Irena Perić

A rare case of pulmonary tuberculosis with simultaneous pulmonary and skin sarcoidosis: a case report

BackgroundTuberculosis and sarcoidosis are chronic diseases that rarely occur concomitantly. Sarcoidosis is a multisystem granulomatous disorder characterized pathologically by the presence of non-caseating granulomas in involved tissues. Tuberculosis is infectious disease caused by Mycobacterium tuberculosis characterized by granulomas with caseous necrosis.Case presentationWe present a case of 43-year-old female refugee from Kosovo with microbiological confirmation of pulmonary tuberculosis and pulmonary and skin sarcoidosis at the same time. Three weeks after corticosteroid therapy for pulmonary sarcoidosis was introduced, positive finding of mycobacterium culture of bronchial aspirate was observed. Based on these results, corticosteroid therapy was excluded and antituberculous therapy was introduced for six months. In the meantime, new nodes on face and nose appeared and skin sarcoidosis was diagnosed. The patient was given corticosteroids and colchicine according to the skin and pulmonary sarcoidosis therapy recommendation.ConclusionThe authors of this study suggest that in cases when there is a dilemma in diagnosis between tuberculosis and sarcoidosis we should advance with corticosteroid therapy until we have microbiological confirmation of mycobacterium culture. This case is remarkable because this is a third described case of sarcoidosis and tuberculosis together (the first reported in Asia, the second in South Africa), and to authors knowledge, this is a first case report in Europe.

Interobserver Variations in Diagnosing Asbestosis According to the ILO Classification

Interobserver Variations in Diagnosing Asbestosis According to the ILO Classification Inhalation of asbestos fibres leads to asbestosis of the pleura and the lung, with possible progression to lung cancer and malignant pleural or peritoneal mesothelioma. Asbestosis remains difficult to diagnose, especially in its early stages. The most important role in its diagnosis is that of chest radiographs. The aim of this cross-sectional study was to address interobserver variations in interpreting chest radiographs in asbestos workers, which remain to be an issue, despite improvements in the International Labour Office (ILO) classification system. In our ten-year study, we investigated 318 workers occupationally exposed to asbestos, and in 210 workers with diagnosed asbestos-related changes we compared interpretations of chest radiographs according to ILO by two independent radiologists. The apparent degree of interobserver variation in classifying lung fibrosis was 26.66% for the diameter of changes and 42.2% for the profusion of the changes. In cases with diffuse pleural thickening, the interobserver variation using ILO procedures was 34.93%. This investigation raises the issue of standardisation and objectivity of interpretation of asbestosis according to the ILO classification system. This study has revealed a significant disagreement in the estimated degree of pleural and parenchymal asbestos pulmonary disease. This is why we believe high-resolution computed tomography (HRCT) should also be used as a part of international classification. Interopservacijske razlike u dijagnosticiranju azbestoze prema klasifikaciji ILO

Endobronchial ALK+ anaplastic large-cell lymphoma resembling asthma in a 13-year-old girl.

Anaplastic large-cell lymphoma is a rare disease in children, and endobronchial localization is extremely rare in any age group. We report the case of a 13-year-old girl with endobronchial anaplastic lymphoma kinase–positive anaplastic large-cell lymphoma presenting as asthma, and discuss the diagnostic, therapeutic, and clinical implications.

Undiagnosed AIDS in patients with progressive dyspnoea: an occupational risk for healthcare workers in Croatia.

