Abstracts
Tuberculosis and cryptococcosis are infectious diseases that can result in the formation of single or multiple nodules in immunocompetent patients. Exposure to silica is known to raise the risk of infection with Mycobacterium tuberculosis. We report the case of an elderly man with no history of opportunistic infections and no clinical evidence of immunodeficiency but with a six-month history of dry cough and nocturnal wheezing. A chest X-ray revealed a mass measuring 5.0 × 3.5 cm in the right upper lobe. The diagnostic approach of the mass revealed tuberculosis. The histopathological analysis of the surrounding parenchyma reveled silicosis and cryptococcosis. Cryptococcosis was also found in masses identified in the mediastinal lymph nodes. The surgical approach was indicated because of the degree of pleuropulmonary involvement, the inconclusive results obtained with the invasive and noninvasive methods applied, and the possibility of malignancy. This case illustrates the difficulty inherent to the assessment of infectious or inflammatory pulmonary pseudotumors, the differential diagnosis of which occasionally requires a radical surgical approach. Despite the presence of respiratory symptoms for six months, the first chest X-ray was performed only at the end of that period. We discuss the possible pathogenic mechanisms that might have led to the combination of three types of granulomatous lesions in the same lobe, and we emphasize the need for greater awareness of atypical presentations of pulmonary tuberculosis.
Tuberculosis, pulmonary; Mass chest X-ray; Silicosis; Cryptococcosis
A tuberculose e a criptococose são infecções que podem cursar com a formação de nódulos isolados ou múltiplos em pacientes imunocompetentes. A exposição à sílica reconhecidamente eleva o risco de doença pelo Mycobacterium tuberculosis. Apresentamos o caso de um paciente idoso sem antecedentes de infecções oportunistas, sem evidência clínica atual de imunodeficiência, com história de tosse seca e sibilos, principalmente noturnos, com duração de seis meses, cuja radiografia de tórax evidenciava uma imagem tumoral medindo 5,0 × 3,5 cm em lobo superior do pulmão direito. A abordagem diagnóstica da massa evidenciou tratar-se de tuberculose, e a análise histopatológica do parênquima circunvizinho revelou a presença de criptococose e de silicose. Criptococose foi diagnosticada também em massas linfonodais mediastinais. A conduta cirúrgica foi imposta pelo grau de comprometimento pleuropulmonar localizado, pelo caráter inconclusivo das abordagens diagnósticas invasivas e não invasivas realizadas, assim como pela possibilidade de tratar-se de neoplasia. Este caso ilustra a dificuldade inerente ao diagnóstico diferencial de massas pulmonares de natureza infecciosa ou inflamatória simulando neoplasia, o que ocasionalmente impõe uma conduta cirúrgica radical. Apesar da presença de sintomas respiratórios por seis meses, a primeira radiografia do tórax só foi realizada tardiamente. São discutidos os possíveis mecanismos patogenéticos que possam ter levado a associação de três tipos de granulomatose no mesmo lobo pulmonar e é enfatizada a necessidade de uma maior divulgação das apresentações atípicas da tuberculose pulmonar.
Tuberculose pulmonar; Radiografia pulmonar de massa; Silicose; Criptococose
Introduction
Although the World Health Organization estimates that the overall tuberculosis incidence
rate has been declining since 2004,(
11. Tuberculosis global facts 2010/2011. Cent Eur J Public Health.
2010;18(4):197. PMid:21361102
) the high prevalence of the disease worldwide, especially in tropical
countries, is still responsible for a high number of deaths and the segregation of
individuals with debilitating sequelae.(
22. Hijjar MA, Procópio MJ, de Freitas LM, Guedes R, Bethlem EP.
Epidemiologia da tuberculose: importância no mundo, no Brasil e no Rio de Janeiro.
Pulmão RJ. 2005;14(4):310-4.
) The classic symptoms of pulmonary tuberculosis consist of dry or productive
cough, asthenia, anorexia, fever, and weight loss, which, when associated with certain
radiological patterns,(
33. Bombarda S, Fiqueiredo CM, Funari MBG, Soares Jr J, Seiscento M,
Terra-Filho M. Imagem em tuberculose pulmonar. J Pneumol. 2001;27(6):329-40.
http://dx.doi.org/10.1590/S0102-35862001000600007
http://dx.doi.org/10.1590/S0102-35862001...
