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Many different factors that are extremely variable for each individual affect the survival of lung cancer patients. Prognosis in lung cancer depends upon tumor type, patient immunity and treatment modalities. The objective of our study was to determine the influence of clinical manifestations including the patient symptoms, laboratory findings, imaging modalities and histopathologic tumor features on the prognosis in lung cancer. Another aim was to evaluate whether the collaboration of these data predicted a more accurate prognostic assessment.

Sarcoidosis is a chronic granulomatous disease of unknown etiology. The disease most commonly involves the lungs and the mediastinal lymph nodes while extrapulmonary organs such as the skin, eye, liver or spleen may also be comprised. Many imaging modalities have been used for the clinical evaluation of sarcoidosis patients, but all have been found to have certain drawbacks for a reliable diagnostic assessment due to the equivocal diagnostic results. This study was designed to determine the clinical trenchancy of simultaneous 68Ga-citrate PET/CT [Positron emission tomography with 68Ga-cit-rate (68Ga-citrate PET/CT)] and 18F-FDG PET/CT [Positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-D-glucose (18F-FDG PET/CT)] imaging in sarcoidosis patients. The main goal was to evaluate sarcoidosis patients with respect to diagnosis, disease activity and organ involvement. A total of eight sarcoidosis patients with a comorbid disease suspicion were included in the study. Conventional clinical parameters used for the diagnosis and the activity of sarcoidosis including clinical, laboratory and computed tomography (CT) manifestations were compared with the 68Ga-cit-rate PET/CT findings. Concurrent 18F-FDG PET/CT was performed to verify the granulomatous inflammation of sarcoidosis and to determine coexisting malignant or other inflammatory diseases. Our study results revealed that 68Ga-citrate PET/CT imaging appears to be highly useful for the diagnosis, activity assessment and extrapulmonary organ involvement in sarcoidosis. Another crucial finding was the detection of extrapulmonary organ disease that are exceptionally involved, almost inaccessible by biopsy and that could not be otherwise displayed by other conventional imaging modalities. The third hallmark was the identification of a clinically asymptomatic and occult malignancy accompanying sarcoidosis that would not be detected in any way if synchronous 18F-FDG PET/CT had not been performed. Simultaneous application of 68Ga-citrate and 18F-FDG PET/CT may provide extremely useful data for the clinical evaluation of sarcoidosis patients in terms of the primary disease diagnosis, activity state, extrapulmonary organ involvement unachievable for biopsy and revealing occult malignant disorders that may coexist with sarcoidosis. © Copyright: the Author(s), 2020

The main objective of this study was to evaluate the clinical features of ocular sarcoidosis. The second aim was to assess the influence of eye involvement on the prognostic outcome, extrapulmonary organ, and endobronchial involvement in sarcoidosis patients. Third objective was to determine the contribution of ocular involvement to final diagnosis in patients presenting with an equivocal sarcoidosis diagnosis due to single organ disease.

Sarcoidosis is a multisystemic granulomatous disease characterised by the histologic evidence of granulomas in various organs. Clinically discernible gastric sarcoidosis is extremely rare, reported in less than 1% of the patients. We present a case of gastric sarcoidosis with atypicial manifestations and without current pulmonary disease. The patient was admitted for gastric fullness, anorexia, and weight loss. She had a history of migraine and nodular goiter. Family history revealed bladder carcinoma in the mother and gastric carcinoma in the uncle. Initial laboratory findings and chest x-ray were normal. Biopsies from the gastric mucosa revealed noncaseating granulomas with focal multinucleate giant cells. Six months after the patient was admitted for dry cough and fatigue. Chest x-ray and CT revealed diffuse nodules in the upper and middle lung zones. Transbronchial biopsy demonstrated noncaseiting granulomas compatible with sarcoidosis. The patient was started on mehtylprednisolone and had a significant improvement in her symptoms. This case is an unique paradigm for the exceptional presentation of sarcoidosis. Isolated extrapulmonary organ involvement without simultaneous lung disease may be the initial manifestation of sarcoidosis. Meticulous follow-up for sarcoidosis is required for patients presenting with atypical symptoms and noncaseiting granulomas in any extrapulmonary organ.

