Shi-Chuan Chang

Pleuritis as a Presenting Manifestation of Rheumatoid Arthritis: Diagnostic Clues in Pleural Fluid Cytology

Pleural effusion is a recognized but relatively uncommon complication of rheumatoid arthritis and has distinctive cytopathologic features. It may occur before, concurrently with, or after the development of joint manifestations of the disease. Clinical diagnosis of rheumatoid pleuritis may be delayed or overlooked in a patient without obvious evidence of arthritis. Failure to recognize the unique cytologic picture of rheumatoid pleuritis caused a 5-month delay in diagnosis of a rheumatoid pleural effusion in an elderly man whose concurrent arthritic symptoms were not given adequate clinical recognition.

The association of non-small-cell Lung cancer, Focal segmental glomerulosclerosis, and platelet dysfunction

Neoplasm-related nephrotic syndrome exhibiting focal segmental glomerulosclerosis (FSGS) has been reported mainly in patients with hematologic malignancies. The association of FSGS with carcinoma is very rare and nephrotic syndrome caused by FSGS has not yet been reported in patients with lung cancer. We report a case of nephrotic syndrome caused by FSGS in a 61-year-old man with advanced non-small-cell lung cancer. In addition, platelet dysfunction evidenced by prolonged bleeding time was noted. The renal problem and prolonged bleeding time resolved dramatically during radiotherapy for lung cancer. We speculate that both FSGS and prolonged bleeding time are paraneoplastic syndromes associated with lung cancer, although the underlying mechanisms of both conditions remain to be elucidated.

The importance of pro-inflammatory and anti-inflammatory cytokines in Pneumocystis jirovecii pneumonia

The role of pro-inflammatory and anti-inflammatory cytokines in Pneumocystis jirovecii pneumonia (PcP) of non-AIDS immunocompromised patients remains unclear. We measured the levels of pro-inflammatory cytokines including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, monocyte chemoattractant protein-1 (MCP-1) and anti-inflammatory cytokines including IL-10 and transforming growth factor (TGF)-β1 in bronchoalveolar lavage fluid (BALF) and blood in 36 non-AIDS immunocompromised patients with PcP diagnosed by BAL and explored their clinical importance. The severity of PcP was determined by arterial oxygen tension/fraction of inspired oxygen concentration (PaO2/FiO2) ratio, the need of mechanical ventilation and the death. Twenty-five subjects without evidence of lung abnormality were included as control group. Compared with control group, PcP patients had significantly higher BALF levels of IL-1β, TNF-α, IL-6, IL-8 and MCP-1 and significantly higher blood levels of IL-10, TGF-β1, IL-8, IL-6 and MCP-1. For PcP patients, BALF levels of IL-8, IL-8/IL-10 ratio and IL-8/TGF-β1 ratio and blood levels of IL-8 and IL-8/IL-10 ratio were significantly higher in the patients with PaO2/FiO2 < 200 mmHg than in those with PaO2/FiO2 > 200 mmHg. Similarly, significantly higher BALF levels of IL-8, IL-8/IL-10 ratio, IL-1β/IL-10, IL-1β/TGF-β1 ratio, MCP-1/TGF-β1 ratio and IL-8/TGF-β1 ratio were found in the patients requiring mechanical ventilation and in non-survivors. In summary, an imbalance of pro-inflammatory and anti-inflammatory cytokines in BALF was found in PcP of non-AIDS immunocompromised patients. BALF levels of IL-8, IL-8/IL-10 ratio, IL-1β/IL-10 ratio, IL-1β/TGF-β1 ratio, MCP-1/TGF-β1 ratio and IL-8/TGF-β1 ratio may be of value in assessing the severity of PcP and in predicting the outcome of the patients.

Amiodarone toxicity in a patient with simultaneous involvement of cornea, thyroid gland, and lung.

Amiodarone, an iodine-rich benzofuran derivative, is a highly effective agent for the prophylaxis and treatment of cardiac arrhythmias, but it is associated with numerous side effects. Amiodarone toxicity involving several organs simultaneously has rarely been reported heretofore. In this report, we describe a case of a 73-year-old man who developed symptomatic hypothyroidism, pulmonary toxicity, and vortex epitheliopathy of the cornea during 6 months of amiodarone therapy for frequent palpitation and angina after myocardial infarction. This case illustrates that amiodarone may cause toxicity involving several organs concurrently in a patient receiving long-term amiodarone therapy. This may be of clinical significance in managing such patients.

Disseminated intravascular coagulation in a lung cancer patient after acute myocardial infarction

A 70-year-old man with adenocarcinoma of the lung suffered from an attack of acute myocardial infarction during hospitalization. Eleven days after the heart attack, clinically obvious disseminated intravascular coagulation (DIC) occurred. The intravascular coagulation abnormalities progressed and eventually the patient died. We suspect that both lung adenocarcinoma and the insult of myocardial infarction may have contributed to the development of DIC in this patient.