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CLINICAL SECTION CLINICO-PATHOLOGICAL CONFERENCE -No' 7 * Postgrad Med J: first published as 10.1136/pgmj.26.299.494 on 1 September 1950. Downloaded from 494 POSTGRADUATE MEDICAL JOURNAL September 1950 test gives no indication whether the deficiency is Very small doses of thyroid, together with primarily pituitary or suprarenal. methyl testosterone, appear to have been of benefit The insulin sensitivity test was helpful in Cases in Cases 2 and 3, and are being used in Case 4. 3 and 4. This test is not without risk, even with Much of the improvement is subjective and in the smaller testing dose, and adequate preparation none of the' cases was there new hair growth or to have adrenaline and glucose by the bedside to recurrence of menarche. That subjective state of deal with the hypoglycaemic state are essential. well-being and new energy, accompanied objec- If the blood pressure is low before the test (as in tively by agility and the ability to do a day's work Case 3) quarter-hourly readings should be taken, and to enjoy it, as related by patient and witnessed and the test should be discontinued if either the by relatives, puts the whole problem of hypo- systolic blood pressure falls to 50 mm. Hg or below, pituitarism on a more than merely academic plane, or if the patient cannot be roused. The results of treatment are difficult to assess. and make the physician's efforts well worth while. It seems that some of these cases are sensitive My thanks are due to Dr. R. Sleigh Johnson, even to small doses of thyroid (as in Case 3), and under whom Cases i, 2 and 3 were admitted, and the optimum dose has to be discovered by clinical to Dr. T. Rowland Hill for Case 4, for permission observation, preferably in hospital, rather than as to publish these notes. Also to Drs. Thomas and an out-patient, with the risk of inducing an Williams of the Department of Pathology for adrenal crisis. advice and help readily given. BIBLIOGRAPHY FRAZER, RUSSELL, and SMITH, PATRICIA H. (1941), Quart. J. Med., 34 (N.S. IO), 297. SHEEHAN, H. L., and SUMMERS, V. K. (1949), Quart. J. Mea., Protected by copyright. i8, 3I9. SIMMONDS, M. (1914), Virchow's Arch., 217, 226. THORN, G. W. (1949), 'Diagnosis and Treatment of Adrenal Insufficiency.' Oxford: Blackwell. CLINICAL SECTION CLINICO-PATHOLOGICAL CONFERENCE -No' 7 * Sarcoidosis with Lung Cavitation http://pmj.bmj.com/ Clinical History (Dr. J. G. Scadding) child is well; the third in 1946 was complicated The case we have to consider today is that of by a retained placenta and haemorrhage, which a housewife who was aged 41 at the time of her necessitated manual removal of the placenta under deatht. anaesthesia, and blood transfusion. The child is In the family history there was nothing relevant well. She appears to have had no other serious to her illness, and she knew of no contact with illness previously. on September 29, 2021 by guest. cases of tuberculosis. She had had three preg- Her illness started insidiously after the birth of nancies, of which the first was in i940 with a the third child and the complications already difficult labour, the child dying at the age of 8 days noted. She thought that she had never felt well with convulsions; the second was in I943 and the since then, but no definite symptoms developed until June 1947, when she noticed pains in the joints, chiefly the fingers, the wrists, the elbows, *Held at the Postgraduate Medical School (Hammer- the shoulders, the jaw, the hips and the knees. smith Hospital) on June 21, ig5o. The report was illness assembled by Dr. Bernard Lennox. The photographs In February I948 she had an acute febrile are by Mr. E. V. Willmott and Mr. K. G. Moreman. diagnosed as broncho-pneumonia and was in bed for two weeks with this. Her cough appears to fThe clinical history of this case up to November 1949 has been briefly described by Scadding (I950), date from this illness, but it was not until July Brit. Med. Jt., I, 745 (Case i6). 1948 that it became troublesome with expectora- Postgrad Med J: first published as 10.1136/pgmj.26.299.494 on 1 September 1950. Downloaded from September 1950 Clinical Section 495 'b~~~~~~~~~~~~~~~~~ sill,2. -. .......................... Pp: OU < 3Po..... M; Protected by copyright. FIG. i.