Sarcoidosis is a chronic granulomatous inflammatory disease characterized by the presence of noncaseating granulomas in various organs. Psoriasis is a persistent and recurrent autoimmune disorder mainly affecting the skin. Cutaneous involvement is observed in one fourth of the sarcoidosis patients and psoriatic plaques may be a manifestation of cutaneous sarcoidosis. The pathogenic mechanism of psoriasis is relevant to the overstimulation of CD4 TH1 and TH17 lymphocytes that are also involved in the granuloma formation of sarcoidosis. We present seven cases of sarcoidosis patients presenting with psoriasiform sarcoidosis. All the patients had cutaneous plaques indistinguishable from psoriasis. Diagnosis of sarcoidosis was confirmed by biopsy in at least two organs. Psoriasiform sarcoidosis was identified by skin biopsy of the involved cutaneous lesions. All patients had stage III sarcoidosis and presented with one or more clinical or laboratory manifestations of sarcoidosis. BAL was negative for infectious agents. Histopathologic examination of the bronchial and transbronchial biopsy samples revealed noncaseiting granulomatous inflammation. Differentiation of sarcoidosis and psoriasis may constitute a diagnostic dilemma for the clinician in terms of the identical skin lesions. The presence of psoriatic plaques may suggest an overlap between the underlying pathogenetic mechanisms of both disorders. Despite the great clinical similarity, the only way to differentiate the two syndromes is pathological examination. The common pathogenetic mechanism involving the TH1 and TH17 pathways for both sarcoidosis and psoriasis may be the fundamental linkage for this occurrence. We present seven cases of sarcoidosis patients presenting with psoriasiform lesions to define the clinical profile of sarcoidosis in these patients including presentation, laboratory findings and prognosis. The coexistence of sarcoidosis and psoriasis, on the other hand may shed light on the common mechanisms that may play a role in the development of both disorders.

A 44 year old female was referred for hyperbaric oxygen treatment of leg ulcers. The patient had port-wine stain, hand vitiligo, hypertrophy of one extremity, collateral abdominal, and varicose leg veins. Calcium was 12 mg/dL and PTH was 309 ng/L. Hepatomegaly, deep vein thrombosis of the right leg, transudative ascites, hypersplenism, parathyroid adenoma, mesenteric cyst, and papillary thyroid carcinoma were identifi ed. The fi nal clinical diagnosis was Klippel-Treanunay-Weber syndrome.

Sarcoidosis is a multisystemic disease that may lead to neurologic complications in 10% of the patients. Carpal tunnel syndrome is very rare in sarcoidosis. We present two identical twin sarcoidosis patients with carpal tunnel syndrome. A number of factors may cause carpal tunnel syndrome like wrist anatomy, occupation, diabetes, rheumatoid arthritis, pregnancy and renal failure. Although the above factors do not directly cause carpal tunnel syndrome, they may increase your chances of developing or aggravate median nerve damage as it is in sarcoidosis. Sarcoidosis relevant neuropathy and granulomas may be the primary mechanism of sarcoidosis associated carpal tunnel syndrome. Although rare, carpal tunnel syndrome may be a feature of sarcoidosis that may lead to irreversible damage in cases of delayed diagnosis. The presence of this syndrome in identical twin patients may shed light into the pathogenesis and the genetic transmission of sarcoidosis with the associated carpal tunnel syndrome.

The main objective of this study was to evaluate the influence of muscle involvement on the clinical features, prognostic outcome, extrapulmonary organ, and endobronchial involvement in sarcoidosis patients. The second aim was to assess the diagnostic yield of muscle biopsy for the histopathologic identification of sarcoidosis. Â Fifty sarcoidosis patients participated in the study. The patients were classified into two groups according to the histopathologic presence of non-caseating granulomatous inflammatory pattern of the muscle biopsy samples and were evaluated retrospectively in regard to clinical features, prognosis, extrapulmonary, and endobronchial disease involvement. Pathologic examination of the muscle biopsy samples revealed non-caseating granulomas in eighteen and myositis in seven patients compatible with sarcoidosis. The diagnostic yield of muscle biopsy for demonstrating non-caseating granulomatous inflammation was fifty percent. Patients with muscle sarcoidosis showed a worse prognosis and a more severe extrapulmonary organ involvement than the patients without muscle disease. Muscle biopsy was not statistically significant to delineate diffuse endobronchial involvement while it was suggestive for endobronchial disease clinically. The results of our study reveal that muscle biopsy appears to be a useful diagnostic tool along with its safety and easy clinical applicability. It is a rewarding utility to predict the prognostic outcome and extrapulmonary involvement in sarcoidosis patients. Positive biopsy on the other hand confirms the identification of sarcoidosis in patients with single organ involvement carrying an equivocal diagnostic clinical pattern. Muscle biopsy may be considered as the initial step for the final diagnosis of sarcoidosis in such cases.

Aims: Airway involvement is a common feature of sarcoidosis and mucosal abnormalities may be evident in the respiratory tract. However, firm data establishing the clinical features and prognosis of sarcoidosis in these patients is lacking although the incidence of endobronchial disease is high. The purpose of this study was to evaluate the clinical features of the patients with limited, diffuse and no endobronchial involvement. Another aim was to investigate the prognostic differences between these patients. Methods: We conducted a retrospective study to evaluate the clinical and laboratory findings of 48 patients with endobronchial sarcoidosis and 50 patients without endobronchial involvement seen at our institution. The patients fulfilled the clinical, radiologic or both features of sarcoidosis supported by the histopathologic evidence of noncaseiting granulomas. Six to ten bronchial biopsies were taken from each patient. The sample was considered positive if it demonstrated noncaseiting Original Research Article Tetikkurt et al.; BJMMR, 11(6): 1-7, 2016; Article no.BJMMR.20786 2 granulomas with negative fungal and mycobacterial cultures. The patients were classified into three groups according to the histopathologic biopsy results: 1) No endobronchial involvement, 2) Limited endobronchial involvement: One biopsy site positive and 3) Diffuse endobronchial involvement: Two or more biopsy sites positive for noncaseaiting granulomas. Results: Bronchial biopsy was positive in 82% of the abnormal appearing airways while it was diagnostic in 36% of the normal appearing mucosa. The most frequent bronchoscopic appearence was miliary infiltration. Nodular, erythematous lesions and edematous mucosal swelling were other bronchoscopic findings. There were no significant differences between the three groups for FEV1, FVC, TLC, DLCO/VA serum and 24 h urinary calcium levels. Serum ACE levels were significantly higher (p