,
44. Capone D, Jansen JM, Lopes AJ, Sant'Anna CC, Soares MOT, Pinto RS, et
al. Diagnóstico por imagem da tuberculose pulmonar. Pulmão RJ.
2006;15(3):166-74.
) lead to a rapid diagnosis. However, certain, unusual, clinical and
radiological presentations or presentations associated with other, chronic, lung
diseases can make the etiologic diagnosis time-consuming and challenging.(
22. Hijjar MA, Procópio MJ, de Freitas LM, Guedes R, Bethlem EP.
Epidemiologia da tuberculose: importância no mundo, no Brasil e no Rio de Janeiro.
Pulmão RJ. 2005;14(4):310-4.
,
55. Lopes AJ, Jansen U, Capone D, Neves DD, Jansen JM. Diagnóstico de
falsos tumores do pulmão. Pulmão RJ. 2005;14(1):33-42.
) Among occupational diseases, silicosis is known to be a contributing factor
to pulmonary tuberculosis and other fungal infections.(
66. Iossifova Y, Bailey R, Wood J, Kreiss K. Concurrent silicosis and
pulmonary mycosis at death. Emerg Infect Dis. 2010;16(2):318-20.
http://dx.doi.org/10.3201/eid1602.090824 PMid:20113570 PMCid:PMC2958007
http://dx.doi.org/10.3201/eid1602.090824...
) Because of its opportunistic nature, tuberculosis is common in
immunocompromised patients.(
77. Conde MB, Melo FA, Marques AM, Cardoso NC, Pinheiro VG, Dalcin Pde T,
et al. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol.
2009;35(10):1018-48. PMid:19918635
) The development of tuberculosis depends on the known interaction between
the host immune status and the aggressiveness of the infectious agent, which is
expressed by virulence, concentration of agents, and ability to induce
hypersensitivity.(
88. Rich AR. Factores responsables de las características de las lesiones
tuberculosas y de los sintomas. In: Rich AR, Croxatto OG, editors. Patogenia de la
tuberculosis. Buenos Aires: Alfa; 1945. p. 609-73.
) In this context, it is necessary to consider the modifying effect of the
disease, which changes the life status of current populations, who benefit from better
nutrition, housing, and health conditions. Such changes include increased susceptibility
to infections in people living with HIV and increased resistance to infections in those
not living with HIV. Our objective was to report the case of an elderly male patient who
was oligosymptomatic and apparently immunocompetent. The patient was a former
construction worker. He underwent lobectomy because of a tumor mass in the right upper
lobe. Pathological examination revealed tuberculosis. In addition, silica infiltration
and cryptococcosis were found in the surrounding lung parenchyma, the latter being also
found in the mediastinal lymph nodes. The literature lacks information regarding
tuberculous pseudotumor.
Case report
We report the case of a 73-year-old White male patient who was a retired construction worker, having worked as a mason's assistant most of his economically active life. The patient was a former smoker (smoking history, 10 pack-years). Over a 6-month period, he had daily episodes of dry cough, dyspnea, and wheezing that improved, albeit partially, with the use of intravenous xanthine and an inhaled β2 agonist, having often sought emergency room treatment. The patient was referred to our hospital after the identification of a lung tumor on a chest X-ray. He reported no fever, chest pain, or bloodstained sputum. In addition, he reported weight loss (3 kg) during that period.
The patient had systemic arterial hypertension and reflux esophagitis, both of which were controlled. He reported no diabetes, dyslipidemia, chronic respiratory diseases, or contact with tuberculosis patients.
The patient reported no alcoholism. In addition, he reported that he had raised animals when he was young and that he had been exposed to smoke from wood-burning stoves until the age of 25 years.
Physical examination revealed good general health. The patient had pallor of the skin and mucosa, and his body mass index was 29.7 kg/m2. He was well hydrated and was breathing normally, having no jaundice or cyanosis. In addition, he had no digital clubbing or lymph node enlargement. Respiratory findings included increased anteroposterior chest diameter, normal breath sounds, and diffuse wheezing. Arterial oxygen saturation was 90% on room air. Cardiovascular and abdominal examination was normal. No leg edema, varicose veins, or ulcers were observed.
