Letter to the Editor
Thoracic paraganglioma diagnosed in a patient with pulmonary tuberculosis – Case report
Paraganglioma torácico diagnosticado num paciente com tuberculose pulmonar – descrição de caso clínico
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A solid and poorly differentiated malignant neoplasm with extensive areas of necrosis (A – HE 200×). The tumor cells had abundant eosinophilic cytoplasm and round nuclei with evident nucleoli (B – HE 600×). Immunohistochemically, the neoplastic cells focally expressed vimentin (C – 600×) and synaptophysin (D – 600×) in the absence of epithelial and other markers (AE1/AE3, CK8/18, CK7, CK20, CK5, 34β12, EMA,TTF1, napsin-A, p63, calretinin, pS100, CD31, CD34, PLAP, beta-HCG, CD45, CD20, CD10, inhibin, C-kit, CD99, actin, desmin, GFAP, CD30, CD21, HMB45, CD56, CD23, alpha-fetoprotein, myeloperoxidase, lysozyme, WT1, ALK, HepPar-1). With those morphological and immunohistochemical characteristics in the appropriate clinical context, the diagnostic hypothesis of paraganglioma/pheochromocytoma was suggested.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.F. Cruz, L. Iglésias, M. Monteiro, M.J. Santos, T. Pimentel, R.P. 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Cruz, L. Iglésias, M. Monteiro, M.J. Santos, T. Pimentel, R.P. Silva" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.F." "apellidos" => "Cruz" "email" => array:1 [ 0 => "joaoffcruz@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Iglésias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Monteiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M.J." "apellidos" => "Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "T." "apellidos" => "Pimentel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "R.P." "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Serviço de Pneumologia, Hospital de Braga, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Medicina Interna, Hospital de Braga, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Serviço de Endocrinologia, Hospital de Braga, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Serviço de Anatomia Patológica, Hospital de São João, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Paraganglioma torácico diagnosticado num paciente com tuberculose pulmonar – descrição de caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 1400 "Tamanyo" => 195388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest radiography: heterogeneous infiltration in the right upper lobe and homogeneous opacity in the left hilar region. (B)–(D) Chest Computed Tomography of the thorax: hypodense mass of 9<span class="elsevierStyleHsp" style=""></span>cm with well defined margins located in the mediastinum with extension to the left upper lobe, areas of consolidation in the right upper lobe associated with micro-nodular infiltration and ground-glass opacities.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paragangliomas are rare tumors with an incidence of 0.3–0.95% of neuroendocrine tumors, which arise from specialized neural crest cells associated with autonomic ganglia (paraganglia) 1. Nearly 90% of these tumors arise from the medulla of the adrenal gland and are called “pheochromocytomas”. When they have an extra-adrenal origin, they are termed “paragangliomas”. Intrathoracic location is infrequent, corresponding only to 10% of paraganglioma cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Herein the authors described the case of a 50-year-old male patient, Caucasian, smoker. As a background he had arterial hypertension and discoid lupus erythematosus. His usual medication was candesartan 16<span class="elsevierStyleHsp" style=""></span>mg, deflazacort 3<span class="elsevierStyleHsp" style=""></span>mg/day and chloroquine 250<span class="elsevierStyleHsp" style=""></span>mg/day. He presented in our hospital complaining of dyspnea, cough, asthenia and weight loss with three weeks evolution. His physical exam was unremarkable, except for malar and cervical cutaneous rash related to his discoid lupus. Chest X-ray and computed tomography showed pulmonary infiltrations in the right upper lobe and a mediastinic mass of 9<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Abdominal CT did not show any abnormalities. Sputum analysis confirmed a diagnosis of pulmonary tuberculosis and the patient started anti-tuberculosis treatment. His HIV and hepatitis virus status were negative. Bronchoalveolar samples were negative for malignancy and