We report 36 cases of spinal tuberculosis who were evaluated at the Internal Medicine Department of Istanbul University between January 1990 and March 2016. Twelve cases were accompanied by active pulmonary tuberculosis while ten patients had a previous history of tuberculosis. Eight patients had diabetes mellitus; six patients were on chronic steroid treatment with a mean dose of 24 mg/day while two patients used azathioprine and methotrexate. The dominant symptom was back pain that was present in 64% of the subjects followed by low grade fever (42%), and malaise (38%). Lytic and destructive lesions were noted in various vertebrae in all of the cases while four patients had spinal compression, and two patients had iliopsoas abscess. The preliminary diagnosis was myeloproliferative disease with vertebral metastasis in eight patients. Tuberculin test was over 15 mm in 20 patients (58.8%) while ERS and Creactive protein were highly elevated in 78%, and 84% of the patients. Diagnosis of tuberculosis was confirmed by culture of aspirated material from intervertebral disc space, collection under CT guidance, sputum or bronchial lavage, and by retrospective anti-tuberculous treatment response. MRI revealed compatible findings with spinal tuberculosis in 30 (80%) patients. In endemic countries, tuberculous spondilitis should be considered in immunosuppressed patients with back pain. Current or past tuberculosis infection is not a reliable indicator for Pott’s disease in these patients. Laboratory findings were not usually useful to support the diagnosis. The low sensitivity of the tuberculin test may lead to an erronous diagnosis. Sensitivity of vertebral radiography and CT was low. MRI was the most useful radiologic investigation for the diagnosis of spinal tuberculosis. Tuberculosis of the spine is a diagnostic impasse notably in immunodeficient patients for the clinician.

Carcinosarcoma is an uncommon mixed tumor of the lung. It is composed of a mixture of carcinoma and sarcoma elements. We present a case of 64-year-old male with carcinosarcoma of the lung associated with tuberculosis involvement of the same site. The patient was admitted for cough, malaise and fever. Bronchial lavage culture revealed M. tuberculosis. Six months after completion of tuberculosis treatment, the patient was admitted for hemoptysis and headache. CT revealed a solid lesion at the left upper lobe anterior bronchus. Histopathologic examination of the bronchial biopsy specimen revealed carcinosarcoma. Cranial MRI showed a metastatic lesion in the cerebellum which was removed surgically. Four months later, the patient developed bilateral malignant pleural effusions, recurrent cerebellar and skeletal metastases and died in the intensive care unit following intubation for respiratory failure. We describe a case of pulmonary carcinosarcoma occurring at the same localization shortly after successful treatment of tuberculosis with reference to relevant literature.

Sarcoidosis is a systemic disease characterized by noncasefied granulomas in various organs. Incidence of splenic disease is variable and is reported to occur in 6.7 to 77 percent of the patients. Firm data establishing the clinical features and the association of splenic involvement with prognosis in sarcoidosis is scant. The aim of our study was to investigate the clinical features and the consequence of splenic involvement on the prognostic outcome of sarcoidosis patients. We evaluated the clinical and laboratory findings in 82 sarcoidosis patients. Forty-two patients with splenic involvement were compared to 48 sarcoidosis patients without splenic disease in regard to laboratory findings, endobronchial disease, extrapulmonary organ involvement, and prognosis. Lung biopsy sample was considered positive if it demonstrated noncaseating granulomas with negative fungal and mycobacterial cultures. Splenic sarcoidosis was identified by ultrasound or computed tomography and was designated as limited, diffuse or without splenic involvement. Extrapulmonary organ sarcoidosis was classified as extensive and limited. Endobronchial disease was categorized as limited or diffuse involvement. The most commonly comprised organ was lung in 95% of the cases followed by lymph nodes, skin, eye, spleen and liver in the order of frequency. Splenic disease was diffuse in 22 patients. Of these patients, 14 had extensive extrapulmonary organ involvement while 16 had diffuse endobronchial disease. There was no significant difference between the three groups for FEV1, FVC, TLC, DLCO/VA, serum and 24h urinary calcium levels. Serum ACE was higher in patients with diffuse splenic involvement (p