Undiagnosed AIDS in Patients with Progressive Dyspnoea: An Occupational Risk for Healthcare Workers in Croatia Pulmonary diseases are well documented and diverse in many patients with HIV in clinical stages 3 and 4. It is not unusual that these patients, most of whom do not know that they are already HIV-infected, are first examined and hospitalised by respiratory medicine specialists. While HIV-infection is relatively simple to diagnose if accompanied by advanced clinical manifestations and is regularly checked in patients with increased risk, this is not the case in low-risk patients, particularly in countries with low-level HIV epidemic and therefore low index of suspicion. Regular examination involves a series of tests, often including bronchoscopy with transbronchal lung biopsy in order to identify an interstitial lung disease and/or progressive dyspnoea. It is not uncommon that patients provide false or incomplete information about their lifestyle, which can mislead the clinician. At this point, HIV-infection is usually not suspected and healthcare workers may not strictly be following the safety principles which are otherwise applied when HIV-infection is known or suspect, although universal precautions are routine practice. At this point, the risk of exposure is the highest and HIV-transmission to healthcare workers is the most likely to occur. The cases presented here indicate that patients with progressive dyspnoea, which is typical of interstitial lung diseases, should undergo HIV-testing as a part of good clinical practice, even in a country with low-level HIV epidemic. Nedijagnosticirani AIDS u bolesnika s progresivnom dispnejom: profesionalni rizik za zdravstvene djelatnike u Hrvatskoj Različiti oblici plućnih bolesti detaljno su opisani u mnogih pacijenata inficiranih HIV-om te značajno pridonose kliničkoj slici AIDS-a. Stoga takve pacijente, koji obično i ne znaju da su HIV-pozitivni, najčešće obrađuju i hospitaliziraju specijalisti za plućne bolesti. Posumnjati na AIDS i tu pretpostavku potvrditi nije problem kod pacijenata s razvijenim kliničkim manifestacijama AIDS-a, a ni u pacijenata s poznatim rizičnim čimbenicima. Teškoće u postavljanju prave dijagnoze nastaju obično u pacijenata u kojih rizični čimbenici nisu poznati ili ih pacijenti namjerno skrivaju, posebno u zemlji niske incidencije HIV-infekcije u kojoj se na AIDS ne pomišlja dovoljno u diferencijalnoj dijagnozi. Tijekom dijagnostičkog procesa pacijent prolazi niz testova i pretraga, koji često uključuje bronhoskopiju i transbronhalnu biopsiju pluća s ciljem identificiranja patologije plućnog intersticija i/ili progresivne dispneje. S obzirom na to da pacijenti često taje podatke o svojim navikama i životnom stilu, kliničar može biti zavaran glede pravog smjera u postavljanju dijagnoze. Upravo u tom razdoblju, dok se ne pomišlja na mogući AIDS, mjere opreza zbogh prijenosa infekcije, kojih se liječnik inače pridržava kad je takva dijagnoza poznata, nisu uvijek strogo poštivane, premda to mora biti dijelom uobičajene prakse. Stoga je u takvim okolnostima rizik od izloženosti i moguće HIV-transmisije na zdravstvene djelatnike velik. Ovdje prikazani slučajevi upućuju na potrebu da se pacijenti s progresivnom dispnejom, tipičnom za bolesti plućnog intersticija, testiraju na prisutnost HIV-a kao dio dobre kliničke prakse, čak i u zemlji niske razine HIV-infekcije.

Dynamics of the Lung Function in Asbestos Pleural Disease

Dynamics of the Lung Function in Asbestos Pleural Disease As a rule, asbestosis is a disease of workers who are occupationally exposed to inhalation of asbestos dust, leaving permanent alterations on the lung parenchyma or pleura. In our ten-year study, we investigated 318 workers with pleural asbestosis from whom we took medical history which included occupational exposure to asbestos, radiological examinations and lung function, which is mandatory for the diagnosis and the follow up of the disease. We analysed functional parameters such as forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) and intermediate forced expiratory flow at 25% to 75% (FEF25%-75%). In addition, we investigated the predicted values of functional parameters according to smoking and non-smoking habits. We found a significant reduction in vital capacity, particularly in smokers after 25 years of exposure to asbestos. During the first 15 years, values of vital capacity on the group basis remained inside the 80% of the normal values and were not significant for assessing the dynamics of the lung function. To better assess the effects of occupational asbestos exposure, it is necessary to interpret lung function data not only on the group basis, but also for each subject individually. Dinamika Funkcije Pluća Kod Azbestne Bolesti Azbestoza je bolest izazvana udisanjem azbestnih čestica koje ostavljaju trajne promjene na parenhimu pluća i/ili pleuri. Dijagnoza se postavlja na osnovi anamnestičkih podataka, uvidom u profesionalnu izloženost azbestu i radiološkom obradom te patohistološkom potvrdom promjena na plućima i/ili pleuri. Funkcionalna obrada pluća obavezna je u postavljanju dijagnoze i praćenju bolesti. Tijekom desetogodišnjeg istraživanja funkcionalno smo obradili 318 osoba profesionalno izloženih azbestu s dokazanom azbestozom pleure. Analizirane su vrijednosti funkcionalnih parametara, i to forsiranoga vitalnog kapaciteta (FVC), forsiranoga ekspiracijskog volumena u prvoj sekundi (FEV1) i srednjega ekspiracijskog protoka (FEF25%--75%)). Dokazan je statistički signifikantan pad vrijednosti FVC i FEV1. Dodatno smo istražili vrijednosti funkcionalnih parametara kod naših ispitanika s navikom pušenja i nepušača. U obje skupine prisutno je značajno sniženje vrijednosti vitalnog kapaciteta tijekom istraživanja, s tim da nakon 25 godina izloženosti azbestu kod pušača dolazi do naglog pada vrijednosti vitalnog kapaciteta u odnosu na nepušače. Bitno je uočiti da tijekom prvih 15 godina vrijednosti vitalnog kapaciteta ostaju unutar 80% normalnih vrijednosti te nemaju značenja za praćenje dinamike funkcije pluća kod azbestne bolesti. Individualnim praćenjem profesionalno izloženih radnika ostvaruje se bolji uvid u dinamiku funkcije pluća kod azbestne bolesti.

Mycobacterium shimoidei—cavitary pulmonary disease with favorable outcome

We report a case of cavitary pulmonary disease caused by Mycobacterium shimoidei in 67-year-old female with history of asthma. Even though susceptibility testing was not available, choice of treatment regimen (streptomycin, rifampicin, ethambutol, and clarithromycin), based on a few cases with favorable outcome reported in the literature, resulted with an excellent clinical, microbiological, and radiological response. This is the first report of pulmonary disease caused by M. shimoidei, but also the first ever isolation of M. shimoidei in Croatia.

