Domenech, M.; Sobrino, J.; Buges, J.; Mir, N.; Barcelo, X.; Diez, S.; Adrian, M. J.; Casañas, L.; Morata, E. Author Information

La sarcoïdose est une affection systémique granulomateuse d’étiologie inconnue. Ses manifestations dermatologiques sont très polymorphes. Elles sont classiquement séparées en lésions spécifiques, car formées de granulomes, d’évolution le plus souvent chronique ; et en lésions non spécifiques, principalement l’érythème noueux d’évolution aiguë. Elles s’observent approximativement chez 25 % des patients atteints de sarcoïdose. L’atteinte cutanée peut être inaugurale. Le diagnostic de sarcoïdose cutanée confronte le clinicien à trois problèmes : la recherche d’une localisation viscérale de la maladie, l’évaluation du pronostic, la prise en charge au long cours associant une surveillance régulière et, en cas de gêne esthétique ou fonctionnelle, un traitement.Sarcoidosis is a systemic granulomatous disorder of unknown aetiology. Its dermatological manifestations are extremely polymorphous. They are normally classed as either specific lesions, comprising granulomas, which are generally chronic, or non-specific lesions, principally acute erythema nodosum. These signs are seen in around 25% of sarcoidosis patients. The disease may be heralded by a skin disorder. Diagnosis of cutaneous sarcoidosis provides the clinician with three problems: screening for a visceral site of the disease, determination of the prognosis, and long-term management with regular monitoring coupled with suitable therapy in the event of cosmetic or functional impairment.

BACKGROUND:The aim of this study was to analyze the complications derived from the use of intravenous cannulae with particular attention being paid to the possible predisposing factors. METHODS:A prospective follow up of 569 intravenous cannulae placed in the emergency department or the medical ward of a county hospital was carried out. 492 of these cannulae were peripheral (PC) and 77 central inserted through peripheral veins (CPVC). RESULTS:Fifty-one percent of the catheters were withdrawn due to complications with the most frequent being phlebitis (35%), followed by extravasation (11.5%). The mean time in situ was 3.61 +/- 3.2 days. The daily risk of complications ranged from 2 to 9% for the CPVC (non significant differences) and between 15% (day 1) and 30% (6 or more days) for the PC. In the latter case there were no differences in the daily specific rate of complications after the first 24 hours. The probability of a catheter remaining in place more than three and six days without complications was 51% and 31%, respectively for the CP and 91% and 87% for the CPVC (p < 0.0001). Of the variables analyzed, age > 65 years, female sex, insertion of the cannula into the back of the hand, the fact of the route being peripheral without the administration of heparin were significantly associated to the development of complications, while the intravenous administration of aminophillin was associated with the appearance of phlebitis. Thirteen percent of the catheters withdrawn due to phlebitis were infected. CONCLUSIONS:The complication most frequent observed in intravenous cannulation was phlebitis, an entity which is generally not of an infectious nature. The risk of unspecific complications every day during catheterization is constant in the case of central peripheral vein cannulae as well as in peripheral cannulae which do show problems during the first 24 hours after placement. Insertion of the cannulae into the veins of the back of the hand, female sex, advanced age and intravenous administration of certain drugs influence in the development of phlebitis.