CT-guided transthoracic core biopsy of the mediastinal mass only showed necrotic tissue, so the patient underwent a surgical lung biopsy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Despite treatment, clinical evolution was not favorable, with persistent fever, one episode of auricular flutter and hemodynamic instability. Antibacillary susceptibility testing revealed resistance to all first class drugs. At the 45th day of admission, patient developed an acute pulmonary edema with no response to medical treatment and he eventually died. Description of the surgical biopsy was only available post-mortem and suggested the diagnosis of a pheochromocytoma/paraganglioma – <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">This clinical case illustrates a patient with concomitant diagnosis of pulmonary tuberculosis and a thoracic paraganglioma. Because the results of surgical biopsy were only known post-mortem, additional research on the evaluation of the diagnosis of paraganglioma, including determination of catecholamine and metanephrine levels, presence of distant metastasis and genetic testing were not possible.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Because this is a rare tumor, most of the literature describes only single case reports.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> In 2008, Mayo Clinic reported their experience with fourteen cases of treated mediastinal paragangliomas.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Concomitant occurrence of tuberculosis and thoracic paraganglioma is even rarer, with very few previous reports<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, making the diagnosis and treatment of these cases difficult and challenging.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, paragangliomas are not usually suspected in the initial evaluation of a mediastinal mass because of its rarity, but it should be part of the differential diagnosis. The concomitant occurrence of tuberculosis may pose a diagnostic challenge in this case, leading to a delay in the diagnosis of this type of tumors.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of people and animals</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this publication.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest to the contents of the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 1400 "Tamanyo" => 195388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest radiography: heterogeneous infiltration in the right upper lobe and homogeneous opacity in the left hilar region. (B)–(D) Chest Computed Tomography of the thorax: hypodense mass of 9<span class="elsevierStyleHsp" style=""></span>cm with well defined margins located in the mediastinum with extension to the left upper lobe, areas of consolidation in the right upper lobe associated with micro-nodular infiltration and ground-glass opacities.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1056 "Ancho" => 1400 "Tamanyo" => 338889 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surgical lung biopsy. A solid and poorly differentiated malignant neoplasm with extensive areas of necrosis (A – HE 200×). The tumor cells had abundant eosinophilic cytoplasm and round nuclei with evident nucleoli (B – HE 600×). Immunohistochemically, the neoplastic cells focally expressed vimentin (C – 600×) and synaptophysin (D – 600×) in the absence of epithelial and other markers (AE1/AE3, CK8/18, CK7, CK20, CK5, 34β12, EMA,TTF1, napsin-A, p63, calretinin, pS100, CD31, CD34, PLAP, beta-HCG, CD45, CD20, CD10, inhibin, C-kit, CD99, actin, desmin, GFAP, CD30, CD21, HMB45, CD56, CD23, alpha-fetoprotein, myeloperoxidase, lysozyme, WT1, ALK, HepPar-1). With those morphological and immunohistochemical characteristics in the appropriate clinical context, the diagnostic hypothesis of paraganglioma/pheochromocytoma was suggested.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracic involvement with pheochromocytoma. A review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Sandur" 1 => "A. Dasgupta" 2 => "L.J. Shapiro" 3 => "A.C. Arroliga" 4 => "A.C. Mehta" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1999" "volumen" => "115" "paginaInicial" => "511" "paginaFinal" => "521" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10027454" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional mediastinal pheochromocytoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.H. Lee" 1 => "S.S. Lee" 2 => "J.C. Lee" 3 => "M.S. Kim" 4 => "J.H. Choi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5090/kjtcs.2013.46.1.88" "Revista" => array:6 [ "tituloSerie" => "Korean J Thorac Cardiovasc Surg" "fecha" => "2013" "volumen" => "46" "paginaInicial" => "88" "paginaFinal" => "91" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23423879" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asymptomatic paraganglioma of the posterior mediastinum misdiagnosed until operation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Liu" 1 => "J. Mei" 2 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 6 | 12 |
