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Cas cliniques
Multiple right-sided pulmonary nodules: metastatic cancer or resectable early stage tumor?  Envoyer

The aim of this paper is to focus attention on complex cases of lung disease that may benefit from being managed outside formal guidelines.

A 52 year-old man who had previously undergone a laryngectomy for squamous cell carcinoma, presented with a 1.2 cm nodule in the right upper pulmonary lobe. Three months later a new CT scan found that the nodule had slightly increased in size and also detected two new smaller nodules in the middle lobe. A PET/CT scan showed metabolic hyperactivity of all nodules. Since needle aspiration of the upper one revealed malignant cells, the patient was considered to be suffering from metastatic cancer and started on chemotherapy. At follow-up both CT and PET scans found a significant reduction in volume and activity of the lower nodules but no change in the upper one. At diagnostic thoracoscopy, histology demonstrated that the upper nodule was an adenocarcinoma while the lower ones were inflammatory. An upper lobectomy and systematic nodal dissection were therefore performed. Histology established a diagnosis of upper pulmonary adenocarcinoma and sarcoidosis.

Our report suggests that in complicated oncologic cases in which non-invasive diagnostic tools yield incongruous results surgery should be considered without delay.

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Serum sickness-like reaction with clarithromycin.  Envoyer

Serum sickness-like reaction is a rare immunological condition which may develop following exposure to certain drugs such as penicillins, cephalosporins, and trimethoprim-sulfamethoxazole, among many others. It is described classically as a type III hypersensitivity response to heterologous proteins. Its true mechanism is still unclear.

We present a case of serum sickness-like reaction to clarithromycin, a commonly prescribed drug for the treatment of respiratory tract infections. The patient had been taking this drug for 3 days when she experienced generalized body aches, rash, arthralgia, and shortness of breath, prompting presentation to the emergency department. Laboratory studies showed decreased C4 and total complement with a slightly elevated sedimentation rate. After exclusion of other possible causes, the diagnosis of serum sickness-like reaction was made. The patient responded well to nonsteroidal antiinflammatory medication, antihistamines, and a short, tapering dose of steroids.

To our knowledge, serum sickness-like reaction to clarithromycin has never been reported previously. This case emphasizes the need for increased clinical awareness of such an adverse outcome to clarithromycin use. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

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Association between Gastroesophageal Reflux and Endobronchial Carcinoid: A Case Report.  Envoyer

Children with neurological disorders may suffer from gastroesophageal reflux disease (GERD). Typical symptoms are vomiting, regurgitation and hematemesis. Patients present with respiratory symptoms only in cases with swallowing disorders causing chronic airway aspiration.

We report the case of a patient affected by chromosome 8 p deletion syndrome with mental retardation, referred to our unit for suspected GERD. Chest X-ray, performed at admission for coexisting respiratory complaints, showed left lower lobe pneumonia; esophageal pH monitoring and upper endoscopy were normal for GERD. To rule out chronic airway aspiration, gastroesophageal 99 mTc scintigraphy with lung scan 18 to 24 h after a test meal and video fluoroscopy swallowing study were performed, both negative. Two months later, a second episode of left lower lobe pneumonia occurred. A chest CT scan was performed and showed an endobronchial mass; the biopsy taken during the broncoscopy was not conclusive.

Surgical excision resulted in a diagnosis of pulmonary carcinoid. Bronchial carcinoids, although rare, should be taken into consideration as a potential cause of recurrent pneumonia even in the presence of demonstrated GERD where severe respiratory infections only occur with coexisting chronic pulmonary aspiration, even in neurologically impaired people.

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A crazy cause of dyspnea.  Envoyer
N Engl J Med. 2010 Dec 16;363(25):e38

Authors: Hunt S, Miller AL, Schissel S, Ross JJ

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A 19–year–old man with severe obstructive lung disease  Envoyer
Abstract: A 19-year-old boy presented to ambulatory clinic with shortness of breath after walking two blocks. He denied any cough, orthopnea, chest pain or hemoptysis. Ten months prior to admission he was admitted to the medical intensive care unit with respiratory failure and was diagnosed with Goodpasture syndrome. He was treated with cyclophosphamide and steroids. He was discharged home after recovering. Patient subsequently developed dyspnea on minimal exertion. Spirometry showed severe obstructive lung disease and HRCT of chest showed diffuse micronodular disease with patchy ground-glass opacities, mild bronchiectasis and bronchiolectasis. Serologies for goodpasture syndrome were normal. A diagnosis of post-Goodpasture syndrome constrictive bronchiolitis was made. Due to severity of s...
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