Patients with sarcoidosis usually have a benign course and a favourable prognosis. Although spontaneous remission is common, a progressive disease with a severe prognosis occurs in a small but significant number of patients. The aim of this study was to evaluate the potential significance of HLA antigens as a clinical marker on the outcome of sarcoidosis patients. We conducted a retrospective cohort study for HLA class I and II allels in 74 sarcoidosis patients and 72 healthy transplant donors. Bronchoscopy and bronchial biopsies were performed in each patient. Two or more positive bronchial biopsy samples revealing granulomatous inflammation was defined as diffuse while one positive biopsy sample was considered as limited endobronchial disease. Three or more extrapulmonary organ involvement was denoted as severe extrapulmonary disease. The patients were followed-up at least for eight years. Incidence of progressive disease was significantly high in patients with positive HLA-DRB1*07, DRB1*14 (p

Sarcoidosis is a systemic granulomatous disease of unknown etiology that can involve nearly all organs. Liver is the third most commonly affected organ following the lungs and the lymph nodes. Cases with liver sarcoidosis are usually silent clinically while a few can progress to cirrhosis and portal hypertension in less than 1% of the patients. A 56 year old female was referred for ecchymosis, protuberant abdomen, bilateral pretibial and ankle edema. Medical history did not reveal any previous disease. Ascites, hepatomegaly, splenomegaly, and facial telengiectasies were present on physical examination. Chest x-ray and CT were normal. Papules and plaques on the knees developed six days after admission. Skin biopsy revealed granulomatous dermatitis. Serum ACE was 250 IU/L. Liver biopsy showed non-caseiting granulomas, severe hepatitis and fibrosis. Sarcoidosis was confirmed based on high serum ACE, histopathologic findings of the skin and liver biopsy samples that revealed non-caseiting granulomas. We report a case of sarcoidosis complicated by cirrhosis as the initial manifestation of the disease without lung involvement. An extensive literature review of sarcoidosis, Case Study British Journal of Medicine & Medical Research, 4(25): 4272-4277, 2014 4273 focusing on case reports, which presented with cirrhosis and portal hypertension without lung involvement, was made.

BACKGROUND Sarcoidosis is a systemic granulomatous disorder associated with high CD4+cell activity, without any detectable pathogen. Clustering in families occurs, and the existence of a genetic predisposition to sarcoidosis is widely accepted. There are differences among different ethnic groups. METHODS We studied HLA polymorphisms in 64 Turkish patients with biopsy proven sarcoidosis. The control group was taken of 160 donor candidates of kidney transplantation within the same period. RESULTS Fifty-one patients were female, and 13 were male. The mean age was 39 +/- 6.1 years. Frequency of HLA A2, A9, A24 (9), A25, A69 (28), B12, B22, B38, B49 (21), DR4, and DR14 antigens were significantly higher, and frequencies of HLA B7 and DR7 were significantly less in sarcoidosis patients. Clustering in some families were also noted in our study. CONCLUSIONS This study implies a genetic predisposition to sarcoidosis in the Turkish population. Clustering in some families should be kept in mind.

A 78-year-old woman was referred to our university hospital due to dry cough, fever, and weight loss. Laboratory revealed blood eosinophilia, high ESR, CRP and LDH. Rheumatologic markers were negative. Chest X-ray showed ground glass opacities in upper lobes. Uveitis developed in the left eye 1 week after admission. Thorax CT revealed ground glass opacities, reticular appearence in the upper lobes, enlarged axillary and mediastinal lymph nodes. Bronchoalveolar lavage CD4/CD8 was 2.1 and had 48% eosinophils. Histopathologic examination revealed eosinophilic infiltration and non-caseating epitheloid granulomas in the lung and mediastinal lymph nodes without vasculitis. Symptoms, blood eosinophilia and initial thorax CT findings improved after two months of methylprednisolone treatment. Chronic eosinophilic pneumonia is a rare disease characterized by systemic and pulmonary manifestations. It may be associated with other diseases.

Reactive hypoglycemia (RH), which is a postprandial hypoglycemic state, occurs within 2-5 h after food intake. It is classified as idiopathic, alimentary, or diabetic reactive hypoglycemia. We studied the incidence of reactive hypoglycemia and looked for any correlations between it and the presence of insulin sensitivity and/or beta cell function in young lean polycystic ovary syndrome (PCOS) patients. This study was designed as a cross-sectional study in 64 lean young women with PCOS (BMIor = 25 kg/m2). Various indices of insulin sensitivity and beta cell function derived from the oral glucose tolerance test (OGTT) results were used. We found the rate of RH to be 50% in lean young women with PCOS. DHEA-S and PRL levels were found to be lower in subjects with RH (P0.05 and P0.05, respectively). Beta cell function indices such as the insulinogenic index (at 120 min), CIR (at 120 min) and HOMA beta cell index were found to be insignificantly higher in the RH group than the nonreactive hypoglycemia (NRH) group. The 4 h glucose level, but not the 3 h glucose level, was significantly correlated with insulin resistance indices, such as fasting insulin level, HOMA-IR, Quicky index, and FIRI in the RH group. Significantly decreased DHEA-S levels were an interesting finding. In conclusion, there is an urgent need to investigate RH in lean young women with PCOS. Our results indicate that more definite insulin resistance occurs in subjects with RH in the fourth hour of the OGTT than those with RH in the third hour. In addition, RH in the fourth hour together with a low DHEA-S level may be predictive of future diabetes in young women with PCOS even when they are not obese.

