chest radiograph were normal. Approximately 1 week after her dermatological evaluation, the fine-needle aspirate culture grew Mycobacterium tuberculosis. A diagnosis of tuberculous lymphadenitis associated with erythema nodosum was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol and pyrazinamide. Her lower limb skins lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.
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PMID:Erythema nodosum associated with reactivation tuberculous lymphadenitis (scrofula). 1201 Mar 45

PRESENTING FEATURES: A 42-year-old man was admitted with a chief complaint of cough and night sweats of 2 months' duration. The cough produced brown sputum but no blood. He also reported drenching sweats every night for the last several weeks before admission. He attributed his cough to exposure to dust while working on demolishing a funeral home 2 months ago; he denied any history of respiratory symptoms before this recent job. The patient smoked less than one pack of cigarettes per week during the previous year. He had no history of tuberculosis or contact with infected persons. He denied a history of severe lung infection, asthma, sinus disease, or overseas travel, as well as behaviors that are risk factors for human immunodeficiency virus (HIV) infection, such as intravenous drug use or multiple sexual partners.His physical examination was notable for a temperature of 101.4 degrees F and an oxygen saturation of 98% on room air. In general, he was thin, although well in appearance, and not visibly short of breath. His lungs were clear to auscultation. Laboratory studies and urinalysis were normal.A chest radiograph showed a 3-cm by 2-cm mass with a surrounding cavity in the right upper lobe (Figure 1). A subsequent chest computed tomographic scan showed a 5-cm by 4-cm cavity in the right upper lobe, with surrounding infiltrates as well as a mass within the cavity suspicious for a fungus ball (Figure 2). Patchy infiltrates were also seen in the left and right lower lobes. What is the diagnosis?
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PMID:Cases from the Osler Medical Service at Johns Hopkins University. Scedosporium apiospermum mycetoma of the lung. 1251 68

The diagnosis and treatment of thoracic tuberculosis follow common principles whatever the localisation. Tuberculosis is diagnosed on clinical signs: night sweats, fever, cough, weight loss, persisting after non-specific treatment, for more than 3 weeks. The demonstration of bacilli in sputum is the keystone of diagnosis, but in extrapulmonary localisations definitive proof is often drawn from a pleural, pericardial or even lymph node biopsy. After diagnosis, or when diagnosis is highly suspected, antituberculous treatment is started. Steroid could be useful in exsudative forms. The overall cure rate is 95% but side effects, poor compliance or bacteriological resistance can yield complex problems and lead to failures.
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PMID:[Thoracic tuberculosis]. 1260 33

Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient's only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors.
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PMID:Acute human immunodeficiency virus syndrome in an adolescent. 1452 19

Bronchiolitis obliterans organizing pneumonia (BOOP) is a well-defined clinicopathological entity. The aetiology of BOOP is generally unknown, although it has been associated with specific diseases or various pharmaceutical drugs. The amiodarone is one of them. We report a patient with BOOP secondary to amiodarone therapy, who presented with cough, fever and sputum production, dyspnoea and night sweats lasting for two months. A chest radiograph showed bilateral patchy and interstitial infiltrates. Lymphocyte phenotyping of bronchoalveolar lavage fluid showed decreased ratio of CD4+:CD8+ lymphocytes. Transbronchial lung biopsy established the diagnosis of BOOP. After stopping amiodarone therapy, symptoms disappeared and the chest radiograph remained normal within two months.
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PMID:[Bronchiolitis obliterans with organizing pneumonia in a patient treated with amiodarone]. 1453 63

We report an unusual case of the 'reverse' variant of follicular lymphoma in which the nodules had central parts that stained dark and cuffs that stained pale. Because diagnosis was difficult relying only on formalin-fixed histopathology, we examined the cell surface markers and karyotype. The patient, a 65-year-old man, presented with multiple lymphadenopathy, low-grade fever, night sweats, anorexia, dry cough and sense of chest oppression. Cell surface marker analysis showed that pathologic lymphocytes were positive for CD 10, CD 19, CD 20, HLA-DR, IgM/IgD and kappa, and t (14; 18) (q 32; q 21) was detected by karyotypic analysis. The 'reverse' variant of follicular lymphoma, clinical stage IVB was diagnosed the rearrangement band was detected with PCR-based clonality analysis in not only the immunoglobulin heavy chain gene but also the T cell receptor gamma chain gene, thus confirming monoclonal proliferation of both B cells and T cells.
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PMID:['Reverse' variant of follicular lymphoma with monoclonality of the immunoglobulin heavy chain and T cell receptor gamma chain genes]. 1468 70

Exposure to asbestos is the most frequent, but not exclusive, cause of malignant mesothelioma. Clinical features include dyspnea, cough, nonspecific chest pain, weight loss and night sweats. Diagnosis may be complicated by histologic difficulties. Thoracoscopic techniques are proving beneficial, but no one method of imaging has proven superior, and disease staging is inconsistent. Conventional treatments such as chemotherapy, surgery, and radiotherapy have had variable impacts, although chemotherapy is useful in palliation and can improve both survival and quality of life. There is hope for new antimetabolite agents. The role of radical surgery is yet to be evaluated in a large trial. New radiotherapeutic techniques to improve local control are promising. Multimodality treatments appear to be the most successful for management of potentially resectable disease. It is likely that biological markers will improve accuracy in staging and prognosis. With new treatments based on better understanding of the biology of the disease, there is cautious optimism for the future for patients with malignant pleural mesothelioma.
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PMID:Malignant pleural mesothelioma--an update. 1507 23


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