368 THE BRITISH J O U R N A L OF TUBERCULOSIS

CORTISONE AND CORTICOTROPHIN FOR TUBERCULOUS PLEURAL EFFUSION

BY MARY JAMES

Liverpool Hospital, Frodsham, Cheshire

CORTISONE and corticotrophin (ACTH), when used in infections, limit the inflammation, granulation and fibrosis with improvement in symptoms but with the risk of spread of infection (New England Journal of Medicine, 195 I). Following this, it seemed quite rational that cortisone and corticotrophin could be used with effect in tuberculosis provided they were covered with adequate antimycobacterial therapy.

Le Maistre et al. (I951) noted that in seven cases of advanced pulmonary tuberculosis treated with cortisone and corticotrophin there were profound changes in the course of the illness. There was an improved sense of well- being, increased strength and an improvement in appetite. The effect, how- ever, was temporary, lasting only as long as the patients were on hormone therapy.

Linden Walner et al. (1952) treated a number of cases of pulmonary and laryngeal tuberculosis with cortisone and corticotrophin. They found that the chest lesions showed some improvement, but the laryngeal lesions were not improved. Biopsy of the laryngeal lesions disclosed an increase in the number of tubercle bacilli, with decrease in the number of tubercles. This exacerbation was due no doubt to the limitation of granulation and fibrosis. The improve- ment occurring with cortisone and corticotrophin was temporary, patients often retrogressing rapidly after termination of hormone therapy.

Richard Johnson et al. (1954) treated thirty-one cases of active pulmonary tuberculosis with combinations of cortisone or corticotrophin and streptomycin. In all cases there were no ill effects, and in many an accelerated improvement of the tuberculous disease, as evidenced by X-ray changes and lowered erythro- cyte sedimentation rate.

Houghton (1954) has shown the effectiveness of corticotrophin when combined with the antimycobacterial drugs streptomycin, PAS and isoniazid (INAH) in the treatment of pulmonary tuberculosis. Cortisone being also effective in reducing allergic reactions to PAS and other drugs, it seemed feasible that it could be used to reduce another allergic manifestation, pleural effusion.

A case is described in which corticotrophin and cortisone were used with antimycobacterial cover for the treatment of pleural effusion complicating artificial pneumothorax.

(Received for publication April 9, 1956.)

AND DISEASES OF THE CHEST 36 9

Case History Male patient aged 24 years admitted to hospital on 7.3.55 with a diagnosis of

pulmonary tuberculosis. His general condition was very good, there being no symptoms.

X-ray 9.3.55: "Unilateral disease with possible left apical cavitation." Treatment given was enteric coated PAS 16" 5 g. daily for four weeks. X-ray 13.4.55: "Diminished infiltration." Left artificial pneumothorax was induced on I8.4.55. X-ray 20.4.55: "L.A.P. with apical adhesion." Thoracoscopy 12.7.55 , all adhesions were successfully cauterised. At the

end of the operation 4 oz. clear fluid were aspirated. Post-operatively the treat- ment was streptomycin i g. alternate days; enteric coated PAS 16" 5 g. daily and INAH 150 rag. daily for two weeks.

. . . . . . . . . . . . . ICOmSONE O__ h,ONE ANO A.C.T.

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OAY8 AFTER CAUTERY

Figure shows acute effusion developing after cauterlsation of adhesions, rapidly decreasing when cortisone and corticotrophin were exhibited under antimycobacterial cover.

Fluoroscopy two days after operation disclosed total collapse of the lung and the presence of fluid.

Aspiration: 6 oz. brown fluid. Fluoroscopy 19.7.55: increased pleural fluid noted. Aspiration 22.7.55:5 oz. clear fluid. Fluoroscopy 23-7.55 showed marked increase in pleural fluid. Clinically

this was accompanied by a rise in temperature and pulse rate. Aspiration 25.7.55: 2o oz. clear fluid. Two weeks' post-operative chemotherapy now having been completed, the

patient was given streptomycin on alternate days with enteric-coated PAS for fourteen days. Cortisone 25 rag. b.d. was exhibited under this cover for seven days.

X-ray 27-7-55: "Left lung fully aerated, no adhesions seen. Fluid present." Corticotrophin was now alternated with cortisone, commencing with Aspiration 4.8.55 : 4 oz. clear fluid.

1o units gel twice weekly, Monday and Friday; cortisone being given on Wed- nesday, Thurday and Sunday.

On 8.8.55 the ACTH was increased to 2o units twice weekly. It was noted,

37 ° T H E B R I T I S H J O U R N A L O F T U B E R C U L O S I S

by means of fluoroscopy, that there was a marked diminution in the rate of formation ofpleural fluid.

X-ray 17.8.55: "Pleural fluid slightly above dome of diaphragm." Aspiration 18.8.55:2 oz. clear fluid. The L.AP. was maintained with refills of 4oo ml. X-ray 31.8.55: "Good pneumothorax, with a trace ofpleural fluid." On 2.9.55 the cortisone was reduced to 12"5 mg. b.d., but the A C T H was

maintained at 2o units. On 7.9.55 the A C T H was reduced to lO units, the cortisone dosage remain-

ing unchanged. After seven days at this level, A C T H and cortisone were dis- continued, chemotherapy being continued for a further two weeks.

X-ray 28.9.55 (at the end of course of chemotherapy and hormonal therapy) : "Trace only of pleural fluid."

No further aspirations have been necessary. X-ray 2.11.55 : "Pleural fluid still a trace. Very good pneumothorax." The patient was discharged on 4. I 1.55.

D i s c u s s i o n

I t has been shown that antimycobacterial therapy has reduced to one-fifth the amount of pleural effusion following cautery of adhesions during artificial pneumothorax treatment. Simultaneously it has eliminated the risk of empy- ema (Birath, 1953; Erwin, 1954).

In this case an acute effusion developed at the end of a two weeks' course of triple chemotherapy. Cortisone was exhibited under streptomycin and PAS cover; after fourteen days corticotrophin was alternated with cortisone under streptomycin and I N A H cover. Under this treatment there was a marked reduction of pleural fluid.

It is known that prolonged administration of cortisone may cause adrenal atrophy. This fact and the shortage of corticotrophin led to the practice of alternating cortisone and corticotrophin. It is probable that more effective economy of corticotrophin could be achieved by giving cortisone for five days, followed by corticotrophin for two days each week.

Topical hydrocortisone has been used for tuberculous effusion by Linquette et al. (I954) , but it was considered that, in the present case, the known lung lesion pointed to systemic treatment, rather than purely intra- pleural therapy.

I wish to express my thanks to Dr. G. S. Erwln for permission to publish this case and for his help in the preparation of it.

REFERENCES

BIRAT~, G. (1953): Tubercle (Lond.), 24, =60. E•WlN, Q. S. (1954): Tubercle (Lond.), 35, 3o2. ttOUG~TON, L. E. (1954): Lancet, 1, 595. JOHNSON, R., and DAvEY, W. (1954) : Amer. Rev. Tuber., 70, 623. LINQUETTE, M., GONDEMAND, M., and WAROT, P. (I954) : Presse Mdd., 670 168. LE MAlSTRE, C. A., TOMPSETT, R., MUSCHENHm~J, C., Moom~, J. A., and McDERMOTT, W.

(I951) : 07. din. Invest., 30, 445. (195I) : New Engl. 07. Med., 245, 75. Editorial. PICK~RING, G. W. (1952) : Brit. Med. 07, 1~ 12o7. WALNER, L. (I952) : Amer. Rev. Tuber., 66~ I6I.