Mycobacterium xenopi infection in an immunosuppressed patient with Crohn's disease.

A 48 year old patient with active Crohn's disease presented with bilateral nodules over his lungs resembling malignant metastasis. Bronchoscopic and pathological examination of the airways and sputum did not show any malignancy. After 6 weeks Mycobacterium xenopi was cultured from his bronchial washings while all other cultures remained negative. Treatment was started with rifampicin, ethambutol, and clarithromycin and, after 9 months of treatment, there was an almost complete resolution of his chest radiograph.

Candida tropicalis arthritis in a patient with acute myeloid leukemia successfully treated with fluconazole: case report and review of the literature.

The case of a 77-year-old woman with acute myeloid leukemia who developed Candida tropicalis septic arthritis of the knee after remission-inducing chemotherapy is reported. A literature review of C. tropicalis non-prosthetic arthritis is included. The isolate was susceptible to fluconazole (MIC 0.25 mg/l). She was treated with fluconazole (400 mg orally) and frequent relieving synovial aspirations. After 1 month of antifungal therapy the synovial fluid became culture negative. Fluconazole concentration in the synovial fluid and serum were 20 mg/l and 19.4 mg/l, respectively. The patient was treated for a total of 7 months and made a full recovery. This is the first report of the successful use of fluconazole in the treatment of septic arthritis due to C. tropicalis.

Expression of surface markers on alveolar macrophages from symptomatic patients with HIV infection as detected by flow cytometry.

Alveolar macrophages (AMs) harvested from 32 HIV-infected patients with respiratory problems (opportunistic pulmonary infections, n = 12; other lung disease, n = 20) and 13 healthy controls were stained with a panel of 15 monoclonal antibodies directed against surface antigens implicated in cell function. Antigen expression was quantified by flow cytometry and expressed as relative linear median fluorescence intensity (RLMFI). On AMs of patients, as compared with controls, there was a significant enhancement of HLA DP (12.1 +/- 1.5 vs 6.5 +/- 0.9, p = 0.01, M +/- SEM, RLMFI units), CD11b (3.4 +/- 0.5 vs 1.7 +/- 0.4, p = 0.014), CD11c (8.9 +/- 1.0 vs 4.8 +/- 0.8, p = 0.0046), CD14 (2.1 +/- 0.3 vs 1.0 +/- 0.2, p = 0.0009), and CD33 (1.7 +/- 0.1 vs 1.0 +/- 0.2, p = 0.0093). No significant differences could be established for HLA-DR (36.9 +/- 5.8 vs 30.9 +/- 7.5, NS), HLA-DQ (3.4 +/- 0.3 vs 3.1 +/- 0.6, NS), CD54 (1.9 +/- 0.3 vs 1.2 +/- 0.1, NS), CD13 (2.5 +/- 0.6 vs 1.5 +/- 0.3, NS), CD36 (1.4 +/- 0.2 vs 0.9 +/- 0.3, NS), CD71 (10.3 +/- 1.9 vs 8.9 +/- 1.8, NS), CD25 (0.8 +/- 0.0 vs 0.9 +/- 0.1, NS), 27E10 (1.1 +/- 0.1 vs 0.8 +/- 0.3, NS), RM3/1 (1.9 +/- 0.4 vs 1.5 +/- 0.4, NS), and CD4 (1.5 +/- 0.3 vs 1.0 +/- 0.0, NS). The expression of CD14 and CD11b, but not of HLA class II antigens and CD71, was increased in the smaller cell population compared with the larger, thus suggesting monocyte recruitment. The increased expression of HLA-DP, CD11c, CD14, and CD33 on the patients' AMs was independent of smoking habits. The degree of immunodeficiency as indicated by the absolute peripheral CD4 count, the character of HIV-related pulmonary disease, and the prophylactic use of pentamidine or zidovudine did not significantly modify the antigen expression pattern. It is concluded that HIV infection may lead, most probably indirectly, to enhanced expression of surface antigens by local upregulation and/or recruitment of monocytes from the peripheral circulation. The functional significance of enhanced marker expression requires further clarification.

[Ergospirometric studies of normal probands for an unsteady-state increment test program]. / Ergospirometrische Normalkollektivuntersuchungen für ein Unsteady-state-Stufentestprogramm.