Spirometry revealed mild obstructive lung disease unresponsive to bronchodilators. The Mantoux tuberculin skin test (TST) was performed, and the induration was 15 mm. Counterimmunoelectrophoresis for antifungal serum antibodies was negative for cryptococcosis, aspergillosis, histoplasmosis, and paracoccidioidomycosis.
A CT scan of the chest (Figure 1) showed a hypodense tumor mass located in the right upper lobe and measuring 5.0 × 3.5 cm. The major axis of the mass was directed toward the pulmonary hilum.
Chest CT scan. In A, lung window. In B, mediastinal window. The lung mass showed no enhancement after contrast administration, being accompanied by a slight apical displacement of the right pulmonary hilum and by a few mediastinal lymph nodes with calcifications.
Wegener's granulomatosis was ruled out by negative antineutrophil cytoplasmic antibody test results associated with an absence of specific upper airway and nervous system symptoms.
Fiberoptic bronchoscopy was performed on two occasions, having shown extrinsic obstruction of the right upper lobe bronchus and its segmental bronchi. In addition, the bronchial mucosa appeared to be infiltrated. However, analysis of the biopsy samples was inconclusive, a surgical approach being therefore adopted.
The surgical specimen consisted of a cavitary mass in the right upper lobe (the contents of which were thick) and enlarged mediastinal lymph nodes.
Pathological examination of the mass revealed a dense chronic inflammatory infiltrate that was granulomatous and exudative, as well as extensive areas of caseous necrosis, fibrosis, and giant cell reaction (Figure 2); none of the various sections examined met histopathological criteria for malignancy. The presence of intracytoplasmic crystalloid structures in the adjacent lung parenchyma (as revealed by H&E staining) constituted evidence of silicosis (Figure 3). The mediastinal lymph nodes showed a marked chronic inflammatory infiltrate that was granulomatous and exudative, as well as extensive areas of necrosis, lymph node architecture being extensively effaced.
Pulmonary tuberculosis. Photomicrograph (H&E; magnification, ×100) showing caseous necrosis (upper half) and granulomatous inflammatory infiltrate containing lymphocytes, epithelioid macrophages, and numerous multinucleated giant cells (lower half). Ziehl-Neelsen staining and the Grocott-Gomori methenamine-silver stain technique were used in order to screen for AFB and fungi, respectively, and the results were negative for all histological slides.
Silicosis. Photomicrograph under polarized light (H&E; magnification, ×400) showing lung parenchyma with an area of inflammatory infiltrate containing lymphocytes and macrophages, the cytoplasm of which contained numerous elongated crystalloid structures that were bright under polarized light, being consistent with silicosis. Fibrotic regions, which were also associated with silicosis, were observed in other areas.
Serial histological sections were examined under oil immersion (total magnification, ×1,000). Ziehl-Neelsen staining and the Grocott-Gomori methenamine-silver stain technique were used in order to screen for AFB and fungi, respectively, and the results were negative for all histological slides. However, culture was positive for Mycobacterium tuberculosis.
The lung mass was tested in an automated culture system, and there was M. tuberculosis growth. In this technique, the tubes containing the biopsy material (classically macerated and decontaminated) are monitored in an automated culture system (BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960; Becton Dickinson, Sparks, MD, USA) for up to 42 days of incubation, and any microorganism growing in a given tube emits fluorescence detectable by the system sensors, which indicate the tube as positive. Ziehl-Neelsen staining was used in order to screen the positive material for AFB, and the material was cultured on Löwenstein-Jensen medium for approximately 10 days. Mycobacterial colonies were analyzed by polymerase chain reaction, which identified M. tuberculosis by insertion sequence IS6110. Culture of the lung tissue surrounding the mass was negative; the lymph node samples were lost.
Lung tissue and mediastinal lymph node samples were cultured on Sabouraud agar, Cryptococcus neoformans having been isolated after 72 h of incubation. For metabolic recovery of the yeast and identification of Cryptococcus sp., a subculture of that isolate was performed, also on Sabouraud agar. The genus and species were confirmed by the VITEK 2 Compact and 21343 YST Test Kit VTK 2 automated system (bioMérieux, Marcy I'Étoile, France). The turbidity of the final suspension of saline solution containing the isolated colonies was analyzed with a DensiCHEK Plus device (bioMérieux), the results being within the 1.80-2.20 range, as established by the manufacturer. A fragment of the lung mass was cultured, and the results were negative.
