Canan Eren Dagli

Clinical review of tuberculous peritonitis in 39 patients in Diyarbakir, Turkey

Abstract  Abdominal tuberculosis (TB) is a rare manifestation, which can be overlooked on long‐lasting and non‐specific findings unless a high index of suspicion is maintained. The purpose of the present study was to investigate the diagnostic features of 39 patients hospitalized with tuberculous peritonitis (TBP) in Dicle University Hospital, Turkey between January 1994 and August 2003. Twenty‐two patients were male; patient age ranged between 1 and 59 years (mean: 16.2 ± 14.4 years). There were 21 patients (54%) under 15 years of age. Thirteen children had a history of familial TB and seven adults had prior history of TB. Six (29%) of 21 pediatric cases had bacille Calmette‐Guerin (BCG) scars and results of 5‐tuberculin units (TU) tuberculin test were positive in seven children (18%). Of all cases, the most common presenting findings were abdominal pain (95%), ascites (92%) and abdominal distention (82%). Five of the patients had accompanying pulmonary TB, and six patients (15%) had intestinal TB who were admitted to emergency service with acute abdomen, of whom three (8%) had perforation and three (8%) had ileus. Histopathologically 20 cases (51%) were proven on abdominal ultrasonography, and computed tomography revealed most commonly ascites and thickening of peritoneum. No microbiologic evidence was obtained except three positive culture results for Mycobacterium tuberculosis. As a result, TBP should be considered for diagnosis, in patients with non‐specific symptoms of abdominal pain, wasting, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen, because early diagnosis and effective treatment will decrease morbidity and mortality.

Prevalence of and factors affecting pulmonary hypertension in hemodialysis patients.

Background: Pulmonary hypertension (PH) has been reported to be high among end-stage renal disease (ESRD) patients. Objectives: The aim of this study was to investigate the role of arteriovenous fistula (AVF) flow in the pathogenesis of PH and the prevalence of PH in patients with chronic renal failure (CRF) and to suggest other possible etiologic factors. Methods: The prevalence of PH was prospectively estimated by Doppler echocardiography in 116 ESRD patients on regular hemodialysis (HD). Laboratory and clinical variables were compared between patients with and without PH (groups 1 and 2, respectively). PH was defined as systolic pulmonary artery pressure (SPAP) over 30 mm Hg. Patients with PH underwent further evaluation by 2 pulmonologists. AVF flow was measured by Doppler ultrasonography. Blood tests including arterial blood gases, hemoglobin, serum calcium, phosphorus and parathyroid hormone were determined. Results: PH was found in 25 (21.6%) patients (group 1) with an SPAP of 37.9 ± 2.8 mm Hg. Mean AVF flow was increased (1,554 ± 207.60 ml/min) in group 1. Left ventricular ejection fraction (LVEF) was significantly different between the 2 groups (55.3 ± 11.5 and 64.4 ± 40, respectively; p < 0.05). Neither significant primary lung disease nor parenchymal lesions were detected in group 1. PH showed a significant difference for cigarette smoking (p < 0.05). In group 1 the prevalence of cigarette smoking was higher. The main etiology of CRF was diabetes mellitus with a ratio of 44% in group 1. Conclusion: Our study demonstrated a surprisingly high prevalence of PH among patients receiving long-term HD. PH was related to high AVF flow, low LVEF and cigarette smoking. AVF flow and cigarette smoking are important correctable causes of PH. Early detection is important in order to avoid the serious consequences.

Relationship of Metabolic Alkalosis, Azotemia and Morbidity in Patients with Chronic Obstructive Pulmonary Disease and Hypercapnia

Background: Exacerbation of chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality, but the effect of metabolic compensation of respiratory acidosis (RA) on mortality is not fully understood. Objective: To investigate the relationship between metabolic compensation and mortality in COPD patients with RA. Methods: We prospectively investigated all COPD patients with RA admitted to the respiratory intensive care unit between February 2001 and March 2007. Two hundred and thirteen patients (159 male, 54 female; mean age 65 ± 10.8 years) were divided into three groups (71 patients each) according to base excess (BE) levels: (1) low BE, (2) medium BE, and (3) high BE. H+ concentration was calculated according to their standard formula and BE was calculated according to the Van Slyke equation. Results: The overall mortality rate was 24.9%. The group mortality rates were 32, 17 and 25% in the low, medium and high BE groups, respectively (p = 0.001). When patients were divided into three groups according to the HCO3– levels, the group mortality rate was 59.1% in the low HCO3– group and 19.8% in the high HCO3– group. Based on univariate analysis, six factors affecting mortality were identified. However, multivariate analysis showed that the levels of serum HCO3– (p = 0.013; OR: 0.552; CI: 0.345–0.882) and creatinine (p = 0.019; OR: 2.114; CI: 1.132–3.949) had an independent effect. Conclusion: In patients with COPD exacerbation and hypercapnia, the development of sufficient metabolic compensation and adequate renal function significantly decreases mortality.

Unusual Combination of Tracheobronchopathia Osteochondroplastica and AA Amyloidosis.