-Chest radiograph in June 1949. tion, which appears to have been purulent and at dyspnoea recurred soon after her discharge from first to have amounted to about 2 oz. a day. At hospital. this time the rheumatic pains in her joints im- She was referred to me at Brompton Hospital proved. About this time she started to become on June 23, 1949, by Dr. Edelston. The X-ray breathless and the breathlessness became gradually appearances at that time are shown in Fig. i. I http://pmj.bmj.com/ more severe. In February 1949 she was investi- arranged her admission to Hammersmith Hospital gated in the Bucklands Hospital, Dover. At this for investigation. time careful bacteriological examinations of the Her first admission was on July 2, I949. She sputum were made and the results of them have was thin, wasted and irregularly febrile, with an been very kindly supplied to us by Dr. H. Bowers, evening temperature usually between 990 and the pathologist at that hospital. On two occasions I000, but with bouts lasting up to ten days when examination of direct smears of her sputum showed the evening temperature might range between i000 on September 29, 2021 by guest. scanty acid-fast bacilli. The specimen from to I030. She had a very troublesome cough, and which one of these smears was made was cultured tended to sit upright afraid to move for fear of for tubercle bacilli with negative results. A third causing an exhausting bout of coughing. The specimen of sputum showed no acid-fast bacilli cough produced 3 oz. to 8 oz. of thick purulent on direct smear. Dr. B. G. Edelston, under whose sputum daily. One firm slightly enlarged lymph care the patient was at the Folkegtone Chest Clinic, node was palpable behind the inner end of the had other examinations of the sputum for tubercle right clavicle; this was the only superficial lymph bacilli made between August 1948 and June I949. node that was palpable. The chest showed on Nine direct examinations and three cultures were physical examination diminished movement, im- negative. While in hospital she was trated with paired percussion note and weak breath sounds penicillin with considerable symptomatic improve- over the right side, with rhonchi and rales all over ment, but the cough, purulent expectoration and both lungs. No abnormal signs were found else- Postgrad Med J: first published as 10.1136/pgmj.26.299.494 on 1 September 1950. Downloaded from 496 POSTGRADUATE MEDICAL JOURNAL September 1950 ..:.:....: ......... !M- I .. .. ..... .X FIG. 2.-Supraclavicular lymph node, July I949. A cluster of sarcoid tubercles on the periphery of the gland. Below and to the left is the edge of the mass of hyaline collagen which fills the bulk of the node. Post-mortem, the tubercles had disappeared and Protected by copyright. only the collagen remained in all the nodes examined. H. & E. FIG. 3.-Chest radiograph in August 1949. ' Spill- over' after postural drainage of the right side cavity has produced a smaller cavity in the left lung. http://pmj.bmj.com/ on September 29, 2021 by guest. FIG. 4.-Tomograph showing the new cavity of Fig. 3. FIGp5.-Right lateral tomograph showing the right upper lobe cavity. Postgrad Med J: first published as 10.1136/pgmj.26.299.494 on 1 September 1950. Downloaded from Scptember I950 Clinical Section 497 where. The chest radiograph showed no change .I from that taken at the Brompton Hospital. There was coarse mottling in both lungs with a large cavity on the right side, which in the lateral view appeared to have originated in the axillary sub- segment of the anterior or posterior segment of the upper lobe. Investigation. Rather complete investigations made, but only the relevant ones will be given here. The sputum gave a profuse growth of Str. pneumoniae on culture. Many examinations for tubercle bacilli, both directly and by culture, were negative. No fungi were found. The Mantoux test FIG. 6.-Olecranon nodules (September I949). was negative to io mg. of old tuberculin. A bron- choscopy showed reddening of the mucosa of the related to the sarcoidosis. The histology was right main bronchus with much purulent secretion, equivocal but favoured a rheumatoid lesion; the but no other abnormality. A biopsy of the palp- sub-dermal layer of the corium was heavily infil- able right supraclavicular lymph node (Fig. 2) trated with polymorphs and mononuclear cells showed a central mass of rather featureless col- arranged in groups and sheets. lagenous connective tissue with a small peripheral Although the sputum was much diminished in zone in which a number of characteristic non- amount, the organisms in it had by this time caseating tubercles were seen. Part of this lymph become penicillin-resistant, and fever irregularly node was inoculated into a guinea pig, but no up to i000 persisted. Accordingly, on September tubercle bacilli were found. i6 streptomycin in doses of i gm. daily was begun,Protected by copyright. On the basis of these findings a diagnosis of and was continued until go gm. had been given. sarcoidosis with extensive pulmonary involvement It was given partly to combat the penicillin- was made. It was thought that the cavity repre- resistant secondary infection and partly also with sented either a secondary pyogenic infection in an the idea that, if the sarcoidosis were of tuberculous emphysematous bulla or distension cyst secondary aetiology, the streptomycin might conceivably be to the fibrosis caused by a late stage of sarcoidosis, of some benefit to the underlying disease process.
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