In this study we aimed to investigate the findings in patients with adult-onset Still's disease (AOSD) admitted with fever of unknown origin (FUO) during the last 18 years in our unit, in order to discover the ratio of such patients to all patients with FUO during the same period, and to determine the clinical features of AOSD in FUO. The number and the aetiologies of the patients with FUO diagnosed between 1984 and 2001, and the clinical features of those with AOSD, were taken from the patient files. The diagnosis of AOSD was reanalysed according to the diagnostic criteria of Cush et al. [11]. The presumed diagnoses before a diagnosis of AOSD was established were also noted. The chi(2) and Fisher's exact tests were used for statistical analysis. We studied 130 patients with a diagnosis of FUO, 36 (28%) of whom had collagen vascular diseases. Of these 36 patients, 20 (56%, 12 female, 8 male, mean age 34 years, range 16-65) had AOSD. Clinical and laboratory findings were as follows: fever (100%), arthralgia (90%), rash (85%), sore throat (75%), arthritis (65%), myalgia (60%), splenomegaly (40%), hepatomegaly (25%), lymphadenopathy (15%), anaemia (65%), neutrophilic leukocytosis (90%), increased erythrocyte sedimentation rate (100%), elevated transaminase levels (65%), a negative RF (100%), and a negative FANA (80%). Antibiotics had been prescribed in 18 (90%) of cases. The presumed infectious diagnoses were streptococcal tonsillitis/pharyngitis (50%), infective endocarditis (four patients), sepsis (two patients) and acute bacterial meningitis (two patients). The presumed non-infectious diagnoses were acute rheumatic fever (three patients), seronegative rheumatoid arthritis (two patients) and polymyositis (two patients). Sixteen patients were followed for a mean duration of 30 months (range 2-59). A remission was obtained with indomethacin in three cases (19%), and with prednisolone in the remainder. Relapse was detected in three cases (19%). AOSD is one of the most frequent aetiologies of FUO. During the diagnostic course of a patient with FUO, a maculopapular rash and/or arthralgia and/or sore throat should raise the suspicion of AOSD. Because the disease has heterogeneous clinical findings, certain bacterial infections (e.g. streptococcal pharyngitis and sepsis) are generally considered and the prescribing of antibiotics is common.

Antiphospholipid syndrome (APS) is defined as the occurrence of thrombosis, recurrent miscarriage, or both in association with laboratory evidence of persistent antiphospholipid antibodies. Owing to protean manifestations and laboratory studies, the diagnosis may be difficult. Because the other signs and symptoms of thrombosis are predominant, prolonged fever is not usually the main clinical finding. We describe a patient who presented with fever of unknown origin (FUO) and was found to have thromboses of the splenic vein, the superior mesenteric vein, and the portal vein due to the primary antiphospholipid syndrome. We also reviewed the medical literature (Medline 1966-2001), including the main FUO series of the previous 40 years, and laparotomy series for FUO. We conclude that although very rare, primary APS and thrombosis may present with FUO. APS should be considered in the differential diagnosis of prolonged fever associated with thrombosis.

Aim: To evaluate epidemiologic and clinical features of the patients with malaria followed in our clinic, and to review current status of malaria in our country. Patients and methods: Epidemiologic, clinical, diagnostic, and therapeutic features of 33 patients with malaria (4 female, 29 male, mean age: 28 ± 11 years, range: 15–60) followed in our clinic between 1981 and 2000 were evaluated retrospectively. Malaria data of our country for 1926–2000 were obtained from Health Ministry. Results: Diagnosis was established by thin smears of blood preparations obtained in the febrile period in all cases. Plasmodium vivax was detected in 26 patients (25 domestic and one imported), and P. falciparum in seven (two domestic and five imported). Sixty-one percent of the patients had the prodromal symptoms of the disease and used various antibiotics. All cases demonstrated the typical pattern of fever with chills. Fever (100%), splenomegaly (91%), hepatomegaly (55%), anemia (70%), leukopenia (48%), thrombocytopenia (48%), a rise in sedimentation rate (100%), and abnormalities in hepatic enzymes (30%) were determined in the patients. Chloroquine+primaquine were given to all patients with P. vivax, chloroquin (for three) or mefloquin (for four) alone were given to the patients with P. falciparum. One patient with P. falciparum died soon after admission, all the remaining recovered. Data from Health Ministry revealed that the most common (∼100%) species in our country is P. vivax. Although an eradication program against malaria initiated in 1926 achieved success, it still remains as an important health problem. Conclusion: Every febrile patient with a history of travel to the regions where malaria is endemic (tropical regions for the world, southeast regions for our country) should raise the suspicion of malaria. Every country should fight against malaria and global cooperation is essential.

