Results of chemotherapy in 30 AIDS patients with symptomatic pulmonary Kaposi's sarcoma.

BACKGROUND: The aim of this study was to report the effects of a three-drug chemotherapy regimen in patients with symptomatic AIDS-related pulmonary Kaposi's sarcoma and to analyse prognostic factors for survival. METHODS: Thirty consecutive HIV seropositive patients with respiratory symptoms and proven pulmonary Kaposi's sarcoma were treated with the same therapeutic regimen comprising adriamycin (30 mg/m2), bleomycin (10 mg/m2), and vincristine (2 mg) administered intravenously once every four weeks. RESULTS: Two patients died during the first course of chemotherapy. In the other 28 cases dyspnoea improved and Pao2 rose despite minimal (n = 17) or no (n = 11) improvement in the chest radiographic appearance. The median survival from the beginning of chemotherapy was 6.5 months. Poor prognostic factors for survival were: (1) absence of cutaneous Kaposi's sarcoma; (2) previous opportunistic infection; (3) CD4 cell count < 100/microliters; (4) leucocytes < 3500/microliters; (5) haemoglobin < 10 g/dl; and (6) absence of radiological response. Of the 28 patients 24 experienced at least one episode of neutropenia which was associated with bacterial infection in 16 cases. CONCLUSIONS: Chemotherapy may improve respiratory impairment in patients with extensive pulmonary Kaposi's sarcoma but the outcome remains poor. The efficacy of chemotherapy may be limited by neutropenia.

Assessment of bone marrow involvement by magnetic resonance imaging in small cell lung cancer. No significant change of staging.

STUDY OBJECTIVE: This prospective study was performed in an attempt to evaluate (1) the rate of magnetic resonance imaging (MRI) demonstrating bone marrow (BM) abnormalities, (2) the correlation of these abnormalities with a pathologic malignant BM involvement, and (3) the possible modification of patients' usual disease staging in the light of these abnormalities. METHODS: After extensive staging investigations, patients' diseases were classified as limited or extensive. Dorsal and lumbar spine MRI was performed for second staging. RESULTS: Thirty-two patients were eligible for this study. In ten patients (31.2 percent), MRI showed abnormalities; in four of them, the BM sample from the posterior iliac crest was free from malignancy. Three of these four patients had extensive disease. The last patient, because he had limited disease, had biopsy at the site of MRI abnormalities; the biopsy specimen revealed a malignant involvement and therefore this patient, initially classified as having limited disease, was classified in the extensive disease group. In only 1 of 32 patients, BM-MRI data modified initial staging. CONCLUSIONS: The metastases disclosure yield of the MRI in the detection of medullar involvement is higher than BM biopsy but especially in patients with extensive disease. Therefore, MRI should not be considered in routine practice, in particular in patients with extensive disease.

Magnetic resonance imaging findings in pulmonary Kaposi's sarcoma: a series of 10 cases.

Since chest X-ray and CT scan features of Kaposi's sarcoma (KS) are nonspecific, we wanted to test the hypothesis that the histological components of this tumour and/or the associated haemorrhagic component, may result in a characteristic signal pattern on magnetic resonance imaging (MRI). Thoracic MRI was performed in a prospective manner in ten patients with acquired immune deficiency syndrome (AIDS) and pulmonary KS. MRI examinations (1.5 Tesla) included Spin-echo T1 (SE-T1), before and after gadolinium injection, as well as T2-weighted sequences (SE-T2). For each sequence the signal intensity of lesions was measured and compared with each other as well as with the signal intensity of muscle. Results were compared to the hemosiderin content of macrophages in the bronchoalveolar lavage (BAL) in all patients and with histological findings in three. The results were compared to values obtained in a control group of seven patients with pneumocystis carinii pneumonia. SE-T1 showed focally increased signal intensity in the pulmonary parenchyma (n = 5). Signal enhancement in parenchymal lesions (n = 10) and along peribronchovascular trees (n = 5) was observed after gadolinium injection. The second echo of SE-T2 showed a markedly reduced signal intensity in pathologic areas (n = 10). This last finding was not observed in the control group. In conclusion, we have identified a pattern of MRI signal abnormalities suggestive of Kaposi's sarcoma. The MRI signal intensity of KS lesions may be related to the angiomatous and fibrous components of the tumour.(ABSTRACT TRUNCATED AT 250 WORDS)

Vitamin D metabolism by alveolar immune cells in tuberculosis: correlation with calcium metabolism and clinical manifestations.

