BackgroundPulmonary tumour thrombotic microangiopathy (PTTM) is a rare complication of metastatic cancer with a distinct histological appearance which presents with dyspnoea and pulmonary arterial hypertension and leads to death in hours to days. It is a challenging diagnosis to make ante mortem, in part due to the rapid clinical decline. Herein, we report a case of a young woman initially felt to have pulmonary sarcoidosis but who then died eight days later from what was found at post mortem to be PTTM.Case presentationA 41 year old Caucasian woman presented with progressive dyspnoea. Computed tomography of her thorax showed diffuse tiny centrilobular nodules in a tree-in-bud appearance along with small volume mediastinal lymphadenopathy. A presumptive diagnosis of pulmonary sarcoidosis was made; bronchoscopy with transbronchial lung biopsy was arranged to confirm the diagnosis. However, she rapidly deteriorated and died eight days later. Post mortem examination revealed metastatic poorly differentiated gastric adenocarcinoma with PTTM being the final cause of death.ConclusionThis case demonstrates the diagnostic difficulties in such a rare and rapidly fatal oncological complication; a greater awareness amongst clinicians may help make a positive diagnosis in the short window of time available. Little is known about its pathogenesis, and even less about optimal management strategies. We review the literature to demonstrate the clinical characteristics that might provide clues towards an ante mortem diagnosis, and highlight how imatinib may provide the key to treating PTTM.
BackgroundThe Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.MethodsA total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source.ResultsMale gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ≤350 cells/μl) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/μl (adjusted OR 2.15, 95% CI 1.28 – 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 – 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services.ConclusionThe community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.
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