Acute hepatitis A virus (HAV) infection is frequent in developing countries. Although some gallbladder abnormalities are defined during the course, an acute cholecystitis is extremely rare. We here report 2 additional cases of cholecystitis due to acute HAV infection and review the previously reported 2 cases. One of our patients was admitted with jaundice and a suspicious portal mass with a presumed diagnosis of cholagiocarcinoma. The other presented with jaundice, abdominal pain, and constitutional symptoms. Both patients were planned to be operated on. During the follow-up, absence of fever, leukocytosis, acute-phase protein response, and calculus in biliary system were against the diagnosis of a bacterial cholecystitis. Moreover the course of cholecystitis was closely parallel to that of the HAV infection. Both patients were managed conservatively. It was concluded that rare, acute viral cholecystitis can develop during the course of acute HAV infection.

A 35-year-old male was admitted to the hospital because of a 6-month history of increasing pain, swelling with erythema, and indurated nodules with intermittent discharge on the dorsum and palmar surface of his right hand. The swelling did not interfere with the normal use of his hand. The patient could not recall any specific incident prior to the onset of the swelling and had not taken antibiotics during this period. Results of the physical examination were normal except for dorsal and palmar swelling and erythema over the second, third, and fourth metacarpals of the right hand. There were three nodules associated with fluctuante surrounded by enduration (Figure 1). No lymphadenopathy in the relevant lymph drainage areas was detected. Results of laboratory investigations revealed a white blood cell count of 8.7 X 109/L; hemoglobin of 150 g/L; erythrocyte sedimentation rate of 10 mm/h (Westergren method); and a C-reactive protein of 3 mg/L (normal value: O-5 mg/L). Radiography and magnetic resonance imaging (MRI) of the right hand showed changes

Background:Sarcoidosis is a systemic disease, characterised by non-caseating granulomas in various organs. Liver involvement is not an uncommon feature of sarcoidosis. However, firm data establishing the clinical features and prognosis in these patients are lacking, although the incidence of liver sarcoidosis is high. In this study, we aimed to investigate the features of liver involvement in patients with sarcoidosis. Another aim was to evaluate the prognostic significance of liver disease by comparing the differences between patients with no liver involvement, limited and diffuse liver involvement.Methods:We conducted a retrospective study to evaluate the clinical and laboratory findings of 271 sarcoidosis patients seen at our institution. Patients with liver sarcoidosis identified by liver biopsy were compared to patients without liver involvement for clinical features and prognosis. The biopsy sample was considered positive if it demonstrated non-caseaiting granulomas with negative fungal and mycobacterial cultures. The patients were classified into three groups according to the radiological and histopathological biopsyresults:no liver involvement; limited liverinvolvement:two sites positive; and diffuse liverinvolvement:three or more sites positive for granulomas.Results:Hepatic involvement was identified by biopsy in 81 (81/271, 29.8%) while 43 (43/271, 15.8%) patients had elevated liver function tests. Most of the patients (94.6%) had lung involvement. Other organs involved, in the order of frequency,were:lymph nodes, skin, eye, spleen and parotid gland. There was no significant difference between the three groups for forced expiratory volume in one second, forced vital capacity, total lung capacity, diffusing capacity of the lungs for carbon monoxide/alveolar volume, serum and 24-hour urinary calcium levels. Serum angiotensin-converting enzyme levels were significantly higher (pConclusions:Diffuse liver involvement in sarcoidosis is a significant risk factor for progressive disease. Patients with diffuse liver disease have a worse prognosis than patients without or with limited liver involvement. Diffuse hepatic involvement in sarcoidosis is also associated with an increased incidence of extra-pulmonary organ involvement. Presence of diffuse liver disease may reveal a severe prognosis for sarcoidosis patients.

Brucellosis is a systemic infectious disease caused by Gram-negative bacilli, the genus Brucella, and clinical features are diverse. Therefore, several infectious and non-infectious diseases are considered in its differential diagnosis. In this study, we aimed to determine the positivity rate of Brucella agglutination tests in the culture-positive brucellosis and in diseases mimicking brucellosis clinically.Thirty patients with culture-positive brucellosis, and 280 patients with the diseases mimicking brucellosis clinically (20 with miliary tuberculosis, 33 with malaria, 20 with typhoid fever, 20 with adult-onset Still's disease, 47 with systemic lupus erythematosus, 50 with rheumatoid arthritis, 27 with sarcoidosis, and 63 with active lymphoma) were included in the study. Brucella agglutination tests (Rose-Bengal and Wright) were studied in serum samples of these 310 patients. Both Rose-Bengal and Wright tests (the latter in a titer of 1/160 or higher) were positive in all patients with brucellosis. For the other diseases, the test was slightly positive (1/40) in one patient with malaria and another with non-Hodgkin's lymphoma, and weakly positive (1/20) in a patient with typhoid fever. It remained negative in the remaining. In conclusion, agglutination tests currently used in the diagnosis of brucellosis are very sensitive and specific. Brucellosis can be effectively excluded from the diseases having similar clinical features by the use of agglutination tests.