Tracheomalatia, to stent or not to stent

Benign thyroid disorders such as goiter, especially retrosternal, can cause tracheostenosis by extrinsic tracheal compression, which is due to the lack of specific symptoms often misdiagnosed. Tracheomalatia develops as a result to long term tracheal compression and refers to weakness of the trachea characterized by softness of the tracheal cartilage arches and by loss of regular tracheal structure. Tracheomalatia is characterized by reduction of the endotracheal lumen and may affect the entire trachea or may be localized to one portion of it. We present the case of a 72-year old patient with distinct tracheostenosis and tracheomalatia, caused by long term pressure by the retrosternal goiter. We have been monitoring the patient for last 20 years after the second endotracheal stent had been placed. The first one was placed 34 years ago, in 1981. On both occasions granulation tissue and colonization of bacteria occurred. In the end the placed stents were rejected and migrated to the main carina. Despite the tracheal diameter narrower than 5 mm the patient has been living normally without the stent for 17 years, with the exception of no hard physical labor. He had a few short term antibiotic therapies and bronchial toilets during symptomatic deteriorations. Diagnosing retrosternal goiter and surgical treatment on time is of crucial importance in cases such as this one. Considering the complications caused by the stent, our opinion is that the majority of patients may require conservative treatment with closely monitoring during respiratory infections.

Level of hypertension control: comparison of a rural and urban family practice centre in South Croatia

SummaryAimArterial hypertension is a serious public health problem because of its frequency and poor management. We compared hypertension control between rural and urban environment over 5 years. Initial hypothesis: arterial pressure control is better in urban (Split) than in rural (Trilj) environment.MethodsHistoric prospective study was conducted in two family medicine outpatient clinics. Data for the years 2005, 2006, and 2010 were analyzed. One hundred and seventeen subjects diagnosed with arterial hypertension in 2005 were examined: 66 in a rural and 51 in urban outpatient clinic. Their average age was 60.92 ± 10.03 (range 30–82 years). Blood pressure records at the onset of the study, the first, and fifth year of treatment, risk factors, and therapy were analyzed. T-test and χ2-test were used in statistical data analysis.ResultsIn the urban clinic, more subjects were smokers, had positive family history, were overweight, and had registered hyperlipidemia. Initial mean arterial pressure readings were similar in both the clinics. Decrease was recorded in the following 5 years. During this study the use of ACE inhibitors (ACEI) (Split by 45 %, Trilj by 133 %) and calcium channel blockers (CCB) (Split by 76.9 %, Trilj by 525 %) was increased. The number of patients receiving monotherapy was reduced.ConclusionsBetter arterial pressure control was recorded in the urban clinic, where, after 5 years, despite increased frequency of additional risk factors, the number of normotensive patients was higher than that in the rural one. Hypertension control in both settings was still poor. Hypertensive patients should participate actively in the treatment.ZusammenfassungZiel der StudieAuf Grund der Häufigkeit und des oft schlechten Managements ist die Hypertonie ein ernstes Problem des öffentlichen Gesundheitswesens. Wir verglichen die Einstellung der Hypertonie über 5 Jahre in einer ländlichen Umgebung mit der einer städtischen. Die anfängliche Hypothese war, dass die Hypertonie- Kontrolle in einer Stadt (Split) besser als am Land (Trilj) sein müsste.MethodikIn einer historisch-prospektiven Studie wurden die Daten von 2005, 2006 und 2010 zweier Familienpraxen ausgewertet. 117 Patienten (66 aus der ländlichen, 51 aus der städtischen Praxis), bei denen 2005 eine Hypertonie festgestellt worden war, wurden untersucht: das mittlere Alter war 60,92 ± 10,03 (30–82) Jahre. Die RR-Werte vom Beginn der Studie, nach einem Jahr und nach 5 Jahren wurden erhoben. T-Test und χ2-Test wurden zu statistischen Auswertung verwendet.ErgebnisseIn der städtischen Praxis war die Anzahl der Raucher, der Patienten mit einer positiven Familienanamnese, mit Übergewicht und mit dokumentierter Hyperlipidämie höher. Die initialen RR-Werte waren in beiden Praxen ähnlich. In den folgenden 5 Jahren wurde ein Abfall festgestellt. Während der Studie stieg der Einsatz von ACE-Hemmern (in Split um 45 %, in Trilj um 133 %) und Calciumkanalblocker (in Split um 76,9 %, in Trilj um 525 %). Die Anzahl der Patienten mit Monotherapie wurde reduziert.SchlussfolgerungenDie Blutdruckeinstellung war in der städtischen Praxis besser. Nach 5 Jahren war die Zahl der normotensiven Patienten trotz der höheren Häufigkeit von zusätzlichen Risikofaktoren höher als in der Land-Praxis. Die Kontrolle des Hochdrucks war in beiden Praxen noch immer mangelhaft. Patienten mit Hypertonie sollten aktiv an der Behandlung teilnehmen.