The patient received pharmacological treatment, being treated with a regimen of rifampin, hydrazide, pyrazinamide, and ethambutol for 2 months, followed by rifampin and hydrazide for 4 months, in accordance with current recommendations for the treatment of tuberculosis.( 77. Conde MB, Melo FA, Marques AM, Cardoso NC, Pinheiro VG, Dalcin Pde T, et al. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol. 2009;35(10):1018-48. PMid:19918635 ) In addition, he received itraconazole for 6 months.
At 5 months of pharmacological treatment for tuberculosis, the patient presented with a symmetric and painful increase in the mammary glands, which remained increased after the end of the treatment. We attribute this to a rare side effect of hydrazide, which has been reported by other authors.( 99. Morrone N, Morrone Junior N, Braz AG, Maia JA. Gynecomastia: a rare adverse effect of isoniazid. J Bras Pneumol. 2008;34(11):978-81. PMid:19099106 )
Discussion
In the case reported here, the primary lesion was identified by histology and culture as
tuberculous granuloma. In the context of pulmonary tuberculosis, parenchymal
pseudotumoral tuberculosis is considered rare in adults.(
1010. Agarwal R, Srinivas R, Aggarwal AN. Parenchymal pseudotumoral
tuberculosis: case series and systematic review of literature. Respir Med.
2008;102(3):382-9. http://dx.doi.org/10.1016/j.rmed.2007.10.017 PMid:18060757
http://dx.doi.org/10.1016/j.rmed.2007.10...
) Although host immunocompetence contributes to pulmonary cryptococcosis
presenting as nodules, such nodules are typically subpleural and smaller in size, as
described in guidelines published in 2008.(
1111. Moretti ML, Resende MR, Lazéra MS, Colombo AL, Shikanai-Yasuda MA.
Guidelines in cryptococcosis--2008 [Article in Portuguese]. Rev Soc Bras Med Trop.
2008;41(5):524-44. Erratum in: Rev Soc Bras Med Trop. 2008;41(6):695. PMid:19009203
) A low level of symptoms is not uncommon, being found in cases of
tuberculosis(
1010. Agarwal R, Srinivas R, Aggarwal AN. Parenchymal pseudotumoral
tuberculosis: case series and systematic review of literature. Respir Med.
2008;102(3):382-9. http://dx.doi.org/10.1016/j.rmed.2007.10.017 PMid:18060757
http://dx.doi.org/10.1016/j.rmed.2007.10...
) and in approximately 25% of all cases of cryptococcosis(
1111. Moretti ML, Resende MR, Lazéra MS, Colombo AL, Shikanai-Yasuda MA.
Guidelines in cryptococcosis--2008 [Article in Portuguese]. Rev Soc Bras Med Trop.
2008;41(5):524-44. Erratum in: Rev Soc Bras Med Trop. 2008;41(6):695. PMid:19009203
) in immunocompetent patients. Nevertheless, in the present case, the finding
of cryptococcosis widely present in the mediastinal lymph nodes and sparsely present in
the lung parenchyma prompted a reassessment of the immune status of the patient. His
immunocompetence was evidenced by a negative HIV test (ELISA) result, normal serum
immunoglobulin levels, a negative antinuclear factor test result, a negative rheumatoid
factor test result, a high proportion of nitroblue tetrazolium-positive cells
(spontaneous, 55 %; stimulated, 71%), and normal levels of CD4 and CD8 lymphocytes. The
concomitant presence of those two processes in a single lung lobe, which was also
affected by silica infiltration and right apical mediastinal and pleural involvement,
mimicked the radiological appearance of a lung neoplasm. Although the conflict involving
the differential diagnosis of lung masses in view of the possibility of malignancy is
well known, the present case is unusual because of the capricious combination of common
and severe diseases, as well as because of the difficulty in identifying the etiologic
agents. This difficulty is due to the intrinsic characteristic of these infectious
lesions; they have a low concentration of agents, which stands in contrast with the host
immune response. Pulmonary pseudotumoral tuberculosis in adults has been defined by the
presence of one or more masses in the parenchyma, such masses being caused by M.
tuberculosis and arising as a primary or post-primary process. The
pathological material, consisting of coalescing pulmonary infiltrates and caseous
necrosis resulting from the presence of M. tuberculosis in the airways,
can achieve large tumor size and only later reach the bronchial lumen,(
1010. Agarwal R, Srinivas R, Aggarwal AN. Parenchymal pseudotumoral
tuberculosis: case series and systematic review of literature. Respir Med.