Exacerbations of chronic bronchitis are commonly characterized by increases in dyspnea, cough, and purulent sputum production. The role of bacterial infection in this disease is unclear because of the heterogeneity of the patients studied and the inaccuracy of routine expectorated sputum cultures in characterizing the tracheobronchial microflora in these patients.1Tager I Speizer FE. Role of infection in chronic bronchitis.N Engl J Med. 1975; 292: 563-569Crossref PubMed Scopus (179) Google Scholar, 2Chodosh S. Sputum evaluation: why, when, how and by whom.in: Brody JS Sneider CL Current topics in the management of respiratory diseases. Churchill Livingstone, New York1985: 123-145Google Scholar, 3Sachs FL. Chronic bronchitis.in: Pennington JE Respiratory infections: diagnosis and treatment. Raven Press, New York1988: 142-158Google Scholar We recently conducted a prospective study of quantitative culture of the distal bronchial microflora in acute exacerbations of chronic bronchitis. In 20 patients who required hospital admission because of an acute exacerbation of chronic bronchitis, written consent was obtained to perform fiberoptic bronchoscopy and culture of bronchial secretions obtained with a protected brush catheter. None of the patients had received antimicrobial therapy in the preceding 15 days, and their chest roentgenograms did not show alveolar infiltrates. The brush specimens were placed on agar plates for aerobic culture and were incubated for 48 h in a 5 percent CO2 atmosphere. The results of quantitative cultures of the protected brush specimens are shown in Table 1. In 18 of the 20 samples (90 percent) some organisms were isolated, and in 15 (75 percent) the concentration was equal to or greater than 103Sachs FL. Chronic bronchitis.in: Pennington JE Respiratory infections: diagnosis and treatment. Raven Press, New York1988: 142-158Google Scholar colonyforming units (CFU) per specimen. In 14 of the 20 samples (70 percent), Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis organisms were isolated. In 10 cases (55 percent of the positive specimens), more than one organism grew (2.2 ± 1.3 organisms per sample). Haemophilus influenzae and M catarrhalis organisms were always isolated as part of a mixed flora, while 5 of 9 strains of S pneumoniae were obtained in pure culture (0 vs 55 percent; p = 0.04, Fisher test). The common respiratory pathogens (S pneumoniae, H influenzae, and M catarrhalis) grew in concentrations equal to or greater than 104Winterbauer RH Hutchinson JF Reinhardt GN Sumida SE Dearden B Thomas CA et al.The use of quantitative cultures and antibody coating of bacteria to diagnose bacterial pneumonia by fiberoptic bronchoscopy.Am Rev Respir Dis. 1983; 128: 98-103Crossref PubMed Scopus (43) Google Scholar CFU per specimen more frequently than the other microorganisms (77 vs 13 percent; p < 0.001, χ2 test).Table 1Frequency and Count of Organisms Recovered From Protected-Brush Specimens*Values are numbers of baterial strains isolated in the 20 specimens obtained. CFU = colony-forming units.Concentration, CFUOrganismTotal105Vereen L Smart LM George RE. Antibody coating and quantitative cultures of bacteria in sputum and bronchial brush specimens from patients with stable chronic bronchitis.Chest. 1986; 90: 534-536Crossref PubMed Scopus (13) Google Scholar104Winterbauer RH Hutchinson JF Reinhardt GN Sumida SE Dearden B Thomas CA et al.The use of quantitative cultures and antibody coating of bacteria to diagnose bacterial pneumonia by fiberoptic bronchoscopy.Am Rev Respir Dis. 1983; 128: 98-103Crossref PubMed Scopus (43) Google Scholar103Sachs FL. Chronic bronchitis.in: Pennington JE Respiratory infections: diagnosis and treatment. Raven Press, New York1988: 142-158Google Scholar102Chodosh S. Sputum evaluation: why, when, how and by whom.in: Brody JS Sneider CL Current topics in the management of respiratory diseases. Churchill Livingstone, New York1985: 123-145Google ScholarStreptococcus pneumoniac94311Haemophilus influenzae53110Moraxella catarrhalis30300Pseudomonas aerufinosa10010Neisseria Meningitidis11000Others†Streptococcus viridans, 12 specimens; Neisseria sp., 5; diphtheroids, 2; coagulase-nefative Staphylosossus organisms, 1; Streptococcus agalactiae, 1; Pasteurella multocida, 1.2203163* Values are numbers of baterial strains isolated in the 20 specimens obtained. CFU = colony-forming units.† Streptococcus viridans, 12 specimens; Neisseria sp., 5; diphtheroids, 2; coagulase-nefative Staphylosossus organisms, 1; Streptococcus agalactiae, 1; Pasteurella multocida, 1. Open table in a new tab In our experience, bronchial secretions from the majority of patients with an acute exacerbation of chronic bronchitis show bacterial densities equal to or greater than 1 million organisms per milliliter (> 103Sachs FL. Chronic bronchitis.in: Pennington JE Respiratory infections: diagnosis and treatment. Raven Press, New York1988: 142-158Google Scholar CFU per specimen).4Winterbauer RH Hutchinson JF Reinhardt GN Sumida SE Dearden B Thomas CA et al.The use of quantitative cultures and antibody coating of bacteria to diagnose bacterial pneumonia by fiberoptic bronchoscopy.Am Rev Respir Dis. 1983; 128: 98-103Crossref PubMed Scopus (43) Google Scholar We have also observed that S pneumoniae, H influenzae, and M catarrhalis are present in concentrations more elevated than those of other organisms, which would support their pathogenic role in the exacerbation, according to other authors.5Vereen L Smart LM George RE. Antibody coating and quantitative cultures of bacteria in sputum and bronchial brush specimens from patients with stable chronic bronchitis.Chest. 1986; 90: 534-536Crossref PubMed Scopus (13) Google Scholar

Malignant pleural mesothelioma is a tumor very difficult to diagnose and with a very controversial therapy. We describe an illustrative case with development of pleural overflow and detection of high adenosine-deaminase levels. Surgical resection combined with radiotherapy and/or chemotherapy is the current therapeutics. We describe the state-of-the-art advances in the immunohistochemical diagnosis and therapeutics and we stress the need to conduct cooperative studies in order to achieve a better knowledge of the prognosis factors, an effective step-by-step approach and innovative therapy strategies.

