Download Ricardo Blanco, Miguel A. Gonzalez

em 1996;22 (May)
BriefReports
Human brucellosis is commonly associated with musculoskeletal manifestations. Apart from sacroiliitis and spondylitis, peripheral arthritis presenting as monarthritis or asymetric peripheral
oligoarthritis has been commonly described [1]. However, to our
knowledge, the occurrence of a Baker's cyst as the first sign of
brucellosis has not been described. We feel that brucellosis must
be considered when a patient presents with a Baker's cyst and a
constitutional syndrome, especially if the patient has risk factors
for the development of this infectious disease.
Ricardo Blanco, Miguel A. Gonzalez-Gay, Jose Varela,
Rafael Monte, Amalia Sanchez-Andrade,
and Carmen Gonzalez-Vela
Divisions of Rheumatology and Infectious Diseases. Hospital XeralCalde, Lugo; and Division of Pathology. Hospital Marques de
Valdecilla, Santander. Spain
References
I.
Alarcon GS, Bocanegra TS, Gotuzzo E, Espinoza LR. The arthritis of
brucellosis: a perspective one hundred years after Bruce's discovery. J
Rheumatol 1987; 14:1083-5.
Tuberculosis-Related Retinal Vasculitis in an
Immunocompetent Patient
In recent years, tuberculosis has reemerged as a serious public
health problem [1], raising the possibility that rare manifestations
of the disease, such as ocular tuberculosis, may also become more
prevalent.
We describe a previously healthy 31-year-old man with retinal
vasculitis associated with systemic tuberculosis. Mycobacterium
tuberculosis was isolated from a cervical lymph node biopsy specimen and sputum. A test for antibody to HIV was negative. Ophthalmologic examination revealed normal visual acuity in both eyes.
Preretinal hemorrhage, exudates, and periphlebitis were observed
on the retina of the right eye (figure 1).
Behcet's syndrome, multiple sclerosis, systemic vasculitis, and
syphilis were clinically and biologically ruled out as potential
causes of retinal vasculitis. The patient was treated with a 6-month
regimen of isoniazid, rifampin, ethambutol, and pyrazinamide for
2 months followed by isoniazid and rifampin for 4 months. Prednisone (30 mg/d) was administered for 2 weeks as treatment for
retinal vasculitis. The patient immediately felt better, and his body
temperature returned to normal within 6 days of initiation of treatment. Three weeks later, examination ofthe fundus showed marked
abatement of the retinal vasculitis, but peripheral ischemic areas
had appeared. Preventive laser photocoagulation of these areas was
performed. Seven months after treatment was begun, fluorescein
angiography showed complete recovery and no residual lesions.
Reprints or correspondence: Dr. Gilles Raguin, Hopital de la Croix-SaintSimon, 125 rue d'Avron, 75960 Paris Cedex 20,France.
Clinical Infectious Diseases 1996; 22:873-4
© 1996 by The University ofChicago. All rights reserved.
1058-4838/9612205-0048$02.00
873
2. Cuende E, Barbadillo C, E-Mazzuehelli R,Isasi C,Trujillo A,Andreu JL.
Candida arthritis inadult patients who arenot intravenous drug addicts:
report ofthree cases and review oftheliterature. Semin Arthritis Rheum
1993; 22:224-41.
3. Austin KS, Testa NN, Luntz RK, Greene JB, Smiles S.Aspergillus infection oftotal knee arthroplasty presenting asa popliteal cyst: case report
and review of the literature. J Arthroplasty 1992; 7:311-4.
4. Ellis ME, el-Ramahi KM, al-Dalaan AN. Tuberculosis ofperipheral joints:
a dilemma in diagnosis. Tuber Lung Dis 1993;74:399-404.
5. Resnick D, Berthiaume MJ. Sartoris D. Imaging. In: Kelley WN, Harris
ED, Ruddy S, Sledge CB, eds. Textbook of rheumatology. Vol. I.
Baltimore: WB Saunders, 1993:598, 892.
