Early detection of hypersensitivity pneumonitis in office workers.

Symptoms of hypersensitivity pneumonitis in three employees in an office building led to an investigation of their work environment. An open spray water air cooling system was implicated when inhalation challenge with the spray water caused acute illness in one of them. A questionnaire survey of the 4,023 co-workers identified 48 other suspect cases, and laboaratory studies confirmed hypersensitivity pneumonitis in three additional workers of this group. A significant change in pulmonary function, occurring only after exposure to the work environment, was the most useful laboratory finding and was found in five workers with no other pulmonary abnormalities, but not is asymptomatic workers or controls, since five of the six patients with hypersensitivy pneumonitis worked in offices cooled by the spray water system and since three had positive responses to inhalation challenge, use of the spray water system was discontinued. The affected workers improved after they were removed from the office complex.

Computed tomography in the staging of small cell lung cancer: implications for combined modality therapy.

Computed tomography of the thorax and abdomen, from the thoracic inlet to the renal hila, was performed as part of initial staging in 51 patients with small cell carcinoma of the lung (SCCL). The computed tomographic (CT) scans were repeated after completion of chemotherapy, as part of routine restaging and assessment of response to therapy. To identify the ways in which CT scanning uniquely benefited evaluation of initial disease extent in comparison to other diagnostic studies exclusive of CT scan, all diagnostic and clinical data were reviewed. CT scan identified more advanced intrathoracic disease than chest radiography in 82% of patients. Mediastinal node involvement not appreciated by chest radiography was seen in 61% of patients. Adrenal and retroperitoneal node involvement, not suspected by other studies, was identified by CT scan in 31% and 12% of patients, respectively. Thirty percent of the patients staged as limited disease (LD) were advanced to extensive disease (ED) by CT scan findings. While confirmation, by biopsy, of positive CT findings was not consistently accomplished, restaging CT scans provided indirect confirmation by displaying improvement or worsening that correlated with disease regression or progression. Thoraco-abdominal CT scanning more accurately identifies the extent of small cell carcinoma than other imaging procedures. This has important implications for reporting results by extent of disease. In addition, CT more accurately identifies the magnitude of intrathoracic primary and nodal tumors, which may influence the choice and conduct of local treatment--surgery and/or radiation therapy--in combination with systemic chemotherapy.

Hypersensitivity studies in popple (Aspen tree) peelers.

In the course of investigation of the relationship between hypersensitivity pneumonitis and the wood industry 45 popple peelers were studied. Four roentgenograms consistent with diffuse lung disease were found. All cases were in examinees who were also dairy farmers. Questionnaires revealed no instance of clinical symptoms of hypersensitivity pneumonitis. Gel immunodiffusion studies were positive to various antigens in eight cases, but no correlation could be made with pulmonary function or chest roentgenogram abnormalities in relation to occupation. Cultures of the wood and the surrounding environment yielded thermophilic fungi as well as other known antigenic material. It is concluded that the occupation of popple peeling does not represent an increased risk of development of hypersensitivity pneumonitis.

Chronic pancreatitis: a cause of biliary stricture.

This is a report of our experience with 13 patients who had a distal common duct stricture associated with chronic relapsing pancreatitis. All patients, when first seen, had an elevated alkaline phosphatase level; eight of 13 patients also had an elevated serum bilirubin level. Five of the jaundiced patients had a febrile course; a preoperative diagnosis of acute cholangitis was made in four of these. Eight of the 13 patients have had a choledochoduodenostomy for relief of biliary obstruction; seven of these patients are living and well; one died of continued alcoholism and pancreatitis. One patient had a loop cholecystojejunostomy; decompression was inadequate and death due to septicemia secondary to ascending cholangitis ensued. Four patients have not yet had an operation. Two are symptomatic, but elective operation has been refused. Two have been lost to follow-up. We recommend investigation of the biliary tract in patients known to have chronic relapsing pancreatitis who also have persisting abdominal symptoms and an elevated alkaline phosphatase. If a stricture of the distal common bile duct is identified in the absence of acute pancreatitis, choledochoduodenostomy should be performed.

Arachnoiditis from experimental myelography with aqueous contrast media.