The aim of this study was to investigate the relationship between the pulmonary vitamin D metabolism in tuberculosis and the calcium metabolism abnormalities and other clinical characteristics of the disease. The metabolism of 25-hydroxyvitamin D3 (25(OH)D3) by alveolar immune cells recovered by bronchoalveolar lavage (BAL) was evaluated in parallel to the results of calcium metabolism, 25(OH) D and 1,25 dihydroxyvitamin D (1,25(OH)2D) plasma levels and other clinical parameters obtained in 14 tuberculosis patients. Whilst predominant metabolites produced by lavage cells in patients and controls were 5(E)--and 5(Z) -19-nor-10-oxo-25(OH)D3, 1,25(OH)2D3 was produced by cells from all tuberculosis patients but not by cells from controls. Calcium metabolism abnormalities were observed in only some patients, but the production of 1,25 (OH)2D3 by lavage cells was found to correlate both with 1,25(OH)2D levels (r = 0.67) and post-load urinary calcium excretion (r = 0.59). 1,25(OH)2D3 production by lavage cells was increased in patients of black origin, and those presenting with hilar adenopathy without pulmonary infiltrates, and was correlated with the number of lymphocytes recovered by lavage (r = 0.87). We conclude that 1,25(OH)2D3 production by alveolar immune cells makes a major contribution to the abnormalities in calcium metabolism seen in tuberculosis patients, and may be partly dependent on the clinical characteristics evaluated here.

[Pulmonary and cerebral nocardiosis in a patient infected with HIV]. / Nocardiose pulmonaire et cérébrale chez un patient infecté par le VIH.

We report a case of pulmonary and cerebral nocardiosis in a patient infected with HIV. On the basis of this observation, the authors review the frequency of nocardiosis during the course of an HIV infection and the diagnostic problems proposed, and finally the therapeutic difficulties encountered.

[Acute drug-induced lung diseases with hypoxemia, cytotoxic drugs excluded]. / Les pneumopathies médicamenteuses aiguës hypoxémiantes non liées aux cytotoxiques.

Drug-induced acute lung diseases constitute a chapter of pneumology and intensive care that is now in full mutation. In practice, these diseases are still inadequately indexed and little known, the only exception being those caused by cytotoxic drugs observed in onco-haematology. They create for clinicians difficult diagnostic and therapeutic problems. From the cases reported in the literature, recent review papers and 10 personal cases, the authors ask five successive questions concerning hypoxic pneumopathies: 1) which patients?; 2) which clinical features?; 3) which initial diagnostic discussion?; 4) which are the elements likely to support the drug-induced hypothesis?; 5) which outcome?

Pulmonary Hodgkin's disease in HIV-infected patient. Diagnosis by bronchoalveolar lavage.

We report herein the pulmonary recurrence of Hodgkin's disease coincidental with a marked decrease in the peripheral blood CD4 lymphocyte count in an HIV-seropositive patient with alveolar consolidation on chest roentgenogram. The diagnosis of lung parenchyma involvement was made by bronchoalveolar lavage cell analysis and illustrates the reliability of Reed-Sternberg cell identification in bronchoalveolar lavage for the diagnosis of pulmonary localization of Hodgkin's disease.

[Pulmonary pathology of drug origin]. / La pathologie pulmonaire d'origine médicamenteuse.

Over the past ten years, there has been an impressively growing number of reports about drug-induced pneumonitis (DIP) due to more than one hundred different drugs. The most troublesome question is how to establish with certainty the diagnosis. Usually, five criteria are necessary. 1) The administration of a drug on a more or less long term basis. 2) Newly occurrence of an interstitial pneumonitis (defined on symptomatology, radiological features, pulmonary function test results). 3) Elimination of all other causes of pneumonitis (haemodynamic, infectious, systemic, environmental diseases). 4) Broncho-alveolar lavage (BAL) cell data showing in most cases a lymphocyte alveolitis with an inverted CD4/CD8 ratio. In a certain number of ambiguous circumstances, coupling a provocation test with a sequentially performed BAL could firmly establish the diagnosis. 5) Rapid resolution within a few days or months of the pneumonitis as early as the incriminated drug administration is stopped. Nevertheless sometimes one or more of these criteria are not met, mainly when the pneumonitis is a fibrosis directly induced by a fibrosing toxic mechanism.

[Interstitial pulmonary involvements in polymyositis and dermatopolymyositis. Apropos of 3 cases. Review of the literature]. / Atteintes pulmonaires interstitielles des polymyosites (PM) et dermatopolymyosites (DP). A propos de 3 observations. Revue de la littérature.