6. Samanta A, Boyd 0, Roy S. An unusual presentation of Baker's cyst
in a patient with rheumatoid arthritis. Br J Rheumatol 1988;27:
500.
7. Anderson CJ, Cannon GW, Andrews JM. Gouty tophus presenting as
"pseudo-Baker's cyst" [letter]. J Rheumatol1989; 16:1281-2.
8. Meehan PL, Daftari T. Pigmented villonodular synovitis presenting as a
popliteal cyst in a child: a case report. J Bone Joint Surg Am
1994;76:593-5.
9. lsdale AH, Iveson JM. Synovial cysts and sarcoid synovitis. BrJ Rheumatol 1992; 31 :497 9.
10. Brancaccio D, Gallieni M, Padovese P, Anelli A, Coggi G, Uslenghi
C. Dialysis amyloidosis with massive popliteal deposition of beta 2mieroglobulin amyloid. Lancet 1988;2:802.
Retinal vasculitis may be primary or secondary to a variety of
systemic disorders [2]. It has been reported in association with
neurological diseases, systemic inflammatory diseases, malignancies, and infectious diseases such as syphilis, endocarditis, malaria,
toxoplasmosis, and fungal and viral infections. Samples of retinal
vasculitic lesions are usually not available for bacteriologic or
histologic examination. Therefore, the diagnosis of tuberculosisrelated retinal vasculitis on the basis of the clinical picture is
presumptive. In our case the systemic tuberculosis, the exclusion
of other possible etiologies, and the favorable evolution of the
Fluorescein angiogram of the right eye of a 31-yearold man with retinal vasculitis associated with systemic tuberculosis
revealeda hemorrhage and exudate (A) and a periphlebitic lesion (B).
Figure 1.
874
Brief Reports
patient's condition with specific treatment made this diagnosis
most probable. To our knowledge, all reported cases oftuberculosis-related retinal vasculitis involved symptomatic patients with
loss of vision who were referred to ophthalmologists. Our case is
remarkable for the identification of retinal vasculitis at a stage
when no visual impairment had occurred. This identification allowed early specific ocular treatment.
The pathogenesis of tuberculosis-related retinal vasculitis is still
unresolved. Two major mechanisms could be implicated. One involves an infectious process; the hypothesis suggests that tuberculous bacilli are directly responsible for the observed lesions. This
mechanism seems probable when tubercles are present on the choroid. However, when no specific ocular lesions are seen, it is
uncertain whether vasculitie lesions contain active bacilli. The
alternative hypothesis states that hypersensitivity mechanisms are
responsible for the observed vasculitis [3, 4]. These two models
are not mutually exclusive and, whatever the actual mechanism,
the treatment remains the same. The appropriate treatment consists
of administration of antituberculous agents, usually in association
with systemic corticosteroid therapy and photocoagulation of the
retina if required. Following treatment, the evolution of the condition is usually favorable. However, after initial substantial abatement of the vaculitis, secondary neovascularization and vitreous
Bacteremia and Hemoptysis Due to an Infected False
Left Ventricular Aneurysm Associated with a
Bronchoventricular Fistula
Hemoptysis in a bacteremic patient may present a diagnostic
dilemma: this complication may represent a secondary inflammation of the airway, septic pulmonary emboli, or, rarely, a mycotic
aneurysm of a bronchial artery. We present a case of massive
hemoptysis due to a false aneurysm ofthe left ventricle that became
secondarily infected with Staphylococcus aureus and fistulized into
the bronchial tree 10 years after a cardiac injury.
A 43-year-old male iv drug user presented with acute onset of
fever and moderate hemoptysis without associated chest pain or
shortness of breath. His medical history revealed a penetrating
chest wound and cardiac injury that had been repaired 10 years
earlier. In addition, 4 months before the onset of hemoptysis, he
developed methicillin-resistant S. aureus (MRSA) bacteremia and
osteomyelitis of the left hip that were treated with a 6-week course
of vancomycin at another facility.