2008;102(3):382-9. http://dx.doi.org/10.1016/j.rmed.2007.10.017 PMid:18060757
http://dx.doi.org/10.1016/j.rmed.2007.10...
) generating cavities and causing elimination of sputum potentially
containing bacilli. The combination of an atypical radiological presentation of
pulmonary tuberculosis with a lack of classic symptoms and expected symptoms of an
infectious disease producing pulmonary necrosis might be related to advanced
age.(
1212. Pérez-Guzmán C, Vargas MH, Torres-Cruz A, Villarreal-Velarde H. Does
aging modify pulmonary tuberculosis?: A meta-analytical review. Chest.
1999;116(4):961-7. http://dx.doi.org/10.1378/chest.116.4.961 PMid:10531160
http://dx.doi.org/10.1378/chest.116.4.96...
) However, in a recent series of eight cases of pulmonary pseudotumoral
tuberculosis,(
1010. Agarwal R, Srinivas R, Aggarwal AN. Parenchymal pseudotumoral
tuberculosis: case series and systematic review of literature. Respir Med.
2008;102(3):382-9. http://dx.doi.org/10.1016/j.rmed.2007.10.017 PMid:18060757
http://dx.doi.org/10.1016/j.rmed.2007.10...
) the mean age was 36.0 ± 13.6 years; all patients reported a history of dry
cough and had a Mantoux TST induration of 15-25 mm (as did our patient), whereas only
two reported a history of fever and hemoptysis, another two having reported
constitutional symptoms. It has been argued that atypical tuberculous lesions possibly
represent delayed presentation of primary infection.(
1313. Choyke PL, Sostman HD, Curtis AM, Ravin CE, Chen JT, Godwin JD, et
al. Adult-onset pulmonary tuberculosis. Radiology. 1983;148(2):357-62. PMid:6867325
) This should be taken into consideration in view of improvements in the
health and living conditions of certain populations, as well as of programs to prevent
and combat the disease. However, in the present case, the positive TST result-which
represents effective specific immunity-and the apical location of the lesion are
suggestive of secondary tuberculosis, which therefore results from the reactivation of
quiescent foci resulting from the primary infection or from exogenous reinfection. In
Brazil, lung lesions of less than 3 cm in diameter are likely to be diagnosed as
tuberculoma, whereas tuberculous lesions the size of lung masses have rarely been
reported and are limited to examples of radiological images.(
33. Bombarda S, Fiqueiredo CM, Funari MBG, Soares Jr J, Seiscento M,
Terra-Filho M. Imagem em tuberculose pulmonar. J Pneumol. 2001;27(6):329-40.
http://dx.doi.org/10.1590/S0102-35862001000600007
http://dx.doi.org/10.1590/S0102-35862001...
4. Capone D, Jansen JM, Lopes AJ, Sant'Anna CC, Soares MOT, Pinto RS, et
al. Diagnóstico por imagem da tuberculose pulmonar. Pulmão RJ.
2006;15(3):166-74.
-
55. Lopes AJ, Jansen U, Capone D, Neves DD, Jansen JM. Diagnóstico de
falsos tumores do pulmão. Pulmão RJ. 2005;14(1):33-42.
,
1414. Pereira BA, Macedo SG, Nogueira RA, Castiel LCP, Penna CR. Aspectos
tomográficos da consolidação lobar na tuberculose pulmonar primária. Radiol Bras.
2009;42(2):109-13. http://dx.doi.org/10.1590/S0100-39842009000200009
http://dx.doi.org/10.1590/S0100-39842009...
) This possibly contributed to our decision to focus on lung cancer in the
present case, given that it is quite common in elderly patients with no comorbidities.
In our patient, the histopathological finding of silicosis was surprising because of the
type of exposure, which is not among the most common risks(
1515. Neto FK, Gronchi CC, Saad IF, da Cunha IA, Possebon J, Teixeira MM,
et al. Sílica: manual do trabalhador. São Paulo: Fundacentro; 1995.
