Paradoxical reaction (PR) refers to an abnormal and exaggerated immune response triggered by viable or nonviable Mycobacterium tuberculosis. This reaction can develop during or after standard antituberculous therapy (ATT), more frequently in HIV-positive individuals and occasionally in HIV-negative ones. Pulmonary nodules are a rare presentation of PR, which is easily misdiagnosed as pulmonary malignancy, fungal infection and other thoracic diseases. Herein we present a 19-year-old HIV-negative young male with right tuberculous pleuritis who underwent standardized ATT. Three months into treatment, routine chest computed tomography (CT) detected multiple new pulmonary nodules on the affected side. CT-guided percutaneous lung biopsy confirmed caseating granulomatous inflammation. After ruling out other potential etiologies, the patient was diagnosed with a tuberculous paradoxical reaction. The original ATT regimen was maintained. During follow-up, three pre-existing nodules in the right lung gradually regressed, while one enlarged and an additional nodule developed. The patient was asymptomatic and declined further examinations, and the initial ATT regimen continued. He eventually finished the full 12-month ATT course. Nine months after treatment completion, the majority of lesions resolved nearly completely. Clinicians should be highly alert to paradoxical reaction when new pulmonary nodules emerge synchronously or asynchronously in the ipsilateral lung with pleural effusion among tuberculous pleurisy patients on ATT. The diagnosis depends on the exclusion of alternative causes. For asymptomatic patients, the original ATT regimen should be continued. Long-term regular follow-up is essential.
Indwelling pleural catheters (IPCs) are generally safe and effective for symptomatic relief and drainage of malignant pleural effusions. Common complications include infection and blockage; however, repeated vasovagal syncopal symptoms during drainage are rare. We report the case of a 62-year-old male with metastatic lung adenocarcinoma complicated by recurrent malignant pleural effusions, who experienced repeated near-syncopal episodes with profound bradycardia (HR < 30 bpm) during the first thoracentesis, during IPC placement and recurrent vasovagal symptoms during subsequent drainage episodes of the catheter at home for two more times. Symptoms were reproducible, occurring even with small-volume removals (<300mL). These episodes were theorized to be due to direct and indirect stimulation of the vagal nerve. The patient was also on atenolol (a betablocker), meaning that his compensatory sympathetic response may have been blunted. Management focused on discontinuation of atenolol and modification of IPC drainage technique (supine positioning and slower flow), which mitigated the episodes. Clinicians must recognize that vagal hypersensitivity, near syncope, and hemodynamic instability are possible complications of IPC drainage.
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is an uncommon systemic vasculitis characterized by asthma, eosinophilia, and multisystem involvement. The diagnosis of ANCA-negative EGPA may be challenging because serological findings are often non-specific, making histopathological confirmation important. We report a case of ANCA-negative EGPA diagnosed by biopsy of the external auditory canal, an uncommon but readily accessible site of disease involvement. Case presentation A 22-year-old Mongolian woman presented with progressive chest tightness and dyspnea. Her medical history was notable for asthma and nasal polyps. She also reported bilateral ear fullness and tinnitus. Laboratory investigations demonstrated marked eosinophilia (35.8% of leukocytes), while ANCA testing was negative. Otoscopic examination revealed inflammatory changes in the left external auditory canal, and biopsy was subsequently performed. Histopathological examination showed vasculitis with prominent eosinophilic infiltration, supporting the diagnosis of EGPA. Treatment with systemic corticosteroids resulted in rapid clinical improvement. At three-month follow-up, eosinophil counts had normalized and no evidence of disease progression was observed. Conclusions This case highlights the potential diagnostic value of external auditory canal biopsy in patients with suspected ANCA-negative EGPA. Otologic manifestations may provide accessible sites for tissue sampling when histological confirmation is required. Careful otologic examination should therefore be considered during the evaluation of patients with suspected EGPA.
Acute eosinophilic pneumonia (AEP) is often triggered by smoking or inhaled antigens, but AEP associated with zygomycetes (order Mucorales) remains poorly documented. A 56-year-old male tomato farmer presented with cough, dyspnea, and hypoxemia approximately one month after handling mold-infested tomatoes and soil without wearing a mask. Marked eosinophilia was noted in peripheral blood (10,500/μL) and bronchoalveolar lavage fluid (92%). Transbronchial cryobiopsy demonstrated prominent eosinophilic infiltration of the alveoli and interstitium without evidence of vascular invasion. Cunninghamella and Rhizopus species were isolated from sputum and soil cultures, respectively. Following initial mild improvement with empirical antibiotics and antigen avoidance, the patient improved further with corticosteroid therapy, without antifungal treatment, and showed no recurrence during three months of follow-up after discontinuation. Whereas previously reported zygomycete-associated eosinophilic lung disease has progressed to fatal disseminated mucormycosis, this case remained confined to allergic inflammation and followed a favorable clinical course.
Human rhinovirus C (HRV-C) can cause severe lower respiratory tract disease after allogeneic hematopoietic cell transplantation (allo-HCT), but evidence supporting extracorporeal membrane oxygenation (ECMO) in this setting is sparse. A 21-year-old Han Chinese man with Philadelphia chromosome-positive B-cell acute lymphoblastic leukemia developed rapidly progressive pneumonia approximately 3 months after paternal haploidentical allo-HCT. Bilateral ground-glass opacities progressed despite empirical antimicrobial therapy. Metagenomic next-generation sequencing of bronchoalveolar lavage fluid detected HRV-C (1136 sequence reads, 440 normalized reads; estimated concentration, 2.4 × 104 copies/mL) without another reported pathogen. Before extracorporeal support, a final arterial blood gas showed PaO2 40 mmHg and PaCO2 80 mmHg, consistent with severe combined hypoxemic and hypercapnic respiratory failure. He also had a blood pressure of 70/35 mmHg despite norepinephrine at 0.2–0.3 μg/kg/min, serum lactate of 3.6 mmol/L, and urine output of approximately 800 mL/24 h. He underwent intubation and venovenous ECMO. Off-label adjunctive therapy comprised intravenous ribavirin 500 mg twice daily for 7 days, subcutaneous interferon alfa-2b 3 million IU once daily for 7 days, and methylprednisolone. He was extubated on November 11, ECMO was discontinued on November 12 after 9 days, and he was discharged without supplemental oxygen. This case illustrates the potential severity of HRV-C after allo-HCT and time-limited venovenous ECMO support in a carefully selected patient with a potentially reversible pulmonary process.
