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Varenika V, Blanc PD. A patient on RIPE therapy presenting with recurrent isoniazid-associated pleural effusions: a case report. J Med Case Rep 2011; 5:558. [PMID: 22129471 PMCID: PMC3296633 DOI: 10.1186/1752-1947-5-558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 11/30/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The clinical scenario of a new or worsening pleural effusion following the initiation of antituberculous therapy has been classically referred to as a 'paradoxical' pleural response, presumably explained by an immunological rebound phenomenon. Emerging evidence suggests that there also may be a role for a lupus-related reaction in the pathophysiology of this disorder. CASE PRESENTATION An 84-year-old Asian man treated with isoniazid, along with rifampin, pyrazinamide and ethambutol for suspected extrapulmonary tuberculosis, presented with a recurrent pleural effusion, his third episode since the initiation of this therapy. The first effusion occurred one month after the start of treatment, without any prior evidence of pulmonary tuberculosis involvement. Follow-up testing, including thoracoscopic pleural biopsies, never confirmed tuberculosis infection. Further evaluation yielded serological evidence suggesting drug-induced lupus. No effusions recurred following the discontinuation of isoniazid, although other antituberculosis medications were continued. CONCLUSION The immunological rebound construct is inconsistent with the evolution of this case, which indicates rather that drug-induced lupus may explain at least some cases of new pleural effusions following the initiation of isoniazid.
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Affiliation(s)
- Vanja Varenika
- Department of Occupational and Environmental Medicine, University of California, San Francisco, 350 Parnassus Avenue, Room 609, San Francisco, CA 94143-0924, USA
| | - Paul D Blanc
- Department of Occupational and Environmental Medicine, University of California, San Francisco, 350 Parnassus Avenue, Room 609, San Francisco, CA 94143-0924, USA
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Rakotoson JL, Rakotomizao JR, Andrianasolo RL, Rakotoharivelo H, Andrianarisoa ACF. [Paradoxical lymphadenopathy during treatment of cavitary tuberculosis in an immunocompetent patient]. REVUE DE PNEUMOLOGIE CLINIQUE 2011; 67:318-321. [PMID: 22017953 DOI: 10.1016/j.pneumo.2010.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Revised: 10/29/2010] [Accepted: 11/03/2010] [Indexed: 05/31/2023]
Abstract
The paradoxical reactions during antituberculosis treatment are defined as a transient, clinical and/or radiological increase in preexisting tuberculous lesions or as the emergence of new symptoms, while treatment is adapted and correctly taken. The authors report a case of paradoxical left axillary lymphadenopathy during the treatment of cavitary tuberculosis, which appeared after seven months of treatment. No consensus on the therapeutic management of this entity has been developed to date but many authors propose an extension of antituberculosis treatment, a short corticosteroid therapy, an aspiration puncture and/or a surgical excision of the lymphadenopathy.
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Affiliation(s)
- J L Rakotoson
- Unité de soins, de formations et de recherches (USFR) de pneumologie, CHU d'Antananarivo, Antananarivo, Madagascar.
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Singh SK, Ahmad Z, Pandey DK, Gupta V, Naaz S. Isoniazid causing pleural effusion. Indian J Pharmacol 2011; 40:87-8. [PMID: 21279173 PMCID: PMC3025133 DOI: 10.4103/0253-7613.41045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 04/25/2008] [Accepted: 05/08/2008] [Indexed: 11/25/2022] Open
Abstract
Isoniazid (INH) is a first-line antitubercular drug. We report a case of a patient who developed a pleural effusion 2 months after starting antitubercular treatment for spinal tuberculosis. Isoniazid was found to be the culprit and its discontinuation caused subsidence of the effusion.
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Affiliation(s)
- S K Singh
- Department of Tuberculosis and Respiratory Diseases, JN Medical College, AMU, Aligarh, UP, India
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Abstract
The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of gamma-interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.
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Affiliation(s)
- Richard W Light
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee 37232-2650, USA.
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Lim SY, Ryu YJ, Lee JH, Chun EM, Chang JH, Shim SS. Organizing pneumonia in a patient with newly diagnosed acquired immunodeficiency syndrome. Intern Med 2010; 49:2327-31. [PMID: 21048369 DOI: 10.2169/internalmedicine.49.2883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Organizing pneumonia (OP) may be secondary to many clinical settings, including various infections, drugs, radiation therapy, malignant diseases, and connective tissue diseases. The concomitant occurrence of OP with human immunodeficiency virus infection has rarely been described. Recently, we encountered a case of OP confirmed by surgical lung biopsy in a patient with newly diagnosed AIDS. This case is the first in Korea and the second worldwide in which the diagnoses of OP and AIDS were made simultaneously. In this case, other possibilities that lead to OP, such as drug toxicity, were ruled out carefully.
