Mystery called sarcoidosis: forty-four years follow-up of chronic systemic disease

INTRODUCTION

This is a presentation of a 61-year-old female patient. Since 44 years have passed from the onset of her first symptoms until the final diagnosis of sarcoidosis, this was the reason of our decision to publish the case.

CASE OUTLINE

During the follow-up period of 44 years the patient had ocassional polymorphic complains, such as adynamia, nausea, abdominal pains, myalgia, arthralgia, body weight loss (8-10 kg) etc. The clinical course was predominated by splenomegaly, hepatitis and arthralgia, and later chronic renal failure also developed. Laboratory findings showed elevated markers of acute inflammation and autoantibodies. The patient was hospitalized in different university internal hospitals (gastroenterology, allergology, rheumatology, nephrology and pulmology). Liver biopsy was performed three times, rectum and kidney biopsy once each and finally bronchoscopy and pulmonary biopsy was done. At last, about 40 years from the onset of the first symptoms, in 2006 the diagnosis of lung sarcoidosis was established.

CONCLUSION

The final diagnosis of spleen sarcoidosis was confirmed by pathologically verified sarcoidosis of the lungs. This case is particularly interesting because of the presence of familial sarcoidosis (the patient's son also had recurrent pulmonary sarcoidosis).

Wegener's granulomatosis: clinico-radiological finding at initial presentation

Diagnosis of Wegener's granulomatosis at the early stage is difficult because of the nonspecific symptoms which mimic other disorders. The aim of this paper is to describe clinical and radiological features of Wegener's granulomatosis (WG) in a Serbian population at initial presentation. A retrospective review of 37 patient's case records was carried out. All those patients were diagnosed with WG and they attended the Institute for lung diseases in Belgrade over the period of 15 years. There were 20 males and 17 females, ranging in age from 18 to 73 years (mean age 46.2 years). The mean period from the onset of the first symptoms to diagnosis of WG was 4.59 +/- 6.15 months. The criteria of American College of Rheumatology were fulfilled in all patients. Twenty-five of 37 patients had systemic, generalized form of WG and while 12 of them had a limited involvement of upper and lower respiratory system. The frequency of different system involvement was: upper respiratory tract 64.8%, lower respiratory tract 100%, kidneys 67.5%, musculoskeletal system 40.5%, skin 27.2%, eyes 8.1%, and nervous system two patients. ANCA (antineutrophil cytoplasmic antibodies) test was positive in 32 ((86.5%) patients, and negative in 5 (13.5%). All patients were ANA negative. Histological evidence of granulomatous vasculitis was obtained in 34 (91.9%), whereas in three patients the diagnosis was based on clinical manifestations and positive c-ANCA test. There are minor variations in our data when compared with those reported in literature.

Social-economic factors and irrational antibiotic use as reasons for antibiotic resistance of bacteria causing common childhood infections in primary healthcare

The most prevalent childhood bacterial infections in primary healthcare are respiratory, gastrointestinal and urogenital infections. The main aim of this paper was to consider factors (socio-economic factors and irrational antibiotic use) that contribute to the development of bacterial resistance, as well as measures that resulted in a reduction of this problem. Computerized search through the Medline of published articles on antibiotic resistance from 1996 to 2011 in English or Serbian was completed in August 2011. Combinations of used terms were antimicrobial/antibacterial/antibiotic and resistance/susceptibility in pediatric/children, and Streptococcus pneumoniae/Streptococci/Haemophilus influenzae/Salmonellae/Escherichia coli/Shigella/Staphylococcus aureus as well as antibiotics/antimicrobials/antibacterials and consumption/utilization/use. In many developing countries, antibiotic dispensing and its use in medicine, cattle breeding and agriculture are inadequately regulated, or existing laws are not being appropriately implemented. In addition, human travel contributes to antimicrobial drug resistance around the world. All of these factors have led to a very high level of bacterial resistance. On the contrary, in countries with a clearly defined and implemented legal framework concerning antibiotic prescribing, dispensing and utilization, the use of antibiotics is under constant surveillance. That resulted in a significantly lower antibacterial resistance. In conclusion, bacterial resistance could be reduced by the implementation of systemic and long-term measures at a country level as well as at all levels of healthcare. In order to reduce bacterial resistance, antibiotic use needs to be precisely regulated, and regulations should be coherent with practice. The international community must have a more active role in solving this global problem.