Myelography was performed on 80 monkeys to study postmyelographic arachnoiditis. Metrizamide myelography caused arachnoiditis when high concentrations were used, but not with the usual clinical concentrations. Arachnoiditis resulted after myelography with meglumine iocarmate; however, the risk of arachnoiditis was reduced by diluting the contrast medium. Prophylactic intrathecal methylprednisolone was not effective in preventing arachnoiditis. Blood in the cerebrospinal fluid did not affect the degree of arachnoiditis.

Apparent reformation of the base of the skull following radiotherapy for nasopharyngeal carcinoma.

Skull radiographs of 11 selected patients with carcinoma of the nasopharynx were reviewed before and after radiotherapy. Apparent bone reformation was seen at the initial sites of osteolytic destruction within four to six months after delivery of cancericidal radiation dosages.

Arachnoiditis following myelography with water-soluble agents. The role of contrast medium osmolality.

The role of contrast medium osmolality in postmyelographic arachnoiditis was studied. Monkeys were injected intrathecally with isotonic saline (290 mOs/kg), hypertonic saline (1,449 mOs/kg), metrizamide (456 or 300 mOs/kg), or methylglucamine iocarnate (1,049 mOs/kg). After 12 weeks the animals were examined for evidence of arachnoiditis, with myelography just prior to sacrifice and microscopic examination of the excised dural sac and its contents. Intrathecal injections of methyglucamine iocarmate or metrizamide caused arachnoiditis while saline did not. Only one animal given 170 mg l/ml (300 mOs/kg) exhibited a more severe reaction than the controls. An increase in the cerebrospinal fluid osmolality alone does not cause arachnoiditis.

Patency evaluation of distal splenorenal shunt with dynamic computed tomography.

The reliability of documenting patency of the shunt by dynamic computed tomographic angiography was compared with celiac arteriography one postoperatively in 13 patients who had had a distal splenorenal shunt one month to six years earlier. This new technique confirmed the arteriographic diagnosis regarding patency of the shunt in 11 patients and demonstrated patency of two with indeterminant, or probably occluded, shunts by arteriography. Its reliability as an standard technique which was less than optimal in precision, and it still contained no false-negative results in this small group of patients. The dynamic scan had excellent patient acceptance for study. It is appropriate for the assessment patency early after operation, or later, as a routine follow-up study or in patients with persistent varices or bleeds from an uncertain upper gastrointestinal source.

Nasal and paranasal sinus polyposis. Current concepts in radiologic diagnosis and surgical therapy.

We believe that hypocycloidal tomography is the method of choice in the pre and postoperative evaluation of chronic nasal and paranasal sinus polyposis, based on the radiographic examinations of 80 patients who have undergone intranasal ethmoidectomy. Although our overall study is incomplete at this time due the extended period necessary for follow-up, we hope that the basic information which is now available will be beneficial to others.

Computed tomography, ultrasonography, and endoscopic retrograde cholangiopancreatography in the diagnosis of pancreatic disease: a comparative study.

A prospective study was performed comparing the sensitivity of computed tomography, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic disease. Forty patients with suspected pancreatic carcinoma, acute recurrent or chronic pancreatitis, and/or jaundice were studied. CT was the most sensitive study in evaluation of pancreatitis. ERCP was most accurate in evaluation of pancreatic malignancy. Ultrasonography was the least sensitive method in detecting pancreatic disease and dilatation of the extrahepatic biliary ducts.

Arachnoiditis following myelography with metrizamide in monkeys. Effect of blood in the cerebrospinal fluid.

Monkeys were injected intrathecally with blood, metrizamide (Amipaque) or a mixture of blood and metrizamide. Twelve weeks later the animals were examined for evidence of arachnoiditis. Either blood or metrizamide alone in sufficient amounts resulted in arachnoiditis. The addition of blood to metrizamide did not alter the severity or risk of arachnoiditis from experimental myelography with metrizamide.

Severity of postmyelographic arachnoiditis and concentration of meglumine locarmate in primates.