One-hundred-sixteen healthy subjects (60 female and 56 male) with normal height (L) and weight (w) were selected to provide an even distribution of age (A, 20-70 years). All underwent an unsteady state cycle ergometer test with work increments of 20 watts each minute to exhaustion. A commercially available exercise testing system (EOS SPRINT, Jäger Corp., FRG) with gas analysis from a mixing chamber was used to study oxygen uptake (VO2), carbon dioxide output (VCO2), heart rate (HR), tidal volume (VT), breathing frequency (BR) and arterial oxygen tension (PO2) with special regard to the ventilatory anaerobic threshold (VAT) and maximum power output. For all parameters multiple regression equations were determined. Furthermore, heart rate reserve (HR-reserve), breathing reserve (VE-reserve), O2-pulse (VO2/HR), the dead space/tidal volume ratio (VD/VT) and the alveolar-arterial PO2-difference (AaDO2) were calculated. Day-to-day reproducibility was proven in 21 subjects. VO2max in females was 1584 +/- 300 ml/min (VO2max = -17 A + 10 L + 10 G + 58, r = 0.75, p < 0.0001), VO2AT 957 +/- 159 ml/min (VO2AT = 0.35 VO2max + 0.40 l/min, r = 0.77, p < 0.0001). The ratio VO2AT/VO2max was 50 +/- 7%. In male, VO2max was 2452 +/- 529 ml/min (VO2max = -23 A + 23 L + 9.5 G - 1395, r = 0.78, p < 0.0001), VO2AT 1209 +/- 213 ml/min (VO2AT = 0.29 VO2max + 0.51 l/min, r = 0.71, p < 0.0001), and VO2AT/VO2max 62 +/- 9%.(ABSTRACT TRUNCATED AT 250 WORDS)

Air trapping and cardiopulmonary exercise testing in patients with mild to moderate bronchial obstruction: clinical role of trapped gas measurements.

UNLABELLED: In 14 patients with obstructive airways disease (7 atopic asthmatics, 7 COPD pts with stable disease, FEV1 < 65% pred., 11 m, 3 f, age 50.9 +/- 17.2 y) the effect of a beta mimetic agent on physical performance was studied. PROTOCOL: Inhalation of 2.5 ml normal saline (P) or salbutamol 0.1% (S) in double-blind random order on 2 successive days. Spirometry, body-plethysmography, single-breath helium dilution at rest. Spiroergometry with incremental workload to tolerance. The volume of trapped gas (D) was derived from: TLC Body-TLC Helium Single Breath. RESULTS: Base line values revealed mild to moderate airways obstruction (FEV1 2.04 +/- 0.81 L, FEV1/VC 60.2 +/- 8.5%). Subsequent to inhaling S FEV1 increased significant by 20% to 2.38 +/- 0.87 L. There was a concomitant substantial improvement of VC (3.37 +/- 1.09 L to 3.60 +/- 0.93 L). Rs declined sign. (2.37 +/- 1.43 to 1.69 +/- 0.8 kPa*s), and so did D (1.15 +/- 0.73 L to 0.55 +/- 0.89 L = -20% from base line). Despite clear-cut bronchodilation exercise performance did not improve in response to S (114.6 +/- 49.3 vs 112.5 +/- 50.0 Watt max, ns). Base line max. VO2 (19.78 +/- 6.36 ml/min/kg) and VO2 at anaerobic threshold (13.29 +/- 3.21 ml/min/kg) suggested only minimal impairment of physical performance. S induced a small but significant decrease in max. VO2 (19.78 +/- 6.36 to 18.43 +/- 6.27 ml/min/kg, p < 0.025). Gas exchange (derived from AaDO2) was impaired at rest (30.18 +/- 10.4 mmHg) and during exercise (28.07 +/- 13.03 mmHg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Predictive value of ergospirometry in preoperative assessment of risk factors before lung resections]. / Prädiktiver Wert der Spiroergometrie in der präoperativen Abschätzung von Risikopatienten vor Lungenresektionen.

Surgical resection for lung cancer provides the only real chance for cure. However, there is a high risk of postoperative complications including death for patients with pulmonary dysfunction. Therefore preoperative identification of patients at risk is necessary. Apart from history and physical examination three tests are currently used: 1. resting lung function (RFL), 2. invasive measurement of pulmonary vascular resistance (PVR) and 3. exercise testing with measurement of oxygen consumption (VO2). Main studies in the literature report the probability of abnormal tests for prediction of pulmonary complications (positive predictive value) and the probability of normal tests for prediction of uneventful outcome (negative predictive value) as follows: [table: see text] In conclusion, the "ideal" test predictive for morbidity and mortality after lung resection has not been found. The positive predictive values of RLF and PVR are disappointing, while the negative predictive values are acceptable. Measurement of VO2 is simple, noninvasive and might predict survivable morbidity, as suggested in the literature. Obviously, additional studies are necessary.