Fatigue in sarcoidosis: detection and treatment

Fatigue is a prominent symptom in a large number of medical conditions, malignant and infectious diseases. Fatigue is also a prominent symptom of sarcoidosis. The occurrence of fatigue in sarcoidosis is well known but exact incidence has not been established and varies from 30-70% of patients depending on age, sex and organ involvement by the granulomatous process. The exact definition of fatigue varies broadly. It can be both physical and mental. The patients describe their sensation of fatigue qualitatively different from that fatigue they experienced before they became sick. Fatigue has a major impact on the quality of life in sarcoidosis. Establishing the extent of fatigue in sarcoidosis provides relevant insight regarding the patient's quality of life. Unfortunately there is no objective parameter for assessing fatigue in sarcoidosis. Generally, fatigue is detected by means of questionnaires. Regarding the therapy, there is no effective treatment for fatigue in sarcoidosis.

[Treatment of community-acquired pneumonia using the modern therapeutical guides]

<zakljucak> Racionalizacija lecenja pneumonija primenom savremenih terapijskih vodica omogucava skracivanje hospitalizacije, lecenje se nastavlja ambulantno, sto doprinosi komforu bolesnika, znatno smanjuje troskove lecenja, smanjuje opterecenje medicinskih radnika, a istovremeno se izbegavaju nezeljene komplikacije dugotrajne hospitalizacije, kao sto su nozokomijalne infekcije, tromboflebitisi i druge komplikacije.

[Liver and splenic sarcoidosis: diagnostic procedures]

INTRODUCTION

Clinical studies indicate involvement of the liver and spleen in approximately 20-30% of patients affected with sarcoidosis and their detection should be based on a standardized diagnostic procedure.

DIAGNOSTIC PROCEDURES

Ultrasonography is a reliable and safe method to assess changes related to size and structure of the affected organs that are pathognomonic for sarcoidosis. Further evaluation may include computerized tomography or magnetic resonance, while percutaneous needle aspiration biopsy or laparoscopy may also be applied when indicated. The most important criterion used for final diagnosis is pathohistological evidence of epithelioid noncaseating granuloma in bioptic material along with already established sarcoidosis of the lungs or some other organ.

MATERIAL AND METHODS

The study on the incidence of liver and spleen sarcoidosis included a group of 130 patients affected with sarcoidosis hospitalized at the Institute of Pulmonary Diseases and Tuberculosis, Clinical Center of Serbia, over the period 2002-2003.

RESULTS

The analysis evidenced that 31.5% of sarcoidosis patients had pathognomonic echographic findings of abdominal organs: splenomegaly (13%), hepatomegaly (10.8%) and hepatosplenomegaly (7.7%). Three patients underwent surgical treatment of liver and spleen sarcoidosis.

CONCLUSION

Pathognomonic findings of liver and spleen sarcoidosis were evidenced in approximately one third of sarcoidosis cases and they represented a significant parameter for further therapy, particularly in chronic patients.

[The role of vitamin D in the formation of granuloma and in calcium metabolism]

INTRODUCTION

Affection of the abdominal organs with sarcoidosis is a part of the generalized granulomatous diseases with clinical manifestations that vary depending on the affected organ.

IMMUNOPATHOGENESIS OF GRANULOMA AND THE ROLE OF VITAMIN D

Formation of granuloma represents a response of the host immune system to different antigen stimuli and it represents an attempt of the host to block the endogenous or exogenous irritant. The active form of vitamin D-1,25-dihydroxyvitamin-D (1,25-D) has an important function in formation of granuloma.

HEPATOMEGALY AND SPLENOMEGALY

As for the abdominal region, sarcoidosis is most frequently clinically manifested by liver and/or spleen enlargement (20-30% of the affected patients). However, granulomatous infiltrations may also be present along with normal sized organs. Other abdominal localizations are significantly less frequent.

THE ROLE OF VITAMIN D IN CALCIUM METABOLISM

Calcium metabolism disorder represents a significant problem in patients affected with sarcoidosis, particularly in extrapulmonary, chronic forms of the disease. It develops as a result of complex metabolic processes consequential to increased level of 1,25-D and it is considered to be a parameter of granuloma activity (physiological blood value is up to 45 pq/ml). An increased level of provitamin D initiates osteoclast activity that causes bone resorption, which represents a factor of osteoporosis that results in hypercalcemia and hypercalciuria.

RENAL CALCULOSIS AS A SIGN OF SARCOIDOSIS ACTIVITY

Increased calcium release into blood results in production of calcium deposits in the soft tissues and certain organs and thus calculosis develops. It is clinically most frequently manifested as renal calculosis, which is approximately 20 times more frequent in patients affected with sarcoidosis in comparison to general population.

CONCLUSION

Examinations of abdominal organ involvement should be a standard procedure in each patient affected with sarcoidosis.

[Analysis of patients with tuberculosis and diabetes mellitus at the Institute of Pulmonary Diseases and Tuberculosis of the Clinical Center of Serbia (2000-2002)]

INTRODUCTION

Tuberculosis and diabetes mellitus are diseases that are commonly found together with adverse mutual effects.

