The aims of this study were to investigate the frequency of Mycobacterium tuberculosis as a cause of community-acquired pneumonia (CAP) requiring hospitalization in Malaysia, and to define the clinical features of pulmonary tuberculosis (PTB) that distinguish it from non-TB CAP.
BACKGROUND: Taking Sauropus androgynus, a Malaysian food, to reduce weight began as a fad in Taiwan in 1994. Some advocates of this fad developed pulmonary dysfunction. The aim of this study is to report the lung injury in patients taking Sauropus androgynus.
METHODS: From July 1995 to November 1995, we investigated 104 nonsmoking patients (one male and 103 females) with chest roentgenography, pulmonary function, test, and Technetium 99m-labeled diethylene triamine penta-acetate (Tc-99m DTPA) radioaerosol inhalation lung scintigraphy.
RESULTS: Among the 90 patients receiving Tc-99m DTPA inhalation lung scan, 46 (51.1%) patients had increased clearance of Tc-99m DTPA from lung and 20 (22.2%) patients had inhomogeneous deposition of the submicronic radioaerosol. Eighteen (18/100) patients had obstructive ventilatory impairment in pulmonary function test. Analyzing the results, we found that the patients with respiratory symptoms (n = 42) took more vegetables (p = 0.016), had increased clearance of Tc-99m DTPA (p = 0.010) and had lower FEV1 (p = 0.001), FEV1/FVC (p < 0.001), FEF25-75 (p = 0.001), VC (p = 0.002) and DLCO (p = 0.009) than the patients without respiratory symptoms (n = 62). FEV1 and FEV1/FVC were significantly reduced in patients with severe impairment of alveolar permeability. The cumulative dosage and duration of exposure were significantly associated with the reduction of FEV1 and FEV1/FVC.
CONCLUSION: The lung injury after taking Sauropus androgynus involves alveoli and/or small airways and is manifest as obstructive ventilatory impairment with inhomogeneous aerosol distribution and increased lung epithelial permeability.
Twelve patients with advanced inoperable non-small cell lung cancer (NSCLC) were treated with mitomycin, vinblastine and cisplatin (MVP) combination chemotherapy. The overall response rate was 33% (4 partial responses and no complete response) with a median survival of seven months. One responder above subsequently achieved complete remission following successful resection of his tumour and is still alive 14 months after initial chemotherapy. Responses were observed in patients with good performance status and limited disease. Side-effects were generally well tolerated and manageable. MVP is an effective regimen and the low response rate achieved here as compared to other centres is also discussed.
We report a case of clear cell "sugar" tumour of the lung (CCTL) occurring in a 26-year-old lady. The patient was asymptomatic and the lesion was picked up in the course of a pre-employment medical examination. A well-defined 5 cm nodule in the right lower lobe was detected on routine chest X-Ray. Microscopical examination of the coin lesion showed clear cells containing abundant diastase-sensitive intracytoplasmic glycogen, as demohstrated with periodic acid-Schiff stains. Tumour immunoreactivity for HMB-45 and non-reactivity for cytokeratin support the histological diagnosis. To our knowledge, this is the first reported case of CCTL in Malaysia.
A 25 year old woman developed a right pleural effusion 6 weeks after commencement of short course chemotherapy for left sided tuberculous pleural effusion. Since the patient improved following continuation of the same treatment, it is presumed to be a case of paradoxical response to anti-tuberculosis treatment.
Objectives: This was a cross sectional study conducted in the Paediatric Institute among infants and children with chronic respiratory symptoms with the following objectives: i) to determine the prevalence of gastro-oesophageal reflux in children with persistent respiratory symptoms, ii) to identify the clinical predictors of GOR (Gastro-oesophageal reflux) in children with persistent respiratory symptoms and iii) assess the validity of abdominal ultrasound, barium oesophagogram and chest radiograph in diagnosing GOR in these patients.
Materials and Methods: Forty-four patients were recruited over a period of six months. All the presenting symptoms were identified. The patients were subjected to chest radiograph, abdominal ultrasound, barium oesophagogram and 24-hour pH oesophageal monitoring.
The predictive validity of clinical symptoms, chest radiograph, abdominal ultrasound and barium oesophagogram were assessed. Twenty-four hours oesophageal pH was the gold standard to diagnose GOR.
Results: The mean age of patients was 9.1 months (1-58 months). Thirty-one patients (70.5%) were confirmed to have GOR by pH study. Respiratory symptoms alone were not useful to predict GOR. Cough had the highest sensitivity of 51.6%. stridor, wheeze and choking each had a specificity of 76%. Wheeze, vomiting, choking and stridor were identified to have high specificity (90-100%) in diagnosing GOR when any two symptoms were taken in combination.
Collapse/consolidation was the commonest radiological abnormality but had low sensitivity (35.5%) and specificity (53.8%). However hyperinflation on chest radiograph had a specificity of 92.3% with positive predictive value at 80% in diagnosing GOR. Barium oesophagogram has low sensitivity (37.9%) and moderate specificity (75%) in diagnosing GOR in children with respiratory symptoms.
