Lessons from Mycobacterium avium complex-associated pneumonitis: a case report

ABSTRACT: INTRODUCTION: Mycobacterium avium complex (MAC) is an increasingly recognized cause of pulmonary disease in immunocompetent individuals. An acute form of MAC lung disease, MAC-associated pneumonitis, has generally been associated with the use of hot tubs. There is controversy in the literature about whether MAC-associated pneumonitis is a classic hypersensitivity pneumonitis or is a direct manifestation of mycobacterial infection. CASE PRESENTATION: We report the second case in the literature of MAC-associated pneumonitis not related to the use of hot tubs. The source of MAC in a 52-year-old immunocompetent patient was an intrapulmonary cyst containing numerous acid-fast bacilli. The patient developed disseminated miliary nodules throughout both lung fields. Histological examination of resected lung tissue revealed well-formed, acid-fast negative granulomas composed predominantly of CD4+ T-cells and CD68+ histiocytes. The granulomas were strongly positive for tumor necrosis factor-alpha, a pro-inflammatory cytokine. CONCLUSION: The attempt to classify MAC-associated pneumonitis as either a classic hypersensitivity pneumonitis or a direct manifestation of mycobacterial infection is not particularly useful. Our case demonstrates that MAC-associated pneumonitis is characterized by a vigorous T-helper 1-like, pro-inflammatory, immune response to pulmonary mycobacterial infection. The immunopathology provides a rationale for clinical studies of anti-MAC therapy with the addition of anti-inflammatory agents (for example, corticosteroids) to hasten the resolution of infection and symptoms

Chemotherapy for locally advanced and metastatic pulmonary carcinoid tumors

Objectives The optimal management of locally advanced and metastatic pulmonary carcinoid tumors remains to be determined. Materials and methods A retrospective review was conducted on patients with typical and atypical pulmonary carcinoid tumors treated at our institutions between 1990 and 2012. Results 300 patients were identified with pulmonary carcinoid, (80 patients with atypical carcinoid), of whom 29 presented with metastatic disease (16 atypical). Of evaluable patients, 26 (41%) with stages I–III atypical carcinoid tumors recurred at a median time of 3.7 years (range, 0.4–32), compared to 3 (1%) patients with typical carcinoid (range, 8–12.3). 39 patients were treated with chemotherapy, including 30 patients with metastatic disease (27 atypical), and 7 patients were treated with adjuvant platinum–etoposide chemoradiation (6 atypical, 1 typical, 6 stage IIIA, 1 stage IIB). At a median follow-up of 2 years there were 2 recurrences in the 7 patients receiving adjuvant treatment. Median survival after diagnosis of metastatic disease for patients with atypical pulmonary carcinoid was 3.3 years with a 5-year survival of 24%. Treatment regimens showing efficacy in pulmonary carcinoid include 15 patients treated with octreotide-based therapies (10% response rate (RR), 70% disease control rate (DCR), 15 month median progression-free survival (PFS)), 13 patients treated with etoposide + platinum (23% RR, 69% DCR, 7 month median PFS), and 14 patients treated with temozolomide-based therapies (14% RR, 57% DCR, 10 month median PFS). 8 of 10 patients with octreotide-avid disease treated with an octreotide-based regimen experienced disease control (1 partial response, 7 stable disease) for a median of 18 months (range 6–72 months). Conclusions These results support our previous finding that a subset of pulmonary carcinoid tumors are responsive to chemotherapy

Changed utterly? continuity and change in the regulation of Irish identities

The Supreme Court decision of A.O. & D.L. v. Minister for Justice [Lobe] and the Irish Citizenship Referendum of 2004 had the cumulative effect of restricting both the rights associated with Irish citizenship and the class of persons entitled to possess it. This thesis considers the dynamics underpinning those restrictions. The history of the regulation of Irish identities is not simply a story of ever tightening border controls. The Nineteenth Amendment to the Constitution of Ireland in 1998 seemingly widened the class of person entitled to call themselves Irish. Moreover, the Republic of Ireland\u27s membership of the European Union has reduced the state\u27s ability to exercise control over its borders and narrowed the distinction between Irish citizens and those of other EU countries. I argue that recent developments in the regulation of Irish identities demonstrate the Janus-like nature of modern law. Accepting the arguments advanced in Lobe and the Citizenship Referendum necessitates the embrace of contradiction, not rationality. They illustrate both continuity and change in the conception of what it means to be Irish. Measures to reduce perceived abuse of Irish citizenship seek to preserve a particular concept of Irishness and yet simultaneously serve to transform it. However, with its adherence to the creed of modernity - reason, objectivity, and the rejection of ambiguity - modern law cannot acknowledge these tensions

