Herpes simplex virus from respiratory tract secretions: epidemiology, clinical characteristics, and outcome in immunocompromised and nonimmunocompromised hosts.

PURPOSE: The purpose of this study was to review the course of patients with herpes simplex virus (HSV) recovered from respiratory tract secretions, and to compare the demographics, clinical characteristics, and outcomes of immunocompromised versus nonimmunocompromised patients. PATIENTS AND METHODS: Retrospective review of medical records of 42 consecutive patients who had respiratory tract cultures positive for HSV-1 between May 1988 and August 1990 at a major university-affiliated hospital. RESULTS: Twenty-seven patients (64%) were not immunocompromised. On the average, the nonimmunocompromised patients were 20 years older (mean age: 67 +/- 15, p = 0.001), had a higher incidence of tobacco smoking (p = 0.04), and were more frequently endotracheally intubated prior to HSV isolation (p = 0.002). Nonimmunocompromised patients more frequently had bronchospasm (44% versus 7%, p = 0.01), leukocytosis (16,400 versus 6,900/mm3, p = 0.001), and difficulty weaning from mechanical ventilation (63% versus 13%, p = 0.002). Mortality was also greater in the nonimmunocompromised group (70% versus 33%, p = 0.02). In addition, for survivors, days of mechanical ventilation (8 +/- 7 versus 2 +/- 4, p = 0.03), length of stay in the intensive care unit (10 +/- 8 versus 2 +/- 4 days, p = 0.004), and length of stay in the hospital (37 +/- 23 versus 16 +/- 14 days, p = 0.04) were all significantly longer for the nonimmunocompromised patients. CONCLUSION: These data suggest that HSV isolation from lower respiratory secretions is associated with a more severe presentation and a worse outcome in immunocompetent patients than in immunosuppressed patients.

Two-dimensional contrast echocardiography in the detection and follow-up of congenital pulmonary arteriovenous malformations.

Pulmonary arteriovenous (A-V) malformation is frequently a manifestation of Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia). We identified 14 patients (9 men and 5 women) with A-V malformation by contrast echocardiography; 10 patients with atrial right-to-left shunt served as control subjects. Agitated saline solution (10 ml) was injected through a peripheral vein during echocardiographic imaging. The delay in the appearance of microcavitations in the left atrium was measured (in number of frames) after right atrial appearance. The degree of left ventricular opacification was graded 1 to 4+ (where 4+ = intense left ventricular endocardial outline, and 1+ = minimal opacification). Results indicated patients with A-V malformation had a significant delay (p less than 0.001) in left atrial appearance of microcavitations compared with those with atrial right-to-left shunt (66 +/- 27 vs 21 +/- 7 frames, mean +/- 1 standard deviation). In the group with A-V malformation, abnormal blood gases were present in only 6 of 14 patients and chest x-ray was positive in 7. Pulmonary angiography was performed in 11 of 14 patients with positive contrast echocardiography, and all 11 had A-V malformation identified. In patients with 3 to 4+ left ventricular opacification (n = 8), large (greater than 5 mm feeding vessel) or multiple malformations were present, whereas patients with small or isolated malformation had 1 to 2+ left ventricular opacification. Balloon occlusion of malformations was performed in all 11 of these patients; repeat contrast echocardiography revealed significant diminution of right-to-left shunt in 9, and 2 required repeat embolotherapy for an additional previously undetected A-V malformation.(ABSTRACT TRUNCATED AT 250 WORDS)

A protocol for initiation of nasal positive pressure ventilation.

BACKGROUND: Respiratory failure related to neuromuscular weakness has commonly been managed with long-term ventilation by tracheostomy. Currently, nasal positive pressure ventilation is being used with success in this patient population. It has been suggested that initiation of nasal positive pressure ventilation is best done in an intensive care setting. METHOD: Nine patients were placed on nasal ventilation during a brief admission to a medical floor staffed by nurses trained in respiratory care. This process was facilitated by use of a standardized protocol for nursing staff that identified treatment objectives. RESULTS: Following the initiation of nasal positive pressure ventilation, this group of patients experienced near normalization of daytime measurements of partial pressure of arterial carbon dioxide, reported increases in daytime energy levels, and relief of nighttime signs and symptoms. These objectives were accomplished with no significant complications. Use of this protocol may also decrease length and cost of hospitalization and improve patient acceptance of noninvasive ventilatory assistance.