| 2024 October | 49 | 59 | 108 |
| 2024 September | 56 | 41 | 97 |
| 2024 August | 71 | 39 | 110 |
| 2024 July | 68 | 42 | 110 |
| 2024 June | 48 | 31 | 79 |
| 2024 May | 52 | 45 | 97 |
| 2024 April | 58 | 38 | 96 |
| 2024 March | 52 | 28 | 80 |
| 2024 February | 43 | 29 | 72 |
| 2024 January | 26 | 29 | 55 |
| 2023 December | 32 | 36 | 68 |
| 2023 November | 40 | 46 | 86 |
| 2023 October | 37 | 36 | 73 |
| 2023 September | 48 | 36 | 84 |
| 2023 August | 31 | 23 | 54 |
| 2023 July | 35 | 25 | 60 |
| 2023 June | 28 | 19 | 47 |
| 2023 May | 52 | 30 | 82 |
| 2023 April | 34 | 13 | 47 |
| 2023 March | 63 | 21 | 84 |
| 2023 February | 53 | 24 | 77 |
| 2023 January | 46 | 28 | 74 |
| 2022 December | 66 | 19 | 85 |
| 2022 November | 61 | 46 | 107 |
| 2022 October | 52 | 41 | 93 |
| 2022 September | 39 | 26 | 65 |
| 2022 August | 41 | 44 | 85 |
| 2022 July | 42 | 46 | 88 |
| 2022 June | 26 | 34 | 60 |
| 2022 May | 48 | 39 | 87 |
| 2022 April | 40 | 31 | 71 |
| 2022 March | 52 | 43 | 95 |
| 2022 February | 47 | 29 | 76 |
| 2022 January | 41 | 27 | 68 |
| 2021 December | 33 | 39 | 72 |
| 2021 November | 35 | 42 | 77 |
| 2021 October | 50 | 52 | 102 |
| 2021 September | 41 | 30 | 71 |
| 2021 August | 52 | 27 | 79 |
| 2021 July | 22 | 27 | 49 |
| 2021 June | 28 | 22 | 50 |
| 2021 May | 48 | 28 | 76 |
| 2021 April | 88 | 75 | 163 |
| 2021 March | 65 | 21 | 86 |
| 2021 February | 67 | 21 | 88 |
| 2021 January | 45 | 25 | 70 |
| 2020 December | 38 | 22 | 60 |
| 2020 November | 50 | 29 | 79 |
| 2020 October | 64 | 17 | 81 |
| 2020 September | 76 | 19 | 95 |
| 2020 August | 75 | 19 | 94 |
| 2020 July | 134 | 26 | 160 |
| 2020 June | 118 | 13 | 131 |
| 2020 May | 122 | 17 | 139 |
| 2020 April | 101 | 11 | 112 |
| 2020 March | 97 | 8 | 105 |
| 2020 February | 103 | 14 | 117 |
| 2020 January | 113 | 22 | 135 |
| 2019 December | 77 | 18 | 95 |
| 2019 November | 114 | 9 | 123 |
| 2019 October | 122 | 22 | 144 |
| 2019 September | 95 | 30 | 125 |
| 2019 August | 169 | 16 | 185 |
| 2019 July | 199 | 21 | 220 |
| 2019 June | 182 | 16 | 198 |
| 2019 May | 178 | 22 | 200 |
| 2019 April | 175 | 25 | 200 |
| 2019 March | 219 | 22 | 241 |
| 2019 February | 180 | 27 | 207 |
| 2019 January | 181 | 40 | 221 |
| 2018 December | 149 | 11 | 160 |
| 2018 November | 55 | 0 | 55 |
| 2018 October | 77 | 9 | 86 |
| 2018 September | 46 | 4 | 50 |
| 2018 August | 61 | 28 | 89 |
| 2018 July | 61 | 17 | 78 |
| 2018 June | 63 | 18 | 81 |
| 2018 May | 78 | 16 | 94 |
| 2018 April | 95 | 25 | 120 |
| 2018 March | 98 | 25 | 123 |
| 2018 February | 66 | 17 | 83 |
| 2018 January | 90 | 11 | 101 |
| 2017 December | 86 | 25 | 111 |
| 2017 November | 65 | 9 | 74 |
| 2017 October | 43 | 12 | 55 |
| 2017 September | 40 | 10 | 50 |
| 2017 August | 28 | 22 | 50 |
| 2017 July | 35 | 15 | 50 |
| 2017 June | 46 | 10 | 56 |
| 2017 May | 42 | 15 | 57 |
| 2017 April | 19 | 9 | 28 |
| 2017 March | 19 | 8 | 27 |
| 2017 February | 12 | 4 | 16 |
| 2017 January | 14 | 7 | 21 |
| 2016 December | 19 | 8 | 27 |
| 2016 November | 20 | 1 | 21 |
| 2016 October | 15 | 6 | 21 |
| 2016 September | 13 | 2 | 15 |
| 2016 August | 14 | 3 | 17 |
| 2016 July | 7 | 5 | 12 |
| 2016 June | 5 | 0 | 5 |
| 2016 May | 18 | 7 | 25 |
| 2016 April | 41 | 1 | 42 |
| 2016 March | 59 | 19 | 78 |
| 2016 February | 78 | 16 | 94 |
| 2016 January | 48 | 19 | 67 |
| 2015 December | 59 | 11 | 70 |
| 2015 November | 44 | 12 | 56 |
| 2015 October | 43 | 18 | 61 |
| 2015 September | 45 | 13 | 58 |
| 2015 August | 52 | 8 | 60 |
| 2015 July | 52 | 5 | 57 |
| 2015 June | 38 | 4 | 42 |
| 2015 May | 54 | 7 | 61 |
| 2015 April | 53 | 18 | 71 |
| 2015 March | 49 | 6 | 55 |
| 2015 February | 54 | 15 | 69 |
| 2015 January | 34 | 18 | 52 |
| 2014 December | 89 | 33 | 122 |
| 2014 November | 86 | 41 | 127 |
| 2014 October | 129 | 60 | 189 |
| 2014 September | 90 | 46 | 136 |
| 2014 August | 35 | 28 | 63 |
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