Prediction of relapse after treatment of coccidioidomycosis.

Relapse after apparently successful treatment of coccidioidomycosis has been a problem with both amphotericin B and the azoles. We conducted a retrospective cohort study of 34 patients who required therapy for coccidioidomycosis between 1973 and 1993; 10 relapsed and 25 (one patient received two courses of therapy) did not relapse during follow-up. The mean time to relapse after completion of therapy was 7.3 months (range, 1-21 months). All 34 patients responded clinically to therapy. A fourfold or greater decrease in titers of antibody, as determined by complement fixation (CF), during therapy was seen in seven (78%) of nine patients who relapsed and 17 (85%) of 20 patients who did not relapse (P = .956). There was no significant difference between relapsers and nonrelapsers in terms of the lowest CF titer during therapy, the CF titer at the end of therapy, or the peak CF titer. The risk of relapse was increased among those with a peak CF titer of > or = 1:256 (relative risk [RR] = 4.7; 95% confidence interval [CI] = 1.4-16.1), as compared with patients who did not mount such a high antibody response. Similarly, the risk of relapse was higher among those with serially negative coccidioidin skin tests (CSTs) than those with serially positive CSTs (RR = 4.8; 95% CI = 1.2-19.5). We conclude that clinical response, lowest CF titer, end-of-therapy CF titer, and decrease in the CF titer of at least fourfold are not predictive of relapse in patients with coccidioidomycosis. Negative serial coccidioidin skin tests and a peak CF antibody titer of > or = 1:256 are independently associated with increased risk of relapse.

Endobronchial tuberculosis. Serial fiberoptic bronchoscopy and natural history.

Endobronchial tuberculosis in the preantibiotic era was considered a complication of advanced post-primary disease. Bronchial mucosa adjacent to parenchymal cavities was bathed in infectious sputum, resulting in implantation. Effective antituberculosis drug therapy has reduced childhood exposure, resulting in an increase in adult primary tuberculosis with unusual clinical and roentgenographic presentations. We studied four adults with endobronchial tuberculosis who presented with unusual lobe involvement mimicking bronchogenic carcinoma. Fiberoptic bronchoscopy illustrated the range of endobronchial appearances, including evolution of mucosal ulcer to hyperplastic polyp and bronchostenosis. Complete fibrostenosis with lobar atelectasis was observed in one patient, and an eroding tuberculous lymph node in another. In the current era, endobronchial tuberculosis is more likely to be discovered in adults with progressive primary tuberculosis who have non-cavitary lower lung field infiltrates. Bronchial mucosal ulceration can result from submucosal lymphatic spread of organisms from adjacent parenchymal disease, as well as implantation.

Comparison of forceps used for transbronchial lung biopsy. Bigger may not be better.

Transbronchial lung biopsy is a useful procedure to obtain an alveolar specimen in the evaluation of diffuse lung infiltrates. Large forceps (cup and alligator) are expected to result in larger specimens and improve diagnostic yield. We performed transbronchial lung biopsy in 20 patients using two different sized forceps in each patient. We compared the histology and histopathologic diagnoses obtained by small cup forceps, large cup forceps, and large alligator forceps. Small and large cup forceps provided equally good results; however, the large open end of the alligator forceps often prevented distal passage through narrowing airways, engaging proximal bifurcating bronchial wall and cartilage rather than lung parenchyma. Small and large cup forceps are more likely to obtain the desired alveolar specimen.

Rounded atelectasis due to acute exudative effusion. Spontaneous resolution.

Rounded atelectasis is an interesting roentgenographic entity that must be distinguished from intrathoracic neoplasm. Chronic pleural disease, particularly that due to asbestos exposure, is a frequently cited cause, and is considered to be a sine qua non by some. We report a case of rounded atelectasis with an acute parapneumonic exudative effusion that resolved spontaneously with roentgenographically normal pleura.

Bone and gallium scanning in the evaluation of disseminated coccidioidomycosis.

Bone and gallium scans were performed on 79 patients to determine the presence and extent of disseminated coccidioidomycosis. Bone scans appeared to be more sensitive than skeletal radiographs or gallium scans in determining the extent of coccidioidal bone involvement. The gallium scan was useful only in the identification of coccidioidal tissue abscesses. All patients with clinical evidence suggestive of dissemination and all patients with poor prognostic factors who are to receive amphotericin B therapy should be evaluated with a bone scan.

Focal increased lung perfusion and intrapulmonary veno-arterial shunting in bronchiolo-alveolar cell carcinoma.

A patient with bronchiolo-alveolar cell carcinoma presented with a veno-arterial shunt localized to the area of tumor involvement by differential position shunt testing. Perfusion lung scan revealed increased radionucleotide uptake in the area of the tumor, confirmed by pulmonary angiography, and suggested that the primary blood supply to the tumor was originating from the pulmonary circulation. Surgical resection of the tumor resulted in marked reduction of the intrapulmonary shunt.

Ventilation-perfusion lung images in the Swyer-James syndrome.

Ventilation-perfusion lung imaging appears to be a significant nonivasive means of supporting the clinical diagnosis of Swyer-James syndrome. Three cases are presented which display characteristic delayed washout of xenon from a small or normal-sized, underperfused hyperlucent lung.