) and which did not allow radiological recognition. This, however, does not
rule out a strong correlation with tuberculosis. Although the mechanisms involved have
yet to be fully elucidated, the relationship between chronic exposure to silica (even in
the absence of silicosis) and an increased risk of developing tuberculosis is a harsh
reality that is well documented in the literature.(
1616. Leung CC, Yu IT, Chen W. Silicosis. Lancet. 2012;379(9830):2008-18.
http://dx.doi.org/10.1016/S0140-6736(12)60235-9
http://dx.doi.org/10.1016/S0140-6736(12)...
17. Barboza CE, Winter DH, Seiscento M, Santos Ude P, Terra Filho M.
Tuberculosis and silicosis: epidemiology, diagnosis and chemoprophylaxis. J Bras
Pneumol. 2008;34(11):959-66. http://dx.doi.org/10.1590/S1806-37132008001100012
PMid:19099104
http://dx.doi.org/10.1590/S1806-37132008...
-
1818. Rees D, Murray J. Silica, silicosis and tuberculosis. Int J Tuberc
Lung Dis. 2007;11(5):474-84. PMid:17439668
) The risk of developing tuberculosis has a direct relationship with the
burden of exposure and, possibly, the duration of exposure (even if individuals are no
longer exposed).(
1919. Corbett EL, Churchyard GJ, Clayton T, Herselman P, Williams B, Hayes
R, et al. Risk factors for pulmonary mycobacterial disease in South African gold
miners. A case-control study. Am J Respir Crit Care Med. 1999;159(1):94-9.
http://dx.doi.org/10.1164/ajrccm.159.1.9803048 PMid:9872824
http://dx.doi.org/10.1164/ajrccm.159.1.9...
)
The guidelines for the diagnosis of lung masses require that physicians be able to
discriminate between malignant and benign lesions in order to avoid delays in the
treatment of a malignant process or inadvertent interference with a benign
process.(
55. Lopes AJ, Jansen U, Capone D, Neves DD, Jansen JM. Diagnóstico de
falsos tumores do pulmão. Pulmão RJ. 2005;14(1):33-42.
,
2020. da Silva GA, Manco JC, Terra Filho J, Glass H, Soares FA. Mass on
chest X-ray. Postgrad Med J. 1997;73(862):515-7.
http://dx.doi.org/10.1136/pgmj.73.862.515 PMid:9307749 PMCid:PMC2431376
http://dx.doi.org/10.1136/pgmj.73.862.51...
) Therefore, physicians should rely on all available diagnostic methods,
including invasive methods.(
55. Lopes AJ, Jansen U, Capone D, Neves DD, Jansen JM. Diagnóstico de
falsos tumores do pulmão. Pulmão RJ. 2005;14(1):33-42.
) An analysis of the chain of increasingly complex interventions required for
diagnosing an uncommon presentation of pulmonary tuberculosis under aggravating
conditions shows the need for wider dissemination of information on atypical forms of
pulmonary tuberculosis and their respective outcomes.
References
-
1Tuberculosis global facts 2010/2011. Cent Eur J Public Health. 2010;18(4):197. PMid:21361102
-
2Hijjar MA, Procópio MJ, de Freitas LM, Guedes R, Bethlem EP. Epidemiologia da tuberculose: importância no mundo, no Brasil e no Rio de Janeiro. Pulmão RJ. 2005;14(4):310-4.
-
3Bombarda S, Fiqueiredo CM, Funari MBG, Soares Jr J, Seiscento M, Terra-Filho M. Imagem em tuberculose pulmonar. J Pneumol. 2001;27(6):329-40. http://dx.doi.org/10.1590/S0102-35862001000600007
» http://dx.doi.org/10.1590/S0102-35862001000600007 -
4Capone D, Jansen JM, Lopes AJ, Sant'Anna CC, Soares MOT, Pinto RS, et al. Diagnóstico por imagem da tuberculose pulmonar. Pulmão RJ. 2006;15(3):166-74.
-
5Lopes AJ, Jansen U, Capone D, Neves DD, Jansen JM. Diagnóstico de falsos tumores do pulmão. Pulmão RJ. 2005;14(1):33-42.