MATERIAL AND METHODS

The aim of this study was to analyze the incidence and association between tuberculosis and diabetes mellitus among TB patients hospitalized at the Institute of Pulmonary Diseases and Tuberculosis, Clinical Center of Serbia over the three-year period: 2000-2002.

RESULTS

Among the tuberculous patients the average incidence of diabetes mellitus over the analyzed period was 9.8%. Most of the patients were above 55 years of age (52.8%), followed by 41.6% of middle aged (30-55 years) patients, while only a small number of patients (6.5%) belonged to the young population group (below 30). Males (64%) were more frequently affected than females (36%). Significant number of patients (61%) had a severe form of diabetes mellitus with frequent glycoregulation disorders necessitating either short-term or permanent insulin therapy. Analysis of clinical forms of tuberculosis at the time of detection revealed that 50% of patients had a moderately disseminated form of the disease with bilateral changes while the other 50% had a disseminated form. The average bacillarity was 56%. Radiological findings of tuberculosis in diabetics was manifested atypically in the lower pulmonary fields with bronchopneumonic shadows found in 11.1% of patients.

CONCLUSION

Tuberculosis presents with changed clinical and radiological pictures in considerable number of diabetics, particularly elderly ones, resembling other unspecific lung diseases and thus it may cause differential-diagnostic dilemmas and delayed detection.

[Risk factors for developing tuberculosis]

INTRODUCTION

Application of modern achievements in the field of medicine such as organ transplantation, long-term immunosuppressive therapy in treatment of numerous diseases, dialysis, successful treatment of malignant diseases prolonged duration of life and consequential continuation of long-term immunodeficiency.

RISK FACTORS FOR DEVELOPING TUBERCULOSIS

HIV infection currently represents a major risk factor for reactivation of tuberculosis with its associated relative risk being 30-170 times higher in comparison to the control group, in regard to the number of CD4 T-lymphocytes. Malignant diseases (hematological, lung and breast carcinomas) are important immunocompromising conditions affecting reactivation of tuberculosis, whereas the relative risk is 16.

METABOLIC DISORDERS AS RISK FACTORS

Development of tuberculosis among diabetics is considerably more frequent in comparison to general population (relative risk 2-4). Prominent glycoregulation disorders point to greater liability to development of tuberculosis. Alcoholism is characterized by general reduction of resistance, resulting from alcohol intoxication, malnutrition, irregular life style, etc. In malabsorption, immunosuppression is induced by deficiency of nutritive components and thus, relative risk for reactivation of tuberculosis is 5-12 in gastrectomy and 27-63 in jejunoileal bypass. In patients with chronic renal failur the relative risk ranges from 10 (nephropathies) to 37 (transplantation). Numerous patients use long-term immunosuppressive therapy that contributes to increased risk for developing tuberculosis (relative risk 12) as early as one month after application of a dose above 15 mg/day.

CONCLUSION

There are numerous of risk factors that have frequently combined effects responsible for immunologic imbalance and development of tuberculosis.

New insights into transmission of tuberculosis

Introduction Considering the fact that tuberculosis is a global problem, that one third of the world population is infected with tuberculosis and that 8-10 million of newly recognized cases are detected per year, the need for acquiring new knowledge on pathogenesis and transmission of tuberculosis becomes obvious. Application of molecular biology methods in clinico-epidemiology practice has identified transmission chain of tuberculous bacilli in numerous intrahospital outbreaks of tuberculosis. Conditions favoring transsmition of tuberculous The possibility of transmission primarily depends on the following conditions: contagiousness of the patient who is a source of infection, conditions in which the exposure takes place, length of exposure, as well as the immune status of the exposed individual. Risk factors for transsmition of tuberculosis Unrecognized, i.e., untreated tuberculosis represents a major risk factor for environmental spread of the bacillus. Therefore, early diagnosis and initiation of adequate therapy are priority tasks. High risk of tuberculous bacilli transmission is associated with all diagnostic and therapeutic procedures inducing cough, such as bronchoscopy, endotracheal intubation, induction of sputum, inhalation therapy as well as work in microbiological laboratories dealing with identification of M. tuberculosis. Discussion Results of numerous studies indicate that there is significant risk for transmission and infection of individuals exposed to the source of infection in family settings, work environment or other close contacts. The problem of exposure of health workers at their workplaces represents a problem in institutions dealing with diagnosis and treatment of tuberculosis. Conclusion A more comprehensive insight into significance of the problem and application of measures aimed at preventing transmission of tuberculosis sholud lead to practical application of preventive measures proposed by the International Union Against Tuberculosis and Lung Disease, in both hospital and non-hospital environments.