Changed utterly? continuity and change in the regulation of Irish identities

The Supreme Court decision of A.O. & D.L. v. Minister for Justice [Lobe] and the Irish Citizenship Referendum of 2004 had the cumulative effect of restricting both the rights associated with Irish citizenship and the class of persons entitled to possess it. This thesis considers the dynamics underpinning those restrictions. The history of the regulation of Irish identities is not simply a story of ever tightening border controls. The Nineteenth Amendment to the Constitution of Ireland in 1998 seemingly widened the class of person entitled to call themselves Irish. Moreover, the Republic of Ireland's membership of the European Union has reduced the state's ability to exercise control over its borders and narrowed the distinction between Irish citizens and those of other EU countries. I argue that recent developments in the regulation of Irish identities demonstrate the Janus-like nature of modern law. Accepting the arguments advanced in Lobe and the Citizenship Referendum necessitates the embrace of contradiction, not rationality. They illustrate both continuity and change in the conception of what it means to be Irish. Measures to reduce perceived "abuse" of Irish citizenship seek to preserve a particular concept of Irishness and yet simultaneously serve to transform it. However, with its adherence to the creed of modernity - reason, objectivity, and the rejection of ambiguity - modern law cannot acknowledge these tensions.Law, Peter A. Allard School ofGraduat

Changed utterly? continuity and change in the regulation of Irish identities

The Supreme Court decision of A.O. & D.L. v. Minister for Justice [Lobe] and the Irish Citizenship Referendum of 2004 had the cumulative effect of restricting both the rights associated with Irish citizenship and the class of persons entitled to possess it. This thesis considers the dynamics underpinning those restrictions. The history of the regulation of Irish identities is not simply a story of ever tightening border controls. The Nineteenth Amendment to the Constitution of Ireland in 1998 seemingly widened the class of person entitled to call themselves Irish. Moreover, the Republic of Ireland\u27s membership of the European Union has reduced the state\u27s ability to exercise control over its borders and narrowed the distinction between Irish citizens and those of other EU countries. I argue that recent developments in the regulation of Irish identities demonstrate the Janus-like nature of modern law. Accepting the arguments advanced in Lobe and the Citizenship Referendum necessitates the embrace of contradiction, not rationality. They illustrate both continuity and change in the conception of what it means to be Irish. Measures to reduce perceived abuse of Irish citizenship seek to preserve a particular concept of Irishness and yet simultaneously serve to transform it. However, with its adherence to the creed of modernity - reason, objectivity, and the rejection of ambiguity - modern law cannot acknowledge these tensions

Ataxia induced by a thymic neuroblastoma in the elderly patient

Thymic neuroblastoma is a rare tumor with only few reports in modern literature. Whereas most data is taken from childhood neuroblastoma, little is known about the characteristics of the disease in the adult and elderly population. There are significant differences between adult and childhood neuroblastoma which are reviewed below. We report a case of a 62-year-old male who presented with neurological symptoms of ataxia and opsoclonus and an anterior mediastinal mass. Ultimately, the patient underwent a resection of the mass and pathologic review identified a thymic neuroblastoma. This is the first case of thymic neuroblastoma associated with symptomatic central nervous system disease; it is presented with an up-to-date review of the previous cases in the field as well with a review of the literature of post adolescent neuroblastoma

Lessons from <it>Mycobacterium avium</it> complex-associated pneumonitis: a case report

Abstract Introduction Mycobacterium avium complex (MAC) is an increasingly recognized cause of pulmonary disease in immunocompetent individuals. An acute form of MAC lung disease, MAC-associated pneumonitis, has generally been associated with the use of hot tubs. There is controversy in the literature about whether MAC-associated pneumonitis is a classic hypersensitivity pneumonitis or is a direct manifestation of mycobacterial infection. Case presentation We report the second case in the literature of MAC-associated pneumonitis not related to the use of hot tubs. The source of MAC in a 52-year-old immunocompetent patient was an intrapulmonary cyst containing numerous acid-fast bacilli. The patient developed disseminated miliary nodules throughout both lung fields. Histological examination of resected lung tissue revealed well-formed, acid-fast negative granulomas composed predominantly of CD4+ T-cells and CD68+ histiocytes. The granulomas were strongly positive for tumor necrosis factor-α, a pro-inflammatory cytokine. Conclusion The attempt to classify MAC-associated pneumonitis as either a classic hypersensitivity pneumonitis or a direct manifestation of mycobacterial infection is not particularly useful. Our case demonstrates that MAC-associated pneumonitis is characterized by a vigorous T-helper 1-like, pro-inflammatory, immune response to pulmonary mycobacterial infection. The immunopathology provides a rationale for clinical studies of anti-MAC therapy with the addition of anti-inflammatory agents (for example, corticosteroids) to hasten the resolution of infection and symptoms.</p