Vol 39 # 2 June 2007 - Kma.org.kw

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June 2007KUWAIT MEDICAL JOURNAL 187reactivation of her disease. Extrathoracic spread ofdisease can occur despite initiation of antifungaltherapy [1] .The diagnosis of aspergillus tracheobronchitis,although rare, should be considered in a patientwith a COPD exacerbation who deterioratesdespite receiving high dose corticosteroids andbroad spectrum antibiotics. Clues to the diagnosisinclude the development of ill-defined nodules onthe chest radiograph, centrilobular nodules witht ree-in-bud appearance on high resolution CT,coughing up casts or thick mucus plugs and thebronchoscopic appearance of pseudomembranes.The diagnosis is confirmed by histopathologicalevidence of inflammatory psuedomembranescontaining Aspergillus in the proximal or distalairways. Urgent treatment with systemic andpossibly nebulized antifungal therapy is essential,as the mortality is high, even with pro m p ttreatment.REFERENCES1) Kemper CA, Hostetler JS, Follansbee SE, et al. Ulcerativeand plaque- like tracheobronchitis due to infection withaspergillus in patients with AIDS. Clin Infect Dis 1993;17:344-352.2) Al-Alawi A, Ryan CF, Flint JD, Muller NL. Aspergillusrelatedlung disease. Can Respir J 2005; 12:377-387.3) Fraser RS. Pulmonary aspergillosis: Pathologic andPathogenetic features. Pathol Annu 1993; 28:231-277.4) Young RC, Bennett JE, Vogel CL, Carbone PP, DeVita VT.Aspergillosis: the spectrum of the disease of 98 patients.Medicine 1970; 49:147-173.5) Boots RJ, Paterson DL, Allworth AM, Faoagali JL.Successful treatment of post-influenza necro t i z i n gb ronchial aspergillosis with liposomal amphotericin B,gamma interferon and GM-CSF. Thorax 1999; 54:1047-1049.6) Hines DW, Haber MH, Yaremko L, Britton C, MclawhonRW, Harris AA. Psuedomembranous tracheobro n c h i t i scaused by aspergillus. Am Rev Respir Dis 1991; 143:1408-1411.7) Nicholson AG, Sim KM, Keogh BF, Corrin B.Psuedomembranous necrotizing bronchial asperg i l l o s i scomplicating chronic airways limitation. Thorax 1995;50:807-808.8) Thommi G, Bell G, Liu J, Nugent K. Spectrum of invasivepulmonary aspergillosis in immunocompetent patientswith chronic obstructive pulmonary disease. South Med J1991; 84:828-831.9) Muquim A, Dial S, Menzies D. Invasive aspergillosis inpatients with chronic obstructive pulmonary diseases. CanResp J 2005; 12:199-204.10) Logan PM, Muller NL. Thoracic radiology. High resolutioncomputed tomography and pathologic findings inpulmonary aspergillosis: a pictorial essay. Can Assoc RadiolJ 1996; 47:444-452.11) Franquet T, Muller NL, Gimenez A, Guembe P, de la TorreJ, Bague S. Spectrum of pulmonary Aspergillosis: histologic,clinical and radiologic findings. Radiographics 2001;21:825-837.
KUWAIT MEDICAL JOURNAL June 2007ABSTRACTCase ReportSymptomatic Large Coronary Artery Aneurysm Associatedwith Sirolimus - Eluting Stent ImplantationMohammad AlMutairi, Khaled AlMerriDivision of Cardiology, Chest Diseases Hospital, KuwaitKuwait Medical Journal 2007, 39 (2):190-192We report a case of a symptomatic large aneurysm in theleft anterior descending coronary artery in a 55-year-oldfemale one year and five months after implantation of asirolimus-eluting stent. This is a rare complication of adrug-eluting stent.KEYWORDS: aneurysm, angioplasty, drug-eluting stent, sirolimusCASE REPORTA 5 5 - y e a r-old lady presented to Card i o l o g ydepartment in June 2005 with crescendo angina andearly positive excercise stress test. Coro n a r yangiography demonstrated good left ventricularsystolic function and mild diffuse atheroscleroticplaques in the right and left circumflex coronaryarteries. There was a 90% long proximal leftanterior descending coronary artery (LAD) stenosis(Fig. 1A). Planned percutaneous coronary interventionwas performed using a 3.0 mm x 33 mm Sirolimus-eluting stent (Cypher). The end result was goodwith no residual stenosis (Fig. 1B). Aspirin andclopidogrel (300 mg) were started 24 hours beforethe procedure. Glycoprotien IIb IIIa inhibitor wasused during the procedure.During hospital stay, the patient evolved withno precordial pain and no electrocardiographic orenzymatic alternations were observed. Twenty-fourhours after stent implantation, the patient wasdischarged from the hospital with a clopidogrelprescription of 75 mg / day for one year and aspirin81 mg / day indefinitely.The patient presented with a similar precordialpain two months later to a hospital in India duringher vacation. Coronary angiography revealed apatent LAD stent.Over the last year the patient continued tocomplain of the same precordial pain and wasre f e r red for exercise stress test with nuclearimaging. Exercise stress testing was positive withhorizontal 1.5 mm ST segment depression in leadsV2 - V6 in stage 2 of the Bruce protocol. Thalliumimaging demonstrated medium size area ofreversible ischemia involving the antero - l a t e r a lwall. The patient was re f e r red for coro n a r yangiography.C o ronary angiography revealed good leftventricular systolic function. A n g i o g r a p h i cappearance of the left main coronary artery wasnormal. Mild to moderate atherosclerotic plaquesin the right and left circumflex coronary arterieswere observed.There was a large coronary aneurysm in theLAD artery in the intra-stent distal portion (Fig. 2).Intravascular coronary ultrasound (IVUS) imagingwas performed (Fig. 3) and this demonstrated thelarge aneurysm, stent malapposition and a 70% instentre-stenosis proximal to the aneurysm.Considering the character of the aneurysm andthe involvement of a large diagonal branch thepatient was advised to undergo coronary arterybypass grafting (CABG).DISCUSSIONRandomized studies with the use of dru g -eluting stents have demonstrated an inhibition ofneointimal hyperplasia in majority of patients [1,2] .With the increasing use of these stents, informationon their longterm effect is extremely important.The formation of a coronary aneurysm, definedas a dilation of the coronary artery that exceed 1.5times the re f e rence diameter of the adjacentc o ronary segments that are angiographicallyn o r m a l [ 3 ] , has been reported after cor o n a r yangioplasty, direct coronary atherectomy and laserangioplasty at a frequency that varies from 2 to10% [4] . At the STRESS study [3] , the presence of a(This article was presented at the 12 th International Conference of the Kuwait Medical Association, April 1-4, 2007)Address Correspondence to:Mohammad AlMutairi, MD, FRCPC, ABIM, Division of Cardiology, Chest Diseases Hospital, Sabah Area, Kuwait. Fax: (965) 4891941, E-mail:malmut99@hotmail.com
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