Tracheobronchopathia osteochondroplastica (TO) is a rare disorder of unknown cause characterized by the presence of multiple submucosal osseous and/or cartilaginous nodules that protrude into the lumen of the trachea and large bronchi. A simultaneous diagnosis of TO and amyloidosis is rarely reported. In this report, a case initially suspected to be asthma bronchiole that could not be treated, was radiologically diagnosed as TO, and also secondary amyloidosis is presented. A 53 years, man patient reported a 3 years history of dyspnea. Pulmonary function tests (PFTs) showed an obstructive pattern. Chest X-rays revealed right middle lobe atelectasis. FOB and CT detected nodular lesions in the trachea and in the anterior and lateral walls of the main bronchi. AA amyloidosis was confirmed by endobronchial biopsy. In the abdominal fat pad biopsy, amyloidosis was not detected. Asthma bronchiole was excluded by PFTs. This case illustrates that it is possible for TO and amyloidosis to masquerade as asthma. TO and amyloidosis should be suspected in patients of older ages with asthma and especially with poorly treated asthmatic patients. Although nodular lesions in the anterior and lateral tracheobronchial walls are typical for TO, a biopsy should be obtained to exclude amyloidosis.

Kartagener's syndrome and polycystic kidney disease.

Sir, Kartageners syndrome (KS) is a clinical variant of primary ciliary dyskinesia (PCD) involving situs inversus associated with chronic airway infections [1]. Ciliopathy has now become recognized as a multisystem disease, of which PCD is an important subgroup. Other known ciliopathies include Bardet–Biedl syndrome, polycystic kidney and liver disease, nephronophthisis, Alstrom syndrome, Meckel–Gruber syndrome and some forms of retinal degeneration [2,3]. We report a patient with KS and polycystic kidney disease, presenting with severe renal failure. A 25-year-old woman who presented with fever, weakness, nausea, cough, dyspnoea, poor general condition and respiratory distress was admitted to our hospital. The patient was diagnosed 15 years previously with KS. On physical examination, blood pressure was 120/ 80 mmHg, heart rate was 117 beats/min and respiratory rate was 22 breaths/min. Heart sounds were distant and deep on cardiac auscultation. Bilateral crackles were determined in lungs. Her laboratory findings were as follows: serum sodium 112 mmol/l, chlorine 77 mmol/l, urea 442 mg/dl, creatinine 7.5 mg/dl, haemoglobin 6.5 g/dl, leucocytes 30 000, arterial blood gas pH 7.1, bicarbonate 8 mmol/l, pCO2 22 mmHg, C-reactive protein (CRP) 41 mg/l. Due to poor general condition of the patient, with acidosis, haemodialysis was started. Ultrasonographic examination of the abdomen revealed the situs inversus and polycystic kidney disease. The CT of the abdomen and thorax CT was performed (Figures ​(Figures11 and ​and22). Fig. 1 Bronchiectasis and dextrocardia in thorax CT. Fig. 2 Polycystic kidney in abdominal CT. To our knowledge, this is the first case of KS and polycystic kidney disease reported in the literature. Conflict of interest statement. None declared.

Cerebral Venous Thrombosis and Pulmonary Embolism with Prothrombin G20210A Gene Mutation.

A 25-year-old man presented with symptoms of syncope, cough, headache and hemoptysis. Cranial MR and venography showed thrombus formation in the right transverse sinus and superior sagittal sinus. Computed tomographic pulmonary angiography (CTPA) showed an embolic thrombus in the right pulmonary truncus and lung abscess. The patient was young, and there were no signs of lower extremity deep venous thrombosis or other major risk factors for pulmonary embolism (PE) including cardiac anomaly. The only risk factor we were able to identify was the presence of the prothrombin G20210A gene mutation. Anticoagulant treatment with oral warfarin (10 mg daily) and imipenem (4X500 mg) was started. The patient was hospitalized for antibiotic and anticoagulation therapies for three weeks and was discharged on lifelong treatment with warfarin (5 mg daily).

Survey of environmental exposure to asbestos in the town of Buyuktatlar, Turkey

Abstract Asbestos-related cases admitted to Chest Diseases Clinic of Kahramanmaras Sutcu Imam University Medical Faculty generally came from Buyuktatlar, a town adjacent to the Afsin district of Kahramanmaraş city. This led us to screen for lung pathologies due to exposure to environmental asbestos in the town of Buyuktatlar. Six hundred and eighty-five inhabitants older than 30 years living in the town were identified as the study group and 488 persons (71·2%) were accepted for evaluation. Then, chest X-rays of these cases were taken and bilateral pleural plaque, bilateral pleural thickening, reticular lung infiltrations, and costophrenic angle obliteration were evaluated as asbestos-related disorders (ARD). ARD were diagnosed in 56 (11·5%) of the 488 chest X-rays that were assessed and no differences were observed between genders. Twenty-five of the cases were investigated by high-resolution computed tomography. Twenty-four were confirmed as ARD. In addition, chrysotile fiber was found in two of four soil samples taken from the town.

Contents Vol. 78, 2009

P.J. Barnes, London E.D. Bateman, Cape Town E. Brambilla, Grenoble P. Camus, Dijon M. Cazzola, Rome P.N. Chhajed, Mumbai U. Costabel, Essen K. Dorrington, Oxford A. Foresi, Sesto San Giovanni M.E. Froudarakis, Alexandroupolis F.J.F. Herth, Heidelberg G. Hoheisel, Leipzig M. Humbert, Clamart M. Kneussl, Vienna J.G. Mastronarde, Columbus, Ohio L.E. Nery, São Paulo A. Palla, Pisa H.-B. Ris, Lausanne J.L. Robotham, Seattle, Wash. F. Rodriguez Panadero, Tomares International Journal of Thoracic Medicine