Abdominal ultrasound was a valid mode of diagnosing GOR when there were three or more reflux episodes demonstrated during the screening period with a specificity of 90.9%. However the sensitivity was low ie 20-25%. The specificity increased to 90-100% when two positive tests were taken in combination (abdominal ultrasound and barium oesophagogram). However the sensitivity remained low (10-20%). Chest radiograph did not improve the predictive value when considered with the above tests. Combination of clinical symptoms were useful as clinical predictors of GOR. In the absence of a pH oesophageal monitoring, a combination of barium oesophagogram and ultrasound may be helpful in diagnosing GOR.
Primary lung malignancy presenting as empyema is rare, with a reported incidence of 0.3%. We report a case of a 60- year-old man presenting with unilateral pleural effusion; diagnostic thoracocentesis confirmed Salmonella empyema. Post-drainage, chest radiograph showed persisting right hemithorax opacity; subsequent computed tomography revealed a right lung mass with right upper lobe bronchus obliteration. Percutaneous biopsy confirmed advanced stage lung adenocarcinoma. We discuss the mechanism of post-obstructive pneumonia in lung cancerassociated empyema and the utility of bedside ultrasound in diagnosis of lung masses. Clinicians are alerted to the possibility of lung malignancy in elderly patients presenting with empyema.
The use of a combination of intrapleural fibrinolytics or tissue plasminogen activator(tPA) Alteplase and deoxyribonuclease (Dnase) has been increasing for cases of complicated pleural infection/parapneumonic effusion worldwide. Its efficacy and success rate in selected cases of complicated parapneumonic effusion unresponsive to antibiotics and chest drainage are well documented. This case report demonstrates the first use of combination intrapleural fibrinolytic (Alteplase) and DNAse (Pulmozyme) in Malaysia for a case of pleural infection/parapneumonic effusion.
Monitoring treatment response to anti-tuberculous therapy remains unsatisfactory in resource-limited countries where sophisticated and expensive tests are not readily available. Sputum culture for mycobacterium is desirable, but not obtainable in many developing countries. Sputum acid-fast bacilli (AFB) smear alone can be misinterpreted in the presence of unviable bacilli or non-tuberculous mycobacteria. Hence the search for a cheaper but reliable monitoring tool, or a combination of several tools, continues. Interesting reports from studies in third world nations have considered weight gain/loss as one such monitoring tool. Since pulmonary tuberculosis is endemic in this country, we take the opportunity to evaluate weight gain and chest radiograph, compared to sputum AFB smear in monitoring patient's response.
Simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare life-threatening condition that requires rapid diagnosis and treatment. Most cases are secondary to various underlying lung pathology but a primary SBSP may occur due to rupture of subpleural blebs or bullae. Surgery via an open or minimally invasive approach provides definitive treatment and can be undertaken as a staged or simultaneous procedure. We report our experience with two such rare cases utilizing a single stage minimally invasive bilateral video assisted thoracoscopic (VATS) approach. The pathogenesis of this rare condition and intra-operative technical considerations for a successful outcome are discussed.
A 15 year-old adolescent was referred with 2 month history of worsening of breathlessness and haemoptysis. He also reported constitutional symptoms of fever, poor appetite and weight loss. The chest roentgenogram showed a massive right pleural effusion with apparent cardiomegaly. The cardiac silhouette over the right heart border was obliterated and the mediastinum was widened. Computed tomogram of the thorax showed a bulky heterogeneous mass in the right lung with extension to the heart. Subsequent CT guided lung biopsy revealed Primitive Neuroectodermal tumour (PNET). Here, we illustrate the clinical course of an aggressive pulmonary PNET with lethal cardiac metastasis.
A 16 year-old man presented with fracture of both his femurs after a road traffic accident. Chest radiograph revealed mediastinal widening. Subsequent CT scan and arch aortogram confirmed the findings of traumatic aortic arch transection at the isthmus. He underwent successful surgical repair. High index of suspicion and prompt actions are important in managing this potentially fatal but treatable condition.
Pericardial rupture after blunt chest trauma is described in the literature. This case report summarises our experience with a 22-year old male patient who suffered blunt chest trauma during a motor vehicle accident. On admission no serious injuries could be detected, but 3 hours later, displacement of the heart to the right hemithorax combined with sudden cardiac failure appeared. Emergency thoracotomy revealed a right-sided rupture of the pericardium with complete herniation of the heart into the right pleural cavity and consequent strangulation by the margins of the pericardial defect.
Swyer-James-MacLeod syndrome is a rare complication of respiratory tract infection occurring in early childhood. We report two children with chronic cough and recurrent wheezing who fulfilled the diagnostic criteria for this disorder: 1) Unilateral loss of lung volume with hyperlucency on chest x-ray. 2) Unilateral reduction in vascularity on CT scan of the chest. 3) Unilateral loss of perfusion on Technetium 99c lung scan.
Patients with upper airway obstruction from malignant disease are difficult to manage. A 62 year old patient presented with stridor and was found to have an upper tracheal tumour. Bronchoscopy, dilatation and stenting were performed successfully. The techniques and indications for the use of dynamic airway stent are discussed.
A three day old male, term infant with hemothorax due to hemorrhagic disease of the newborn was treated successfully with vitamin K and thoracocentesis. Exclusive breast feeding and absence of vitamin K prophylaxis were important diagnostic clues, although hemothorax as a sole manifestation of hemorrhagic disease of the newborn is rare. This case highlighted the good prognosis of an uncommon complication when prompt diagnosis and appropriate treatment are instituted. The importance of vitamin K prophylaxis to all newborns is emphasized.