S Saheer

Ethionamide-induced hypothyroidism.

Along with other agents, ethionamide (ETH), an a lpha-ethyl derivate of thioisonicotinamide, is used in the management of multidrug-resistant tuberculosis (MDR-TB), a global health problem.1–5 Besides its better-known side effects, ETH inhibits thyroid hormone synthesis, leading to hypothyroidism, a rare occurrence, with only six cases reported from 1965 to 2005.2–4 We studied 52 culture-proven cases of MDR-TB (29 males and 23 females aged 14–70 years), over 3 years from March 2004 to February 2007 who were treated with ETH 250 mg twice daily in addition to other anti-tuberculosis drugs based on their drug susceptibility profi les. During treatment, overt hypothyroidism was initially observed among three cases for whom thyroid function tests had not been performed prior to initiation of anti-tuberculosis treatment. They were thus excluded from the present report. On reviewing the literature,2–5 in addition to paraaminosalicylic acid (PAS), ETH was found to cause hypothyroidism. No patient in the study population had concomitantly received both PAS and ETH. Subsequently, estimation of serum thyroxine, triiodothyronine and thyroid stimulating hormone (TSH) was performed using immunochemiluminiscence microparticle assay serially before and during treatment, and after discontinuation of ETH on completion of anti-tuberculosis treatment (Table). Tests for thyroid peroxidase antibodies were negative in all patients. Overall, 11 (21.1%) patients developed hypothyroidism (with goiter in three cases) during 3–5 months of treatment with ETH, representing the largest reported series to date. Seven patients developed hypothyroidism within 3 months of initiating ETH and the remaining four cases within 5 months. Levothyroxine supplementation was provided to only fi ve patients with overt hypothyroidism. After discontinuation of ETH and levothyroxine, nine patients became euthyroid over a period of 4 weeks and one within 6 weeks, indicating ETH as the causative agent. One patient (Table, No. 6), who was non-adherent to levothyroxine, developed myxedema coma during the seventh month of treatment and died following cardiopulmonary arrest, giving a mortality rate of 9%. This study clearly demonstrates that hypothyroidism due to ETH is reversible following discontinuation of the drug, but mortality as observed in our study is not to be underestimated. The paucity of ETH-induced hypothyroidism in the literature refl ects the fact that this side effect is underdiagnosed by the medical community due to lack of awareness. We predict that this adverse effect may also be, to some extent, a contributory factor to overall increased MDR-TB-related mortality. In view of the increased chances of occurrence of hypothyroidism, we endorse the statement of McDonnell et al.4 and guidelines put forward by the World Health Organization5 that thyroid function tests should be used to monitor patients receiving ETH and that ETH should be included in the list of agents causing hypothyroidism.

Poland sequence: Series of two cases and brief review of the literature

Poland sequence is a rare congenital anomaly involving the chest wall and arm, displaying differing degrees of severity, functional and aesthetic impairments. Here we report a series of two cases that presented to us with this anomaly. These cases illustrate, for physicians, the importance of physical diagnosis and reinforce the practice of looking for additional anomalies when one is discovered.

Swyer–James–MacLeod syndrome with ipsilateral herniation of hyperinflated hyperlucent lung

Swyer–James–MacLeod syndrome is characterised by unilateral hyperlucency on chest radiograph with small or normal-sized lung on the affected side and compensatory hyperinflation of opposite lung. Hyperinflation of the affected lung is a very rarely reported entity. An adult female patient, who presented with exertional breathlessness and diagnosed to have hypoplastic left pulmonary artery with hyperlucent, hyperinflated and herniated left lung is described.

Bilateral nodular pulmonary tuberculomas simulating metastatic disease

A 62-year-old lady presented with bilateral nodular lung opacities suspicious of metastatic disease on chest radiography and high-resolution CT. Histopathology, however, revealed caseating granulomas. The correct diagnosis of tuberculosis (TB) was confirmed when she responded clinically and radiologically to antitubercular treatment. TB should be considered in the differential diagnosis of bilateral nodular opacities which is the usual presentation of secondary malignancies of lung.

Extra-pulmonary primary multidrug-resistant tubercular lymphadenitis in an HIV negative patient

A 28-year-old woman without any history of prior antituberculosis treatment presented with cervical lymphadenopathy and a cold abscess near medial end of clavicle of 5 months duration. Pus culture and sensitivity revealed Mycobacterium tuberculosis resistant to rifampicin and isoniazid. Thus she was diagnosed as a case of primary multidrug-resistant tuberculosis and treated with second line drugs according to culture susceptibility pattern. On completion of therapy, patent showed good clinical response. This case highlights the observation that even extra-pulmonary primary multidrug-resistant tuberculosis can be successfully treated with currently available second line drugs.

Pyopneumothorax secondary to Aspergillus infection: a case report.

A 32 -year- old male presented with complaints of fever, dry cough, breathlessness and right sided chest pain of two months duration. Chest radiograph showed right sided hydropneumothorax which revealed frank pus on diagnostic thoracocentesis, for which tube thoracostomy was done. Despite vigorous broad spectrum antibiotic coverage, postural drainage and chest physiotherapy, there was no clinical improvement. Further work up included serology, pleural fluid culture, closed as well as thoracoscopic guided pleural biopsy revealed growth of Aspergillus fumigatus. Patient was prescribed antifungal medication (Voriconazole) and subsequent thoracotomy with right sided pneumonectomy showed good clinical recovery.

Pulmonary congenital cystic adenomatoid malformation involving upper lobe with successful surgical management

A four-week-old infant born after a normal vaginal delivery presented with dyspnea of one month duration. His radiologic evaluation showed multiple cystic lesions involving the left upper lobe, although lower lobe is the usual site. It was removed after pnemonectomy and the fi nal pathological diagnosis was congenital cystic adenomatoid malformation (type II). The postoperative follow up showed excellent recovery and normal development of the child.

Spontaneous Resolution of Massive Spontaneous Tubercular Pneumothorax

A 29-year-old female presented with complaints of fever and productive cough of three weeks duration. Pulmonary tuberculosis was diagnosed bacteriologically and she was prescribed antituberculosis drugs. During follow-up she developed massive pneumothorax, for which patient refused surgical management and was managed conservatively. After six months there was complete spontaneous resolution of pneumothorax. The unusual presentation and unexpected outcome prompted us to report this case.