Myelography with meglumine iocarmate, a dilute meglumine iocarmate solution, or gas was performed in macaque monkeys. Twelve weeks later the animals were examined myelographically and histologically for evidence of arachnoiditis. Arachnoiditis in the animals treated with dilute meglumine iocarmate and gas was significantly less than in those treated with meglumine iocarmate.

Experimental production of arachnoiditis with water-soluble myelographic media.

After myelography with either metrizamide (300mg l/ml) or meglumine iocarmate (280 mg l/ml), mild to severe arachnoid fibrosis was demonstrated radiographically and histologically in primates. Intrathecal injections of metrizamide (170 mg l/ml) or autologous cerebrospinal fluid produced less arachnoiditis. The risk of arachnoiditis is probably minimized by the use of reduced volumes and concentrations of water-soluble media. Controlled studies of arachnoiditis following myelography are probably more reliable in the primate model than in other experimental animals.

Ineffectiveness of prophylactic intrathecal methylprednisolone in myelography with aqueous media.

The effectiveness of prophylactic intrathecal methylprednisone (MP) in preventing arachnoiditis from iocarmate myelography was studied. Monkeys were injected intrathecally with locarmate, MP, or a combination of the two. Twelve weeks later the severity of arachnoiditis was determined in each animal. There was no significant prophylactic effect of intrathecal MP on arachnoiditis from locarmate. Some arachnoiditis was found in control animals treated with MP alone.

Comparison of arachnoiditis produced by meglumine iocarmate and metrizamide myelography in an animal model.

Myelography in monkeys was performed with either meglumine iocarmate or metrizamide. The severity of resultant arachnoiditis in each animal 12 weeks later was evaluated by repeat myelography and by histologic study of the arachnoid. Three of the four animals examined with meglumine iocarmate had severe arachnoiditis; none of the four animals examined with metrizamide had as severe changes. The difference between the two groups was statistically significant (P less than .05).

Allergic bronchopulmonary aspergillosis in cystic fibrosis.

One hundred patients with CF were screened for ABPA. Forty-eight male patients and 52 female patients with age range of 2 to 34 yr (mean 14.2) were studied. Patients were evaluated for skin reactivity and serum precipitating antibodies to Af, predominant sputum organisms, total blood eosinophil levels, total serum IgE, and Af-specific IgE and IgG, as well as abnormalities of pulmonary function and chest x-ray films. Careful evaluation of all patients with CF demonstrated that 10% had features indicative of ABPA, which is another potentially destructive pulmonary disorder. Thus careful evaluation of patients with CF, especially those with asthma, may be rewarding in uncovering a disorder that may slow progression of CF when it is appropriately treated.

Dynamic computed tomography and pulsed Doppler ultrasonography in the evaluation of splenorenal shunt patency.

Dynamic computed tomography (CT) and real-time/pulsed Doppler ultrasonography were performed in 13 patients following a distal end-to-side splenorenal shunt (Warren procedure). The results were correlated with angiography. The anastomotic site was demonstrated by CT in all patients. Coincident enhancement of the distal splenic vein and left renal vein as demonstrated by dynamic CT was an accurate predictor of shunt patency. Ultrasound studies were performed using a transsplenic coronal imaging approach. Although the proximal splenic vein and left renal vein could be identified, it was not possible to directly evaluate the anastomotic site in any patients. Dynamic CT evaluation of splenorenal shunts may be a useful technique for monitoring shunt patency during long term follow-up and for evaluating patients who later rebleed.

Interstital lung disease due to contamination of forced air systems.

Eight patients had hypersensitivity pneumonitis due to contaminated home or office forced-air heating or air-conditioning systems. We studied their clinical and laboratory features, and the results indicated that this disease may occur as an acute or insidious form differing in type and intensity of respiratory and systemic symptoms. Thermophilic actinomycetes contaminatinf the forced air systems were identified as the sensitizing agents in most cases. Precipitating antibodies to the organisms could be shown in the serums of the patients and the antigen identified by immunofluorescent studies in the three lung biopsies examined by this method. Inhalation challenge studies with the cultured organism or other materials obtained from the forced air systems reproduced the clinical syndrome in the four patients tested. Avoidance of the contaminated system, and the use of corticosteroids in more severe cases,seems to be appropriate therapy for patients with this disease.