Chronic Pneumocystis carinii pneumonia in AIDS.

The clinical and radiologic presentation as well as the macroscopic and histologic characteristics of lung parenchyma in three HIV-infected patients with Pneumocystis carinii pneumonia (PCP) are detailed. The distinguishing clinical feature in these patients was a prolonged stable clinical course of the disease over at least 4 to approximately 24 months. Serial chest radiographs in two patients demonstrated persistent focal radiographic lesions. In one patient blebs in both upper lobes were not recognized until thoracoscopy/thoracotomy was performed. Biopsy specimens of affected areas revealed extensive interstitial fibrosis, occasional giant cell reactions, and honeycombing. In view of the combined clinical, radiologic, macroscopic, and histologic patterns, it is suggested that these patients had a chronic productive form of PCP rather than the well-known acute presentation of the disease. Data from the literature confirm the impression that atypical histologic lesions of PCP, either of a productive or destructive nature, are frequently related to a prolonged clinical course. It is unlikely that prophylactic pentamidine contributes to this entity. Coinfection with other pathogens may have a role. Given the recent evidence on augmented release of tumor necrosis factor a (TNFa) in HIV-associated pulmonary complications, it is speculated that TNFa may be of importance in producing focal fibrosis in Pneumocystis infection of the lung.

Reversible volume changes of trapped gas in nonspecific bronchoprovocation tests.

Thirty patients with a history of asthma and ten patients with suspected bronchial hyperreactivity underwent nonspecific provocation testing. The control group consisted of ten normal volunteers without a history of lung disease. The patients' baseline FEV1 (percent predicted) revealed mild obstructive disease (72.9 +/- 8.9 percent and 74.6 +/- 7.7 percent) compared with controls (87.2 +/- 8.5 percent, p less than 0.001). The mean volume of trapped gas (D) (ie, TLCB-TLCHe) was not significantly different between groups (0.11 +/- 0.49 L vs 0.15 +/- 0.4 L vs 0.18 +/- 0.45 L), and no correlation was established with any of the remaining lung function data. Bronchial hyperreactivity in response to inhaling acetylcholine could be observed in the asthma group only. Their mean D increased significantly from 0.11 +/- 0.49 L to 0.62 +/- 0.66 L (p less than 0.001), and returned to baseline (0.26 +/- 0.55, NS) subsequent to inhaling salbutamol. D changes induced by acetylcholine correlated weakly with concurrent changes of FEV1 (r = -0.44, p = 0.01), RV (r = 0.59, p less than 0.001), and Rs (r = 0.59, p less than 0.001). In response to bronchodilating doses of salbutamol, however, D was changed in close correlation with FEV1 (r = -0.82, p less than 0.0001), RV (r = 0.85, p less than 0.0001), and Rs (r = 0.76, p less than 0.0001). Provided that D is a valid parameter of small airways function, these data may give a clue to the site of action of both drugs. Acetylcholine affects small and large airways alike with no clear-cut preference, whereas salbutamol's predominant target appears to be the small airways. These conclusions are only partially supported by the pertinent literature.

[Transesophageal echography in staging of bronchial cancers]. / Transösophageale Echographie im Staging von Bronchialkarzinomen.

The kind of relation of central lung cancer (c) to the walls of the central pulmonary arteries (PA) and the aorta is an important information prior to operative or interventional (laser/afterloading) therapy. As computed tomography (CT) and angiography are often inaccurate in the assessment of PA-infiltration, we assessed the diagnostic value of transesophageal echography (TEE) in the staging of LC. 16 patients (pts.) were investigated using TEE in addition to CT or magnetic resonance imaging (MRI). Eleven pts. had central LC, 3 peripheral LC, 1 anterior mediastinal mass and 1 central pneumonia (cancer excluded). 2 pts. with central LC were unable to swallow the probe. In 9/9 pts. with central LC, 1/3 pts. with peripheral LC and 1 pt. with enlarged anterior mediastinum the tumour mass could be visualized. In the pt. with a centrally located infiltrate on chest radiogram TEE demonstrated enlarged hilar lymph nodes, but excluded a central tumour. Main PA branches could be identified in all 14/14 pts. Central left or right PA were compressed slightly in 3 pts. and severely in 2 pts., with a near total occlusion in one (confirmed by MRI/CT). TEE revealed PA-infiltration in 2 pts. and aortic wall infiltration in 2 other pts. Despite adjacent tumour mass aortic wall infiltration was excluded in 2 pts. Enlarged hilar lymph nodes could be demonstrated in 2/9 pts. with central LC, whereas CT/MRI showed enlarged mediastinal lymph nodes in 7/9 pts. In conclusion, TEE is able to visualize central lung cancer and gives useful additional informations about the kind of relation to central PA and the aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

