Clinical Cases

Multimacronodular pulmonary tuberculosis (bacteriologically negative) confirmed histologically

Background: Pulmonary tuberculosis can be confirmed by positive bacteriology of sputum, bronchial aspirate or by biopsies (microscopy and/ or culture) or by histopathological examination highlighting specific tuberculous granulomas. When microscopy is repeatedly negative during noninvasive methods, lung biopsy by thoracoscopy is needed for confirmation and differential diagnosis.

Case presentation: A 40-year-old female patient (nonsmoker, diabetic, with previous exposure to chemicals) was admitted to the hospital for weight loss, dry cough, loss of appetite, pallor, and fatigue. Chest-X-ray and thoracic CT revealed multiple irregular macronodules with various shapes, randomly spread across the lungs. Bacteriology for acid fast bacilli (AFB) from six spontaneous sputum was negative. Bronchoscopy showed an acute bronchitis. Bronchial aspirate was negative for tumor cells and AFB. Several biopsies from bronchial wall showed unspecific changes. The molecular biology tests for specific nucleic acids detection (Polymerase Chain Reaction) or positron-emission-tomography (to differentiate benign nodules from malign ones) were not accessible. Multiple biopsies from lung parenchyma and pleura were obtained using thoracoscopy. Histopathology revealed multiple specific tuberculous granulomas. The complex antituberculous treatment (9 months) has led to the total cure of the disease and resorption of the nodules. The patient’s last visit (after 2 years) showed no clinical/imagistic or bacteriologic relapse of the disease.

Conclusion: Tuberculosis may present in the form of multiple macronodules spread randomly across the lung parenchyma. Thoracoscopy coupled with multiple large lung biopsies are recommended for diagnosis of multinodular lung lesions, especially when common bacteriology/cytology from bronchoscopic aspiration failed to achieve diagnosis. Histological exam from thoracoscopic biopsies allows differential diagnosis between entities that have macronodular features: tuberculosis, primitive lung cancer, lymphomas, metastatic disease or invasive fungal disease.

Keywords: tuberculosis, macronodular lesions, tuberculous caseous granuloma

Multimacronodular pulmonary tuberculosis (bacteriologically negative) confirmed histologically

Atrial fibrillation in an asthmatic patient with albuterol-induced lactic acidosis

Asthma is a highly prevalent chronic respiratory disease affecting millions of people worldwide. Short-acting beta 2-agonists induce bronchodilation and usually are prescribed as a rescue medication. They are recognized as a cause of hyperlactatemia and, less frequently, lactic acidosis. Short-acting beta 2-agonists are also known for their potentially adverse cardiovascular effects, such as atrial fibrillation. Differential diagnosis and subsequent treatment of the latter entity are important due to the adverse prognosis related to it. In this case report, we describe the unusual association between albuterol-induced lactic acidosis and atrial fibrillation in a patient with an asthma exacerbation.

Keywords: Acidosis, Lactic; Albuterol; Asthma; Atrial Fibrillation

Atrial fibrillation in an asthmatic patient with albuterol-induced lactic acidosis

Infectious cause of an interstitial lung disease

We present a case of a previously healthy middleage male patient, without personal history of other condition, who was admitted in our hospital presenting fever, weight loss, and signs and symptoms of acute respiratory distress. The chest computed tomography showed numerous cystic lesions, diffuse ground-glass opacities, honeycombing, and consolidation areas. An HIV infection was confirmed, and the diagnosis of Pneumocystis jirovecii pneumonia was made on induced sputum smear stain. After the initiation of oral treatment with trimethoprim-sulfamethoxazole, the clinical course was rapidly improved. It is important to consider that opportunistic infections such as Pneumocystis jirovecii pneumonia can occur not only in patients previously diagnosed with HIV-infection, but also in patients without a medical history of immunosuppressing disorders.

Keywords: HIV infection, Pneumocystis jirovecii, interstitial lung disease

Infectious cause of an interstitial lung disease

Hepatopulmonary syndrome: an unusual cause of dyspnea in the pulmonology ward – case presentation

Hepatopulmonary syndrome is one of the possible complications of chronic liver disease, defined clinically by impaired oxygenation. The underlying cause of the respiratory failure is the presence of intrapulmonary shunting, as a result of abnormal vascular dilatations in the lungs. We report the case of 52-year-old male, exsmoker, with a history of pulmonary TB and also of heavy drinking, who was admitted to the pulmonology ward for dyspnea at rest and limb cyanosis. His clinical exam was suggestive of liver cirrhosis, with signs of pneumonia, but also chronic lung disease. Variations in SaO2 with posture were noted: platypnea and orthodeoxia. Arterial gas assessment revealed severe hypoxemia, only partially corrected by high-flow oxygen therapy, while plethysmography showed only a mild obstructive syndrome, but with severely impaired alveolar-capillary diffusion. The suspicion of a hepatopulmonary syndrome was raised and a contrast echocardiography confirmed the diagnosis by revealing the presence of an intrapulmonary shunt. Although it is believed to be a fairly common complication of chronic liver disease, it is possible for a case of hepatopulmonary syndrome to be admitted solely for respiratory symptoms. The patient’s poor socio-economic status is the main reason for both the lack of proper followup for his liver disease and the limited therapeutic options.

Keywords: Hepatopulmonary syndrome, liver cirrhosis, respiratory failure, contrast echocardiography

Hepatopulmonary syndrome: an unusual cause of dyspnea in the pulmonology ward – case presentation

Chylothorax and chylous ascites due to Mycobacterium tuberculosis in an AIDS patient whose PCR tested negative

Mycobacterium tuberculosis as a cause of both chylothorax and chylous ascites is extremely rare. A 46-year-old non-adherent woman with AIDS and pulmonary tuberculosis presented to our clinic with dyspnea, pleuritic chest and abdominal pain. Chest x-ray demonstrated a left pleural effusion. Contrast-enhanced CT showed free abdominal fluid. Thoracentesis revealed a chylothorax, and paracentesis a chylous ascites. AFB staining and PCR for M. tuberculosis (GeneXpert MTB/ RIF Assay) were both negative. Malignant cells cytology also tested negative. Tuberculosis could account for both chylothorax and chylousascites, as she clinically improved when antituberculous drugs were resumed. Even when PCR tested negative, M. tuberculosis should be included in the differential diagnosis because of its therapeutic and prognostic implications.

Keywords: Chylothorax, chylous ascites, Mycobacterium tuberculosis, acquired immunodeficiency syndrom, antituberculous drugs

Chylothorax and chylous ascites due to Mycobacterium tuberculosis in an AIDS patient whose PCR tested negative