Physical examination showed the patient to be alert, oriented,
and in no distress. His temperature was 39.4°C; blood pressure,
136/80 mm Hg; pulse rate, 102; and respiratory rate, 20. The rest
of the examination was unremarkable except for tenderness in the
left groin and decreased range of motion in the hip. All four blood
cultures that were performed over a 3-day period were positive
Reprints or correspondence: Dr. Riad Khatib, Medical Education Office, St.
John Hospital and Medical Center, 22101 Moross Road, Detroit, Michigan
48236.
Clinical Infectious Diseases 1996;22:874-5
© 1996 by The University of Chicago. All rights reserved.
1058-4838/96/2205-0049$02.00
CID 1996;22 (May)
hemorrhage have been described [4]. Therefore, until complete
recovery, ophthalmologic follow-up is required.
Even though it is a rare complication of systemic tuberculosis
[5], retinal vasculitis should be searched for in this era of recurrence of tuberculosis. Indeed, retinal tuberculosis may have serious
consequences for the patient if the diagnosis and appropriate treatment are delayed. A biomicroscopic eye evaluation is a rapid,
sensitive, nonaggressive, low-cost procedure; it should therefore
be a routine means of examination of tuberculous patients.
Jean L. Reny, Georges ChaUe, Philippe Geisert, Jean Aerts,
Jean M. Ziza, and Gilles Raguin
Service de Medecine Interne et Maladies Infectieuses,
Hopital de la Croix-Saint-Simon, Paris, France
References
I. Comstock GW. Variability of tuberculosis trends in a time of resurgence.
Clin Infect Dis 1994; 19:1015-22.
2. Vine AK. Retinal vasculitis. Semin Neurol 1994; 14:354-60.
3. Helm CG, Holland GN. Ocular tuberculosis. Surv Ophthalmol 1993;
38:229·56.
4. Rosen PH, Spalton OJ, Graham EM. Intraocular tuberculosis. Eye 1990;
4:486-92.
5. Donahue He. Ophthalmologic experience in a tuberculous sanatorium. Am
J Ophthalmol 1967;64:742-8.
for MRSA. His chest roentgenogram showed a density adjacent
to the left heart border.
Initially, he was suspected of having pulmonary emboli secondary to septic thrombophlebitis ofthe left femoral vein in association
with septic arthritis of the left hip. However, a pulmonary angiogram did not show any abnormalities. He defervesced while receiving vancomycin therapy, and his condition seemed to improve,
but occasional scant hemoptysis persisted. Bronchoscopic evaluation of his airway showed bloody secretions in the left lower
lobe, without any obvious intrabronchial defect. A transthoracic
echocardiogram demonstrated a cystic lesion (4.5 X 6 em) posterolateral to the left ventricle. A CT scan of the chest showed that
this lesion represented two contiguous masses (10 X 5 em) that
were associated with the ventricle (figure 1). Ventriculography
illustrated mild left ventricular enlargement with evidence of anteroapical akinesis and flow into the adjacent mass, consistent with
a false aneurysm.
On the tenth hospital day, the patient underwent surgery after
he developed massive hemoptysis (about I pint of blood), shortness
of breath, and hypotension (systolic blood pressure, 80-100 mm
Hg; diastolic blood pressure, 45-55 mm Hg). Evidence of an old,
healed anterior wound was noted in the left ventricle. The inferior
wall had a defect (1.5 X 1.5 ern) leading to a large aneurysmal
sac with a chronic thrombus in the exposed left ventricle. Culture
of the thrombus yielded MRSA. The patient was treated with
a 56-day course of vancomycin and gentamicin (peak levels of
gentamicin, 3 j.lg/mL). His left hip was resected because of persistent disabling pain (culture of the resected bone yielded MRSA),
and eventually he was discharged. He was well at a 6-month
follow-up examination.
False aneurysm is a known complication of traumatic cardiac
injuries [1- 3]. It may be associated with a variety of symptoms
or may cause sudden death. It may also be asymptomatic and
be detected during a routine follow-up examination. Our patient