A 53-year-old woman presented in September 1991 to Adiyaman State Hospital with pain on the left side of the chest, dyspnoea, and dry cough.

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1 Mesotelioma de pulmão - DR H. Ziya Ozel - Nerium oleander Nerium oleander Usou ANVIRZEL extrato da planta CASE REPORT Diagnosis: Mesothelioma - HD A 53-year-old woman presented in September 1991 to Adiyaman State Hospital with pain on the left side of the chest, dyspnoea, and dry cough.

2 Chest radiograph, taken on 22 October 1991 ( Appendix HD1 ), and medical examination revealed fluid accumulation in the left pleural cavity, and she was referred to a specialized medical center in Istanbul. The patient was admitted to Heybeliada Sanatorium for Chest Diseases and Chest Surgery [HSCDCS] on 4 November 1991 ( Appendix HD2 ). Chest radiograph showed at left side up to the top a homogenous density increase that pushed the heart and the mediastinum to the right. Some of the laboratory findings are listed in ( Appendix HD2 ). Thoracoscopy demonstrated tumoral tissue; pleural biopsy was performed; histopathological examination of the specimen revealed the diagnosis as "poorly differentiated fibrous malignant mesothelioma." One ampoule of Coparvacs was administered following the thoracoscopy. No expansion of the lung was observed. A 1x1 cm lymph node was discovered on the left of the neck at the supraclavicular site. A total of 4,500 ml of serofibrinous fluid was removed until the patient was discharged on 2 December The patient presented to Dr. Ozel on 11 December 1991 with a chest x-ray taken on 22 October 1991 ( Appendix HD1 ), and the medical report issued at HSCDCS ( Appendix HD2 ). On examination she was distressed and short of breath. There was dullness up to the top in the left hemithorax. No sound of respiration was audible over the left lung. Each movement caused dyspnea and tachycardia, and she could only move with help. Edema was present from the left hemithorax to the lodge of the spleen. There was a 1x1 cm node at the supraclavicular site. The patient had experienced extreme loss of weight. A test dose of 0.3cc N.O.I. caused the body temperature of the patient to increase to 38 C, and the patient was placed on a daily regimen of 0.3cc NOI to be given six times a week. The patient presented to Dr. Ozel on 2 February 1992 with an x-ray taken on 31 January ( Appendix HD3 ). The radiograph showed that the density increase persisted only in the lower half of the lung. On physical examination, there was no edema present. She experienced no more dyspnea and could move around alone without any support. Mediate auscultation demonstrated participation of the upper half of the left lung in breathing. Dullness still persisted in the lower half of the hemithorax. The patient was recommended to continue on the same regimen for another sixty days. The patient presented to Dr. Ozel on 9 April 1992 with a roentgenogram taken the previous day ( Appendix HD4 ). The x-ray showed that the high density region was limited to lower one-third of the left lung. On physical examination, breathing sound was less audible over the lower third of the left lung. The patient reported no specific complaint. The general condition of the patient had improved considerably, and she could perform her daily routine activities as a healthy person. She was advised to continue on the same regimen. The injections started to cause no fever after 15 May 1992, and the patient was placed on a maintenace regimen of 0.3cc N.O.I. to be given every three days.

3 The patient presented to Dr. Ozel on 10 August 1992 with an x-ray taken on the same day. The reontgenogram showed a return to normal with the exception of a blockage of the left sinus. On physical examination, breathing sound was audible over the whole of the left lung. The patient was in complete health and was recommended to stop the treatment. Another follow up x-ray was taken on 28 June 1994 ( Appendix HD5 ). Blockage of the left sinus was still present, but there was no sign of the original disease. Dr. Ozel last heard from her in 2000; she was in remission. CASE REPORTS Diagnosis: Mesothelioma - HD APPENDIX HD1 Roentgenogram taken on 22 October 1991 shows homogenous density increase on the left side up to the top. The heart and the mediastinum are pushed to the right.

4 CASE REPORTS Diagnosis: Mesothelioma - MH APPENDIX HD2 Translation of of the medical report issued on 2 December 1991 at the Heybeliada Sanatorium for Chest Diseases and Chest Surgery. Diagnosis: Malignant fibrous mesothelioma. CASE REPORTS Diagnosis: Mesothelioma - HD APPENDIX HD3 Roentgenogram taken on 31 January 1992 shows that the density increase persisted only in the lower half of the left lung.

5 CASE REPORTS Diagnosis: Mesothelioma - HD APPENDIX HD4

6 Roentgenogram taken on 8 April 1992 shows that the density increase was only in the lower one-third of the left lung. CASE REPORTS Diagnosis: Mesothelioma - HD APPENDIX HD5 Roentgenogram taken on 28 June 1994 demonstrates complete and sustained regression of the malignant disease. Also shown is a

7 blockage of the left sinus. Republic of Turkey Ministry of Health and Social Help Heybeliada Sanatorium for Chest Diseases and Chest Surgery Number : Istanbul Subject: / / 198 Medical Report H. D. 2 December years old/from Adiyaman Registration # Admission-Discharge dates: 4 Nov Dec COMPLAINTS: STORY: Pain on left side, dyspnea, dry cough. She has been having these complaints for about two months. Shortness of breath started 20 days after the complaints commenced. 12 days ago she presented to Kahta/Adiyaman state hospital. An x-ray was taken. She was started on IHN, SM (anti-tuberculosis drugs)

8 HEREDITARY HISTORY: LABORATORY: and was recommended to go to Istanbul. She presented in Instanbul to a private physician who removed from the patient some serofibrous fluid. The physician referred her to our hospital. Her daughter was treated for tuberculosis seven years ago. She has nine children. She has been in menopause for the last two years. She has no bad habits. Glucose (fasting): 35 mg, Glucose (fasting): 55 mg, SGOT: 17 units, SGPT: 33 units, Total Protein: 7400 mg, Albumin: 3750 mg, Globulin: 3650 mg, Nothing significant in urine, PPD (skin test for tuberculosis) negative, Sedimentation: 106 mm/h, ARB (arborization) in phlegm and pleural fluid is negative, Cytologic examination of the pleural fluid: Class II. A total of about 4,500 ml serofibrous fluid was removed from the patient at different times. In pleural fluid: NaCl: 5,840 g, Rivalta: /++/, Gly: 70 mg, LDH: 1581 units, Protein: 5,7 gr, Cholesterol: 112 mg. ROENTGENOGRAPHY: On the left side there is increased homogeneous density that goes up to the top, and that pushes the heart and the mediastinum to the right. PLEURAL BIOPSY: THORACOSCOPY: CLINICAL PROGRESS AND CONCLUSION: MALIGNANT FIBROUS MESOTHELIOMA. Tumoral tissue detected. Biopsy: POORLY DIFFERENCIATED FIBROUS MALIGNANT MESOTHELIOMA. The patient was admitted. Specific therapy was started. Following definite diagnosis, specific therapy was stopped, nonspecific and symptomatic therapy was given. One ampoule of Coparvax was applied following the thoracoscopy performed on 22 November No complete expansion of the lung could be achieved. The latest radiological examination revealed on the left side many air-fluid levels in the form of compartments. A 1 x 1 cm hard LAM grew at the left supraclavicular site while the patient was under treatment. Further, sensitivity and hardness occurred in the region at the level of spleen on the line from the middle of the left armpit till os coxae. Upon the request of her family, the patient was given a prescription and was discharged. Dr. E. Erdem Assistant Signature Dr. M. Kurutepe Deputy chief of department Signature

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