romana english

Clinical cases

Asthma-like symptoms in a patient with rheumatoid arthritis and Adalimumab treatment

After the introduction of anti-TNFα medication for treatment of autoimmune conditions, clinicians have investigated not only other possible uses for the drugs, but also less common side-effects and interactions with other pathologies.
Despite some succes registered with Adalimumab as an antiinflammatory agent in severe asthma, there have been case reports of patients developing asthma or asthma-like symptoms following anti-TNFα therapy.
The case presents a patient without previous family or personal history of respiratory or atopic conditions that developed bronchospasm immediately after the initiation of Adalimumab and Methotrexate treatment for rheumatoid arthritis. Despite the patient presenting asthma characteristics (expiratory wheezing, dry cough, partial reversibility at post bronchodilator test) and asthma medication alleviating simtomathology, biological markers (eosenophil granulocytes in sputum, serum IgE) for asthma are absent. The relationship between bronchospasm and medication and other possible causes for her respiratory symptoms are discussed.
Keywords: asthma, rheumatoid arthritis, drug interactions

Immune reconstitution inflammatory syndrome in central nervous system tuberculosis

Background. Immune reconstitution inflammatory syndrome (IRIS) related to tuberculosis (TB) is an exacerbation of an inflammatory response that most often occurs in HIV-infected patients but it has also been observed in non-HIV immunocompromised hosts. We describe two cases of TB associated IRIS with CNS involvement, one in a patient diagnosed with HIV infection and the other in a patient with immunosuppression due to anti tumor necrosis factor treatment.
Case report. The first case was a 40-year-old man, newly diagnosed with HIV infection, who developed right hemiplegia and expressive aphasia. Lumbar puncture and MRI sustained the diagnosis of TB meningoencephalitis. He initially improved under standard antituberculous therapy (ATT). After 6 weeks of ATT antiretroviral treatment (ART) was initiated and one week later the patient experienced worsening of his symptoms (left hemiparesis and mixed aphasia), of CSF and MRI changes. He improved after he was starting on corticosteroids in tapering doses, with clinical deterioration at lower doses over a 5-month period. The second case was a 56-year-old male, treated for 3 years with Infliximab for ankylosing spondylitis. He was diagnosed with disseminated TB (CNS tuberculomas and pulmonary TB), histological and bacteriological confirmed the diagnosis. His neurological symptoms improved after starting ATT, but after 2 weeks of therapy he presented with diplopia and generalized tonic-clonic seizures. These symptoms improved only after corticosteroids were added (tapering doses during the next 6 months).
Conclusion. TB-associated IRIS with CNS involvement is potentially life threatening. Corticosteroids should be used to control the IRIS symptoms in those patients. The dosing and duration should be tailored to each patient.
Keywords: tuberculosis, immune reconstruction, corticosteroid treatment

Haemoptysis as a primary manifestation of cryptogenic organizing pneumonia (COP)

Cryptogenic organizing pneumonia (COP), previously called bronchiolitis obliterans organizing pneumonia (BOOP) is a clinicopathological disorder of unknown aetiology but increasingly reported. It usually presents with symptoms of dyspnea, cough, fever, weight loss accompanied by the presence of alveolar opacities on chest radiograph. Haemoptysis, described as blood streaking has only rarely been reported as primary presentation of COP. Herein, we report a case of COP in which submassive haemoptysis was the main clinical manifestation. The clinical, radiological, pathological, and therapeutic aspects of the disease are briefly discussed. Cryptogenic organizing pneumonia should be taken into consideration in the differential diagnosis of severe haemoptysis.
Keywords: cryptogenic organizing pneumonia, haemoptysis, corticosteroids

The efficiency of continuous positive airway pressure therapy in reducing cardiovascular dysfunction in a patient with arterial hypertension and obstructive sleep apnea

Obstructive sleep apnea (OSA) has been included by European and American hypertension therapy guidelines as a common cause of high blood pressure. Recent studies have demonstrated a strong link between OSA and HBP and the treatment thereof should consist of combination therapy, especially in patients with refractory AHT and a non-dipping profile. We present the case of a patient with high grade hypertension, with secondary organ damage and severe OSA. The ultimate method for controlling blood pressure and reversing subclinical cardiac and cerebrovascular dysfunction of this patient was the specific therapy with continuous positive airway pressure (cPAP).
Keywords: obstructive sleep apnea, arterial hypertension, cardiovascular dysfunction, continuous positive pressure