-
6Iossifova Y, Bailey R, Wood J, Kreiss K. Concurrent silicosis and pulmonary mycosis at death. Emerg Infect Dis. 2010;16(2):318-20. http://dx.doi.org/10.3201/eid1602.090824 PMid:20113570 PMCid:PMC2958007
» http://dx.doi.org/10.3201/eid1602.090824 -
7Conde MB, Melo FA, Marques AM, Cardoso NC, Pinheiro VG, Dalcin Pde T, et al. III Brazilian Thoracic Association Guidelines on tuberculosis. J Bras Pneumol. 2009;35(10):1018-48. PMid:19918635
-
8Rich AR. Factores responsables de las características de las lesiones tuberculosas y de los sintomas. In: Rich AR, Croxatto OG, editors. Patogenia de la tuberculosis. Buenos Aires: Alfa; 1945. p. 609-73.
-
9Morrone N, Morrone Junior N, Braz AG, Maia JA. Gynecomastia: a rare adverse effect of isoniazid. J Bras Pneumol. 2008;34(11):978-81. PMid:19099106
-
10Agarwal R, Srinivas R, Aggarwal AN. Parenchymal pseudotumoral tuberculosis: case series and systematic review of literature. Respir Med. 2008;102(3):382-9. http://dx.doi.org/10.1016/j.rmed.2007.10.017 PMid:18060757
» http://dx.doi.org/10.1016/j.rmed.2007.10.017 -
11Moretti ML, Resende MR, Lazéra MS, Colombo AL, Shikanai-Yasuda MA. Guidelines in cryptococcosis--2008 [Article in Portuguese]. Rev Soc Bras Med Trop. 2008;41(5):524-44. Erratum in: Rev Soc Bras Med Trop. 2008;41(6):695. PMid:19009203
-
12Pérez-Guzmán C, Vargas MH, Torres-Cruz A, Villarreal-Velarde H. Does aging modify pulmonary tuberculosis?: A meta-analytical review. Chest. 1999;116(4):961-7. http://dx.doi.org/10.1378/chest.116.4.961 PMid:10531160
» http://dx.doi.org/10.1378/chest.116.4.961 -
13Choyke PL, Sostman HD, Curtis AM, Ravin CE, Chen JT, Godwin JD, et al. Adult-onset pulmonary tuberculosis. Radiology. 1983;148(2):357-62. PMid:6867325
-
14Pereira BA, Macedo SG, Nogueira RA, Castiel LCP, Penna CR. Aspectos tomográficos da consolidação lobar na tuberculose pulmonar primária. Radiol Bras. 2009;42(2):109-13. http://dx.doi.org/10.1590/S0100-39842009000200009
» http://dx.doi.org/10.1590/S0100-39842009000200009 -
15Neto FK, Gronchi CC, Saad IF, da Cunha IA, Possebon J, Teixeira MM, et al. Sílica: manual do trabalhador. São Paulo: Fundacentro; 1995.
-
16Leung CC, Yu IT, Chen W. Silicosis. Lancet. 2012;379(9830):2008-18. http://dx.doi.org/10.1016/S0140-6736(12)60235-9
» http://dx.doi.org/10.1016/S0140-6736(12)60235-9 -
17Barboza CE, Winter DH, Seiscento M, Santos Ude P, Terra Filho M. Tuberculosis and silicosis: epidemiology, diagnosis and chemoprophylaxis. J Bras Pneumol. 2008;34(11):959-66. http://dx.doi.org/10.1590/S1806-37132008001100012 PMid:19099104
» http://dx.doi.org/10.1590/S1806-37132008001100012 -
18Rees D, Murray J. Silica, silicosis and tuberculosis. Int J Tuberc Lung Dis. 2007;11(5):474-84. PMid:17439668
-
19Corbett EL, Churchyard GJ, Clayton T, Herselman P, Williams B, Hayes R, et al. Risk factors for pulmonary mycobacterial disease in South African gold miners. A case-control study. Am J Respir Crit Care Med. 1999;159(1):94-9. http://dx.doi.org/10.1164/ajrccm.159.1.9803048 PMid:9872824
» http://dx.doi.org/10.1164/ajrccm.159.1.9803048 -
20da Silva GA, Manco JC, Terra Filho J, Glass H, Soares FA. Mass on chest X-ray. Postgrad Med J. 1997;73(862):515-7. http://dx.doi.org/10.1136/pgmj.73.862.515 PMid:9307749 PMCid:PMC2431376
» http://dx.doi.org/10.1136/pgmj.73.862.515
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*
Study carried out at the University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil.
Publication Dates
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Publication in this collection
Sep-Oct 2013
History
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Received
27 July 2012 -
Accepted
25 Jan 2013