To the Editor: The diagnostic value of the pleural adenosine deaminase (ADA) level has been known for several years. A pleural ADA level over 50 U/L is associated with pleural effusions due to tuberculosis, rheumatoid arthritis, or empyema.1Van Keimpema ARJ Slaats EH Wagenaar JPM Adenosine deaminase activity not diagnostic for tuberculous pleurisy.Eur J Respir Dis. 1987; 71: 15-18PubMed Google Scholar Among carcinomatous pleural effusions, only isolated cases have been described in adenocarcinomas, mesotheliomas, and lymphoproliferative disorders.1Van Keimpema ARJ Slaats EH Wagenaar JPM Adenosine deaminase activity not diagnostic for tuberculous pleurisy.Eur J Respir Dis. 1987; 71: 15-18PubMed Google Scholar, 2Monteagudo M Mundet X Arderiu MA Elevated adenosine deaminase in neoplastic pleural fluid.Chest. 1986; 90: 466-467Crossref Scopus (4) Google Scholar, 3Perez Vidal R Arán X Broquetas J High adenosine deaminase activity level in pleural effusion [letter].Chest. 1986; 90: 625Crossref Scopus (11) Google Scholar We report the case of a patient with pleural effusion due to bronchoalveolar carcinoma and a very high level of ADA in pleural fluid. The patient was a 39-year-old woman who was admitted to the hospital because of a toxic syndrome and a productive cough, which bad started six months previously. On physical examination a right pleural effusion with inspiratory crackles was noted. The chest x-ray film confirmed the presence of the pleural effusion and an opacity with an air bronchogram in the right hemithorax. Laboratory study of the pleural fluid disclosed the following values: pH, 7.20; protein, 6.8 g/dl; lactate dehydrogenase (LDH), 4.180 IU/L; glucose, 10 mg/dl; cholesterol, 189 mg/dl; ADA, 138 U/L; carcinoembryonic antigen, 156 mg/dl; 18,000 white blood cells per cubic millimeter with 75 percent lymphocytes. Ziehl-Neelsen and Gram stains and fungal and mycobacterial cultures were all negative. The bronchial aspirate and bronchoalveolar lavage specimens obtained by fiberoptic bronchoscopy showed bronchoalveolar carcinoma cells, as did the pleural fluid specimens. Adenosine deaminase is an enzyme of purine catabolism, which is required for the conversion of adenosine to inosine. Its increase has been related to T-lymphocyte differentiation and to stimulation of cellular immunity in pleural effusions due to tuberculosis, rheumatoid arthritis, and empyema.1Van Keimpema ARJ Slaats EH Wagenaar JPM Adenosine deaminase activity not diagnostic for tuberculous pleurisy.Eur J Respir Dis. 1987; 71: 15-18PubMed Google Scholar In cases of carcinomatous pleural effusions,2Monteagudo M Mundet X Arderiu MA Elevated adenosine deaminase in neoplastic pleural fluid.Chest. 1986; 90: 466-467Crossref Scopus (4) Google Scholar it may depend on the increased metabolic activity indicated by decreases in the glucose level and increases in the LDH level, as noted in our patient. Only 2 percent of lung cancer cases are of the bronchoalveolar type,4Greco RJ Steiner RM Goldman S Cotler H Patchefsky A Cohn HE Bronchoalveolar cell carcinoma of the lung.Ann Thorac Surg. 1986; 41: 652-656Abstract Full Text PDF PubMed Scopus (84) Google Scholar and in these cases pleural effusions are rare,5Tao LC Delarue NC Sanders D Weisbrod G Bronchioloalveolar carcinoma: a correlative clinical and cytologic study.Cancer. 1978; 42: 2759-2767Crossref PubMed Scopus (31) Google Scholar which could explain the lack of previous reports on this subject.

A 19-year-old man had fever, sore throat, and general malaise for 4 days. Physical examination revealed exudative tonsillitis, a right submandibular lymph node, and swelling along the right sternocleidomastoid muscle. Initial results of a chest x-ray were normal. Blood cultures were positive for Fusobacterium necrophorum. Radionuclide venography with in vitro Tc-99m labeled red blood cells showed a delay in the right carotid-jugular complex blood flow. An ECHO Doppler examination demonstrated both a thickening of the wall and a partial thrombosis of the right internal jugular vein, suggesting thrombophlebitis. Lemierre syndrome (suppurative thrombophlebitis of the internal jugular vein secondary to an oropharyngeal infection) was diagnosed. The patient was given clindamycin, with good response.

Los autores describen un caso de sarcoidosis con datos clínicos, biológicos y anatomopatológicos característicos de esta enfermedad y con cultivo de Löwenstein positivo para Mycobacterium tuberculosis en la biopsia hepática. Se revisa la literatura reciente acerca de esta asociación y se comenta la buena respuesta obtenida tras el tratamiento corti-coideo y tuberculostático administrado. The authors report a case of sarcoidosis with characteristic clinical, biological, and anatomopathological findings of this disease associated with positive Löwenstein culture for Mycobacterium tuberculosis in hepatic biopsy. Present literature on this association is reviewed and the authors comment upon the clinical good response after treatment with steroidal and tuberculostatic drugs.