Pentamidine aerosol increases the number of alveolar macrophages in HIV-infected patients.

In order to determine the possible effect of aerosolized pentamidine on the cellular composition of the bronchoalveolar lavage fluid in HIV-infected patients, differential counts of 22 consecutive patients who had been rebronchoscopied after 3-19 months were reviewed. Eleven patients were started on pentamidine prophylaxis subsequent to their first presentation. Eleven patients had never taken pentamidine or had discontinued the prophylactic regimen. Compared to first bronchoscopy, the bronchoalveolar lavage (BAL) from patients on regular prophylaxis revealed a significant increase in absolute alveolar macrophage (AM) counts at second presentation (20.8 +/- 11.2 to 50.3 +/- 39.4 x 10(5) cells/100 ml BAL; P less than 0.01). The AM counts of those without pentamidine remained essentially unchanged. Lymphocytes, including CD4 and CD8 subtypes, and neutrophils did not change over time in either group. The results of this retrospective analysis suggest that, in addition to its antimicrobial action, pentamidine may modulate local lung defence mechanisms, particularly by increasing the absolute number of AM.

[Acute pneumocystosis during polychemotherapy following the MACOP-B protocol]. / Akute Pneumozystosen unter Polychemotherapie nach dem MACOP-B-Protokoll.

Four out of eleven patients--none of them HIV positive--who received treatment for non-Hodgkin lymphoma by the MACOP-B protocol between June 1989 and February 1990 were taken ill during or shortly after the conclusion of the course with fulminant pneumonia necessitating artificial ventilation. In three cases Pneumocystis carinii was identified as the pathogen, and in one patient the diagnosis of pneumocystosis seemed probable. The mean cumulative doses given before the outbreak of pneumonia were as follows: cyclophosphamide 2753 +/- 1161 mg, methotrexate 1590 +/- 667 mg, bleomycin 36 +/- 16.8 mg and prednisone 4378 +/- 1734 mg. The mean haemoglobin concentration was 10.7 +/- 0.5 g/dl, leucocyte count 5250 +/- 2100/microliters, lymphocyte count 1300 +/- 300/microliters and lactate dehydrogenase 227 +/- 34 U/l. The cumulative doses and laboratory findings in the seven patients not affected by pneumocytosis were not significantly different. The patients with pneumonia were supported by mechanical ventilation for 6-26 days and treated with large doses of corticosteroids and co-trimoxazole. One patient died after 17 days' ventilation. Three patients were successfully weaned from the ventilator. Chemotherapy protocols such as MACOP-B predispose to acute Pneumocystis pneumonia. The risk of infection is independent of the cumulative doses of the drugs employed. For this reason, prophylaxis with co-trimoxazole is normally mandatory.

[Difficulties in the diagnosis of AIDS-associated intrapulmonary Kaposi sarcoma]. / Schwierigkeiten in der Diagnostik eines AIDS-assoziierten intrapulmonalen Kaposi-Sarkoms.

Diagnosis of intrapulmonary Kaposi's sarcoma in HIV-infected patients may be extremely difficult. This is demonstrated in a case of a male patient with disseminated Kaposi's sarcoma and lethal pulmonary involvement. The value of various diagnostic procedures is discussed.

Bacteraemia caused by Stomatococcus mucilaginosus in a granulocytopenic patient with acute lymphocytic leukaemia.

A patient undergoing chemotherapy for acute lymphoblastic leukaemia developed bacteraemia caused by Stomatococcus mucilaginosus while he was granulocytopenic. The organism may have been selected from the upper respiratory tract flora during prophylaxis with oral ciprofloxacin and then translocated to the blood stream via the mucosa. The strain produced an API-Staph profile indistinguishable from that of Micrococcus kristinae. Since a catalase-negative reaction is highly suggestive of S. mucilaginosus, the test should be performed routinely if this organism is not to be overlooked.