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Affiliation(s)
- So Yeon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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Fernández-Fúnez Á. Respuesta paradójica durante el tratamiento tuberculostático en pacientes inmunocompetentes. Med Clin (Barc) 2009; 133:637-43. [DOI: 10.1016/j.medcli.2008.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 12/18/2008] [Indexed: 11/28/2022]
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Park JM, Shin YH, Chon GR, Shin HJ, Choi YC. A case of newly developed pulmonary lesion during the antitubercular agents in tuberculous pleurisy : A paradoxical response. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.6.717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jee Min Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Youn Ho Shin
- Department of Pediatrics, Pochon CHA University, College of Medicine, Seoul, Korea
| | - Gyu Rak Chon
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Konkuk University College of Medicine, Chungju, Chungbuk, Korea
| | - Hyun Joon Shin
- Department of Radiology, Konkuk University College of Medicine, Chungju, Chungbuk, Korea
| | - Young Chil Choi
- Department of Radiology, Konkuk University College of Medicine, Chungju, Chungbuk, Korea
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Song EJ, Baek DH, Jung JY, Lee SR, Lee MH, Lee SH, Lee JH, Lee KD, Lee BH, Kim SH. Paradoxical Response Developed during the Antituberculous Treatment in Tuberculous Pleurisy. Tuberc Respir Dis (Seoul) 2008. [DOI: 10.4046/trd.2008.64.6.427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eun Ju Song
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Dae Hyun Baek
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Jun Young Jung
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Sang Ryul Lee
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Myong Ha Lee
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Sung Hyuk Lee
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Jae Hyung Lee
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Ki Deok Lee
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Byoung Hoon Lee
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Sang Hoon Kim
- Department of Internal Medicine, Eulji Hospital, College of Medicine, Eulji University, Seoul, Korea
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Abstract
INTRODUCTION Tuberculosis continues to be a major cause of morbidity and mortality worldwide. Currently available drugs are effective for treatment of the disease or latent infection, but may cause serious adverse effects. METHODS The authors reviewed the literature for side effects of five first-line antituberculous medications (isoniazid, rifampin, pyrazinamide, ethambutol and streptomycin). Incidence of the major side effects were compiled with particular attention to the incidence of isoniazid hepatotoxicity. RESULTS Hepatotoxicity to isoniazid is a serious problem. Although overall incidence may be decreasing, incidence averaged 9.2 per 1000 patients who were compliant, in multiple studies, with a case fatality rate of 4.7%. The incidence is higher with increasing age. Other serious adverse effects include dermatological, gastrointestinal, hypersensitivity, neurological, haematological and renal reactions. They can lead to drug discontinuation (in up to 10% of patients) or even more serious morbidity or mortality. CONCLUSIONS Side effects to antituberculosis drugs are common, and include hepatitis, cutaneous reactions, gastrointestinal intolerance, haematological reactions and renal failure. These adverse effects must be recognised early, to reduce associated morbidity and mortality.
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Affiliation(s)
- Eric J Forget
- Respiratory Epidemiology Unit, Montreal Chest Institute, McGill University, Montréal, Québec, H2X 2P4, Canada
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de Lima Mota PJ. Iatrogenia a fármacos no contexto do Aparelho Respiratório. REVISTA PORTUGUESA DE PNEUMOLOGIA 2002. [DOI: 10.1016/s0873-2159(15)30803-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Choi YW, Jeon SC, Seo HS, Park CK, Park SS, Hahm CK, Joo KB. Tuberculous pleural effusion: new pulmonary lesions during treatment. Radiology 2002; 224:493-502. [PMID: 12147848 DOI: 10.1148/radiol.2242011280] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To evaluate patients who have a paradoxical response (development of new opacities) to treatment for tuberculous pleural effusion not related to acquired immunodeficiency syndrome. MATERIALS AND METHODS In 16 patients, follow-up chest radiographs (n = 16) and initial (n = 2) and follow-up (n = 9) computed tomographic (CT) scans of the chest were retrospectively reviewed by two radiologists. Patient records (n = 16) and results of percutaneous needle aspiration and/or biopsy (n = 6) were reviewed by one radiologist. RESULTS Eighteen episodes of new lesion development were identified on radiographs in 16 patients. Each episode showed single (nine of 18 episodes, 50%) or multiple (nine of 18 episodes, 50%) nodules, most of which were in the peripheral lung (16 of 18 episodes, 89%) ipsilateral to the side of previous effusion (17 of 18 episodes, 94%). On CT scans, all lesions were peripheral pulmonary nodules, not round atelectasis. Needle aspiration and/or biopsy of the lesions showed findings consistent with tuberculosis in all six patients. Lesions usually evolved within 3 months after the start of medication (13 of 18 episodes) and finally disappeared (15 episodes) or left residual opacities (three episodes) 3-18 months later, with continuation of medication. CONCLUSION New lung lesions that develop during medication for tuberculous pleural effusion should be considered a transient worsening that ultimately improves with continuation of medication.
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Affiliation(s)
- Yo Won Choi
- Department of Radiology, Hanyang University Seoul Hospital, 17 Haengdang-dong, Sungdong-ku, Seoul 133-792, South Korea.
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Affiliation(s)
- S C Hung
- Department of Medicine, Veterans General Hospital-Taipei, Taiwan, Republic of China
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