Concordance of antibiotic prophylaxis, direct Gram staining and protected brush specimen culture results for postoperative patients with suspected pneumonia.

BACKGROUND AND OBJECTIVES: Antibiotic therapy alters the diagnostic value of protected brush specimens. With protected brush specimens alone, diagnosing pneumonia requires 24 or 48 h. Addition of direct Gram staining shortens this delay. Antibiotic prophylaxis, recommended after major surgery, may influence the contribution of Gram staining to diagnosing postoperative pneumonia. METHODS: During a 1-yr period, we retrospectively studied all patients on mechanical ventilation suspected of having postoperative pneumonia who had undergone fibreoptic bronchoscopy with protected brush specimens. Postoperative pneumonia was diagnosed when quantitative protected brush specimens culture results yielded 103 colony-forming units mL-1. RESULTS: Fifty patients were clinically suspected of having postoperative pneumonia after cardiac (n=42), vascular (n=5) or thoracic (n=3) surgery. Eleven (22%) samples were obtained during antibiotic prophylaxis. Twenty-two (44%) episodes were microbiologically proven. Gram-stain sensitivity was 95.5%, with 82.1% specificity, 80.7% positive-predictive value and 95.8% negative-predictive value. Concordance between direct Gram-stain-identified pathogens and Gram stain of cultured pathogens was significantly less frequent during antibiotic prophylaxis (63.6%) than afterwards (94.9%) (P<0.05). CONCLUSION: Antibiotic prophylaxis diminished the diagnostic value of Gram staining of protected brush specimens. When protected brush specimens was performed during antibiotic prophylaxis, Gram staining accurately enabled early exclusion of postoperative pneumonia because of its excellent negative-predictive value. After antibiotic prophylaxis, Gram staining permitted early diagnosis of postoperative pneumonia identification of the responsible pathogen.

A highly unusual combination of pulmonary pathogens in an HIV infected patient.

We report on a case with an unusual combination of pulmonary pathogens including Pneumocystis carinii, Rhodococcus equi and Toxoplasma gondii in an HIV infected patient. The multiple microbiological procedures required to ascertain the etiological diagnoses of pneumonitis in HIV-seropositive subjects are discussed.

[Demyelinating nervous lesions in myalgia-eosinophilia syndrome induced by L Tryptophan]. / Lésions nerveuses démyélinisantes au cours du syndrome myalgies-éosinophilie secondaire à la prise de L-tryptophane.

A case of severe peripheral nerve lesions in a patient with eosinophilia-myalgia syndrome induced by L-Tryptophan is reported. Both superficial radial nerves were very tender on palpation. Biopsy of the radial nerve showed myelin abnormalities of the type observed in experimental chronic nerve entrapment. Nerve lesions included asymmetrical distortion of the myelin sheath, segmental demyelination, axonal degeneration and regeneration. Such abnormalities suggest that mechanical factors, presumably due to proliferation of connective tissue, play a role in the nerve lesions observed in this patient.

Cytomegalovirus neuropathy in acquired immunodeficiency syndrome: a clinical and pathological study.

We have observed typical cytomegalovirus cytopathology associated with multifocal inflammatory and necrotic lesions of peripheral nerve in biopsy specimens from 4 patients who developed a rapidly progressive, multifocal neuropathy late in the course of human immunodeficiency virus infection. The inflammatory infiltrates, which contained numerous polymorphonuclear cells, were associated with mixed, axonal, and demyelinative lesions of nerve fibers. One of these patients improved on treatment with DHPG (9-[2-hydroxy-l(hydroxymethyl) ethoxymethyl] guanine) and remains stable after 18 months. The other 3 died soon after the onset of the neuropathy. In another patient with acquired immunodeficiency syndrome, who developed a severe, predominantly motor neuropathy of the lower limbs, the nerve biopsy did not reveal cytomegalovirus inclusions, but the neurological deficit improved on treatment with DHPG. The patient died from cachexia 2 months later; numerous cytomegalovirus lesions were found in the spinal cord at the time of postmortem examination. The multifocal necrotic endoneurial nerve lesions with polymorphonuclear cell infiltration we describe may help identify cytomegalovirus neuropathy when characteristic inclusions are not present in the biopsy specimen.

Cisplatin and vindesine for disseminated non-small cell lung cancer. Results of a prospective trial with 81 patients.

Eighty-one patients with disseminated non-small cell lung cancer (stage IV) were treated with 2 monthly cycles of initial chemotherapy combining cisplatin with vindesine. The initial chemotherapy-responding patients (CR, PR, MR) were randomized to 2 cycles or 4 cycles of maintenance chemotherapy. After initial chemotherapy, the response rate was 33% (CR, PR, MR) with 18.5% objective responses. The overall 1-year survival rate was 15% with 37% for responders as opposed to 2% for non-responders. Maintenance chemotherapy did not improve the response rate obtained after initial cycles. The small number of patients does not allow us to reach a definite conclusion on the optimum duration of maintenance chemotherapy. In the absence of large placebo versus chemotherapy randomized trials, no definite conclusion can be made on the benefit of chemotherapy in disseminated non-small cell lung cancer. This study suggests, however, that chemotherapy is associated with a significantly longer survival in responding patients.

[Periarteritis nodosa complicated by intrapancreatic vascular rupture]. / Périartérite noueuse compliquée d'une rupture vasculaire intra-pancréatique.

Clinical pancreatic manifestations are unusual in polyarteritis nodosa. A case of intrapancreatic hemorrhage due to vascular rupture occurring during the course of histologically proven polyarteritis nodosa is described. The patient presented with massive hemoperitoneum requiring emergency laparotomy. Splenopancreatectomy was performed to control bleeding. Steroid therapy was continued during the postoperative course, with favorable outcome. The mechanism of vascular rupture is not clear, but is probably related to focal arteritis with consequent infarction. No ruptured microaneurysm was found in this case.

[Lung diseases during therapeutic aplasia: diagnostic and therapeutic strategy]. / Les pneumopathies survenant en cours d'aplasie thérapeutique: stratégie diagnostique et thérapeutique.

Lung diseases that occur in patients with drug-induced bone marrow aplasia are part of a wider group of lung diseases in immunocompromised patients. Their most common causes are infections due to Gram-negative bacilli, staphylococci or Aspergillus spp. and intra-alveolar haemorrhages. Their diagnostic approach is often limited by disorders of coagulation, risks of infection by bronchial or pulmonary seeding during endoscopy and the lethal risk of mechanical ventilation after bronchoalveolar lavage in patients with respiratory failure. The therapeutic approach is frequently empirical due to the fact that antibiotic therapy cannot be delayed, even for a few hours, and to the aforementioned diagnostic problems. In practice, the diagnostic and therapeutic approaches usually result from a rational compromise depending on whether the lung disease has occurred at the onset or at the end of an episode of bone marrow aplasia.