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Clinical Cases

Operability in chronic thromboembolic pulmonary hypertension

Tudor Constantinescu, Miron Alexandru Bogdan
Institutul de Pneumoftiziologie „Marius Nasta“ București

We present the case of a 86-year-old male patient diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) with proximal bilateral obstructions of the pulmonary arteries. The history included systemic hypertension, benign prostate adenoma and in situ colonic adenocarcinoma, cured by local radiotherapy; no prior history of thromboembolic disease was noted.
The work-up comprised of a detailed analysis of pulmonary hemodynamics and right ventricular function by echocardiography and right heart catheterization, imagistic evaluation of the pulmonary circulation by contrast tomography, but also a complete evaluation of the left heart, respiratory function, neurologic status, liver and kidney function. A new colonoscopy confirmed the absence of relapse of the colonic carcinoma.
The only curative therapy in proximal CTEPH is pulmonary endarterectomy, a very complex surgical procedures available in only a few centres worldwide. The case was discussed in a multidisciplinary meeting and the indications for surgery were based on exercise tolerance impairment, surgically accessible thrombi, absence of comorbidities and patient informed consent. The limits for the intervention were considered the extreme age and oncological history.
The procedure was performed in Cardiovascular surgical department Timișoara, by prof. dr. Walter Klepetko and prof. dr. Marian Gașpar, with good clinical and hemodinamic outcome. We present the post surgical side effects and the most important functional parameters of the follow-up.
Conclusion: pulmonary endarterectomy should be evaluated initially in all patients diagnosed with CTEPH and the old age should not be considered an absolute contraindication if no other significant comorbidities are identified.

Keywords: chronic thromboembolic pulmonary hypertension, pulmonary endarterectomy

Drug induced eosinophilic pleural effusion

Raluca Vasilescu
Medic Primar Pneumologie, Secţia Pneumologie I, Spitalul Clinic de Boli Infecţioase și Tropicale „Dr. Victor Babeș“ București

The hypersensitivity reactions induced by drugs, some widely used, like central nervous system medication, can have various presentations. The lung is a frequent target for such events.
We present the case of 40-year-old male patient, non-smoker, with infant encephalopaty, seizures since age of 6 with polimorphic crisis (mainly absences), with anticonvulsivant treatment since 2011 (carbamazepine, sodium valproate, levetiracetam), with no respiratory medical history. Current symptoms started two weeks before, with chest pain, dry cough. He received no antibiotics. Chest X-ray and thoracic CT scan (27 June 2013) showed a left pleral effusion. Left exploratory thoracocentesis extracted 20 ml reddish pleural fluid: eosinophilic exsudate (60%) with normal adenosin deaminase. He also presents moderate blood eosinophilia (13.7% - 1780/mm3).
Pulmonary infarction with secondary pleurisy, thoracic trauma, acute pancreatitis with secondary pleurisy were excluded.
No Loeffler transient infiltrates were documented, serology for Toxocara is IgG positive (historical) and not significant for current episode, no symptoms suggestive for toxocarosis (characteristic to young children, patient had no liver enlargement etc.), no hidatidosis or trichinelosis were found.
As an exclusion diagnosis, a hypersensitivity reaction to anticonvulsivant medication was considered (mentioned in literature) carbamazepine and sodium valproate (even if medication was taken for a longer time), with blood and pleural eosinophilia.
Together with the neurologist, the mentioned drugs were stopped and he was started on lamotrigine 2 tb/day and levetiracetam 1 tb/day, well tolerated, no absences were noticed. Total remission of blood eosinophilia and partial remission of pleural effusion were noticed. Subsequent follow-ups confirm favourable evolution, with healing of pleurisy and normal blood cell count, which are stable at 7 months after changing anticonvulsivant treatment.

Keywords: pleural effusion, eosinophils, hypersensitivity, anticonvulsivant drugs

Complex case with respiratory, endocrine and digestive manifestations – late complications after a colic replacement of the esophagus for lye ingestion

Ciprian Bolca, Mihaela Tănăsescu, Olga Dănăilă, Cristian Paleru, Ioan Cordoș
Institutul de Pneumoftiziologie „Marius Nasta“ București

Long term complications after colic replacement of the esophagus are well known and their managment is known as being difficult, due to multiple associated comorbidities; we present the case of a 26-year-old patient with multiple late complications after a coloesophagoplaty for lye ingestion during childhood. The patient finally died despite all the eforts of treatement during a prolonged hospitalisation. We will try to analyse the key moments on patient's evolution and discuss other possible options in this case.

Keywords: coloesophagoplasty, pneumonectomy, primary hipoparatiroidism