• PDF / 171,494 Bytes
• 1 Pages / 595.245 x 841.846 pts (A4) Page_size
• 89 Downloads / 128 Views

DOWNLOAD

REPORT

---

1 S

Localised pulmonary melioidosis and lack of efficacy: case report A 63-year-old man developed localised pulmonary melioidosis during immunosuppressive therapy with ciclosporin and mycophenolate mofetil. Additionally, he exhibited no response during treatment with meropenem for bacterial pneumonia [dosages not stated; not all routes stated]. The man, who was a farmer residing in central Thailand, presented with non-productive cough and prolonged fever for 3 months. Additionally, he had intermittent chest tightness at the left hemithorax. He reported weight loss of 4kg. He was admitted to a hospital in Thailand and was diagnosed with bacterial pneumonia. Therefore, he was treated with IV meropenem for 14 days; however, no response was observed with this treatment, and his fever did not resolve. Therefore, he was transferred to another hospital for additional investigations. Anamnesis revealed that he was a former smoker and had kidney transplantation four years ago, due to end-stage renal disease, and since then, he had started receiving immunosuppressive therapy with mycophenolate mofetil and ciclosporin. Concurrently, he also had been receiving aciclovir for herpes infection prophylaxis. Physical examination revealed an asthenic patient with anicteric sclera. Further investigations showed a body temperature of 38°C, BP 100/60mm Hg, pulse rate 90 /minute and RR 17 /minute. His oxygen saturation was found to be 95% at ambient air. Respiratory examination showed decreased breath sound at the left upper lung zone with no crackles or egophony. Blood analysis showed mild anaemia and leukocytosis. The chest radiograph and contrast-enhanced chest CT-scan demonstrated a large mass in the left upper lobe. A transthoracic core-needle biopsy of the left upper lobe mass was done, and the histopathology revealed non-small cell carcinoma admixed with necrotic tissues. The immunohistochemical studies for cytokeratin (CK) AE1/AE3, CK7 and thyroid transcription factor-1 (TTF-1) were positive, suggesting primary lung adenocarcinoma. The Brown-Hopp stain showed a single cluster of gramnegative bipolar rods with safety pin appearance characteristics of B. pseudomallei, and subsequently, B. pseudomallei grew on tissue culture. The serum antibody titer against B. pseudomallei was positive. Based on these findings and clinical picture, he was diagnosed with stage-IIIA non-small cell lung cancer (T4N0M0) co-existing with localised pulmonary melioidosis. The immunosuppressive therapy was considered as a risk factor for development of localised pulmonary melioidosis. The man’s antibiotic therapy was switched to ceftazidime, due to lack of response to meropenem. His fever improved after 3 weeks. Gradually, he gained weight. After completion of ceftazidime, he was treated with cotrimoxazole. Thereafter, he underwent surgery for the left upper lobectomy and left thoracotomy, but the procedure was not accomplished because of severe adhesion surrounding the entire left lung and great vessels. After the surgery, he was treated with chemoradia