The diagnosis of brucellosis is generally made when a standard tube agglutination titer of 1/160 or more for anti-Brucella antibodies in the presence of compatible clinical signs and symptoms. However isolation of the organism from blood or bone marrow is the proof of the disease. In this study we aimed to describe the rate and duration of isolation of Brucella spp. from blood and bone marrow by use of automated blood culture system (BACTEC 9240). Between 1997 to 2001, 23 adults were diagnosed as brucellosis. Blood culture was obtained in all and simultaneous bone marrow culture in 18 and both specimens were cultured by BACTEC 9240. Brucella was isolated from blood and bone marrow cultures in 19 (82.6%) and 13 (81.2%) respectively. All positive blood cultures yielded within 7 days and bone marrow cultures in 4 days. We concluded that automated BACTEC culture systems can isolate Brucella spp. in a fast and efficient way.

Objective: The aim of the study was to determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and prognostic variables in patients with miliary tuberculosis (TB). Methodology: The records of 38 patients (15 male, 23 female; mean age 41 years, range 16–76 years) with miliary TB from 1978 to 1998 were analyzed. Patients were evaluated also as to whether they presented with a fever of unknown origin (FUO). Criteria for the diagnosis of miliary TB were (i) miliary pattern on chest X-ray or (ii) biopsy or autopsy evidence of miliary organ involvement. Paraffin-embedded tissues with granulomata (n = 15) were re-evaluated for the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR). Results: Predisposing conditions were present in 24% of the patients. The findings were fever, weakness, night sweats, anorexia/weight loss (100% for each), hepatomegaly (37%), splenomegaly (32%), choroidal tubercles (13%), neck stiffness (11%), altered mental status (8%), anaemia (76%), leukopenia (26%), thrombocytopenia (16%), lymphopenia (76%), pancytopenia (8%) and hypertransaminasemia (55%). Eighteen patients (47%) met the criteria for a FUO. Miliary infiltrates were found on chest X-rays of 32 of 38 cases (84%). In six cases without miliary infiltrates, the diagnosis was made by laparotomy in four cases, and autopsy in two cases. Tuberculin skin test was positive in 32% of cases. Acid-fast bacilli were demonstrated in 37% (16/43), and cultures for M. tuberculosis were positive in 90% (9/10) of tested specimens (predominantly sputum and bronchial lavage). Granulomas were found in 85% (11/13) of lung, 100% (15/15) of liver, and 56% (9/16) of bone marrow tissue specimens. Acid-fast bacilli staining was negative in all (0/21), while PCR was positive in 47% (7/15) of specimens with granulomata. Mortality was 18%. Stepwise logistic regression identified male sex (P = 0.005), non-typical miliary pattern (P = 0.015), altered mental status (P = 0.002) and failure to treat for TB (P = 0.00001) as independent predictors of mortality. Conclusions: Miliary infiltrates on chest X-ray or FUO should raise the possibility of miliary TB. Therapy should be administered urgently to prevent an otherwise fatal outcome.

Small bowel perforation is a rare complication of miliary tuberculosis. We report the case of a 21-year old patient who developed a small bowel perforation 70 days after the initiation of adequate tuberculosis treatment. We also present a review of the literature.

Primary tuberculosis of the parotid gland is relatively rare even in those areas where the disease is endemic although involvements of cervical lymph nodes by mycobacteria are not uncommon. It may result from the involvements of intraparotid lymph nodes (the localized form) or the infection of parenchyma either primary or secondary to nodal disease (the diffuse form). Clinically a parotid mass may not be distinguishable from a neoplasm. This report presents a patient with a parotid mass that was thought to be a malignancy but after surgery was diagnosed to be tuberculosis of intracapsular lymph nodes. A 66-year-old woman was admitted because of a 1-month history of increasingly swelling at the angle of the jaw on the right side. She had no relevant symptoms and gave no personal or family history of tuberculosis. Systemic examination was normal except for a 4 X 2 cm mobile rubbery nontender mass in the right parotid region. All the hematologic findings biochemical data erythrocyte sedimentation rate and C-reactive protein (CRP) were within normal limits. The chest radiograph was normal. A tuberculin skin test was positive (an enduration of 30 X 32 mm). Tests for anti-human immunodeficiency virus (HIV) 1 and 2 antibodies were negative. With ultrasonography an anechoic mass measuring 36 X 16 X 18 mm was detected. Computed tomography (CT) of this region revealed a 35 X 25 mm homogeneous mass extending from the superficial lobe to the inferior border of the parotid gland (Figure 1). (excerpt)

Background: Sarcoidosis is known to be associated with defects in cellular immunity, especially in reference to T helper lymphocytes. Anergy to a tuberculin skin test is most characteristic of this disease. Objectives: To further the data on impaired immunity, we studied the antibody response to hepatitis B vaccination in patients with sarcoidosis. Methods: Serologic markers of hepatitis B virus (HBV) (HBsAg, anti-HBs, anti-HBc) were studied in 40 patients with sarcoidosis (32 female, 8 male; mean age: 45 ± 11 years, range: 25–66 years) with a mean duration of disease of 6 years. While all the markers were negative in 22 patients (55%), 2 had isolated anti-HBc positivity and 16 had both anti-HBc and anti-HBs antibodies. Thirty-five age- and sex-matched healthy subjects were studied as controls. Recombinant HBV vaccines (Genhevac B Pasteur, 20 µg) were administered (at 0 , 1, and 6 months) to 16 of the seronegative cases and the controls and antibody titres were measured 1 month after the last dose. The tuberculin skin test was negative in all cases. Results: While none of the vaccinees in the diseased group responded, the control group yielded an antibody response rate of 85.7% (30/35), with a mean titre of 257.9 mIU/ml. Conclusions: Patients with sarcoidosis were invariably unresponsive to standard vaccination, while some of the diseased subjects had already mounted a natural antibody response, either before or after the development of the original disease. Cellular immunodeficiency in sarcoidosis could be a suitable model for studying immunological interactions between HBV and the host.

Although rare, paradoxical subcutaneous abscesses may develop during appropriate treatment of miliary tuberculosis. While the pathogenesis of this phenomenon is not clear, some theories have been postulated. A case of a 37-y-old woman diagnosed as having miliary tuberculosis who developed subcutaneous abscesses within the 5 months of antituberculous treatment is described and all 6 similar cases published in English from 1954 to 1999 are discussed.

To assess the safety and efficacy of diagnostic laparoscopy in patients with tuberculous peritonitis.Retrospective clinical study.University hospital, Turkey.8 patients (2 women, 6 men; mean age 26 years) who presented with tuberculous peritonitis between January 1994 and January 1996.Laparoscopy under local anaesthesia with sedation (the 4 who presented with ascites) and laparotomy (the 4 who presented with an acute abdomen).Clinical and laboratory findings, biochemical and microbiological analysis of ascites, histopathological examination of specimens, morbidity, and mortality.4 patients presented with ascites, and 4 with adhesions. Ascites; adhesions between liver and diaphragm, liver and intestines, and intestines and the abdominal wall; miliary nodes on the peritoneal surface; and inflamed haemorrhagic areas on the peritoneum could all be seen at laparoscopy. One of the 8 patients who underwent laparotomy developed a spontaneous enterocutaneous fistula during the early postoperative period. Two of eight patients died, one of an early enterocutaneous fistula and the other of cor pulmonale 3 1/2 months later. The remaining 6 patients survived without complications after antituberculous medical treatment.Laparoscopy is a safe and accurate method of diagnosis of tuberculous peritonitis.

Muammer Bilir, Sevtap Sipahi, Ali Mert*, Halil Yanardag, Resat Ozaras, Hilal Aki, Tuncer Karayel Department of Internal Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty, University of Istanbul, 34303 Aksaray, Istanbul, Turkey Department of Pathology, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey

Background: Sarcoidosis is a systemic disease characterized by the formation of noncaseating granulomas in various tissues. Cutaneous involvement occurs in 20 to 35 percent of the patients and may be the initial manifestation of the disease. Our study was performed to discriminate the clinical, laboratory, and prognostic differences between patients with specific and nonspecific cutaneous involvement. The second aim was to asses the diagnostic usefulness of punch biopsy in sarcoidosis. Methods: The clinical, laboratory, pathological features, and skin biopsy results of 120 patients with cutaneous sarcoidosis were evaluated. The patients fulfilled clinical, radiologic or both features of sarcoidosis supported by the histopathologic evidence of noncaseating granulomas. Skin involvement was the initial finding in 30% of the patients. Erythema nodosum and lupus pernio were the most common skin lesions. Almost all of the patients with LP were either stage 0 or 1. Respiratory symptoms occurred in 72.2% of the patients with specific skin involvement. Bronchoalveolar Lavage (BAL) lymphocytosis, high ratio of CD4/ CD8 and elevated serum Angiotensin Converting Enzyme (ACE) were more frequent in patients with specific cutaneous lesions. The frequency of progressive disease was significantly higher in this group. Punch skin biopsy was diagnostic in 81.6% of the patients with a complication rate of 4%. Conclusions: Specific cutaneous lesions along with BAL lymphocytosis, high CD4/CD8 ratio and elevated serum ACE levels may be predictors of progressive disease in sarcoidosis. Punch biopsy is a simple technique with a high diagnostic yield and a low complication rate for cutaneous sarcoidosis.

A 58-year-old female patient diagnosed as having sarcoidosis 23 years ago developed nephrotic syndrome. No pathology was found which could explain this, so it was attributed to her sarcoidosis. Renal biopsy showed global and segmental sclerosis. The occurrence of focal segmentary glomerulosclerosis in a case of sarcoidosis is rare. In systemic sarcoidosis it is thought that T-cell dysfunction may play a role in the pathogenesis of glomerulonephritis. When treatment is considered, corticosteroid therapy may be used according to the clinical status at diagnosis as well as on follow-up of the patient.

Hyperinsulinemia in nondiabetic, both obese and nonobese patients with nonalcoholic steatohepatitis