The authors report 3 cases of myositis associated with pulmonary lesions that preceded or succeeded the muscular disorder. In one of these cases, which was particularly difficult to diagnose, the patient's serum was positive for the anti-Jol antibody. These 3 cases have encouraged the authors to review the literature with particular attention to the diagnostic approach, the latest physiopathological data and the therapeutic basis of the "specific" pulmonary lesions associated with polymyositis and dermatomyositis.

Minocycline-induced cell-mediated hypersensitivity pneumonitis.

OBJECTIVE: To identify the cause of a hypersensitivity pneumonitis and to determine its pathogenesis. DESIGN: Case study. SETTING: Intensive care unit of a referral hospital. PATIENT: A 51-year-old man with chronic bronchitis who developed a hypersensitivity pneumonitis within 1 month after exposure to minocycline, amoxicillin, and erythromycin. INTERVENTION: Sequential bronchoalveolar lavages after reexposure to minocycline and amoxicillin. MEASUREMENTS: Immunologic analysis of the phenotype and function of alveolar lymphocytes. RESULTS: Reexposure to minocycline but not to amoxicillin was followed by an interstitial pneumonitis. Sequential bronchoalveolar lavages showed a transient rise of eosinophils and neutrophils and a persistent alveolar lymphocytosis. Alveolar lymphocytes consisted predominantly of CD8+ but also CD4+ cells. Two CD8+ lymphocyte subsets were identified: CD8+ D44+ cytotoxic T cells that increased rapidly after the drug was resumed and CD8+ CD57+ suppressor T cells that predominated 11 days after the drug's withdrawal. In-vitro assays showed the presence of a lymphocyte-mediated specific cytotoxicity against minocycline-bearing alveolar macrophages. CONCLUSION: These results support the hypothesis of a central role of T lymphocytes in the pathogenesis of drug-related hypersensitivity pneumonitis.

Severe hypoxemia-associated intrapulmonary shunt in a patient with chronic liver disease: improvement after medical treatment.

A 20-yr-old woman with chronic liver disease and angioimmunoblastic lymphadenopathy presented with marked hypoxemia caused by intrapulmonary shunt. Her respiratory tract showed her to be free of angioimmunoblastic lymphadenopathy manifestations. After 12 months of treatment with cyclophosphamide and corticosteroid, the immunologic disease disappeared. Unexpectedly, hypoxia-associated intrapulmonary shunt was no longer present either. To the best of our knowledge, this is the first case of dramatic improvement, with medical therapy, of severe hypoxemia related to noncirrhotic liver disease. However, the mechanism by which this treatment caused the regression of intrapulmonary shunt is unknown.

[Epidemiology of micro-organisms responsible for community-acquired pneumonia]. / Epidémiologie des germes responsables au cours des pneumopathies communautaires.

Pneumonias occupy a prominent situation among lower respiratory tract infections where they are remarkable for their potential mortality and for our relative knowledge of the responsible micro-organisms. Analysis and synthesis of each series published must answer several questions, such as: what are the lung diseases considered? which investigations have been performed? which criteria of imputability have been used? in which patients has the study been carried out? in which place, which period and which structure? In spite of methodological lacunae and of the inhomogeneous answers to the questions asked, there is some concordance between the series found in the literature. Thus, more than 90% of community-acquired pneumonias with microbiological identification are caused by Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia psittaci (or pneumoniae), or Influenza A virus.

Technetium-99m-DTPA aerosol and gallium-67 scanning in pulmonary complications of human immunodeficiency virus infection.

We retrospectively compared the results of 67Ga chest scans and 99mTc-DTPA aerosol clearance measurements with those of fiberoptic bronchoscopy in 88 patients infected with the human immunodeficiency virus. Of 100 investigations, a pulmonary infection was diagnosed in 39, mainly Pneumocystis carinii pneumonia and a noninfectious disorder was found in 42, mainly Kaposi's sarcoma and lymphocytic alveolitis. Gallium scans and DTPA clearance were abnormal respectively in 74% and 92% of infectious complications, and in 12% and 60% of noninfectious disorders. In 10 cases, DTPA clearance was accelerated, while chest x-ray, arterial blood gases and even gallium scanning were normal. A value of DTPA clearance greater than 4.5%.min-1 was both sensitive and specific for the diagnosis of Pneumocystis carinii pneumonia. The gallium scan was always normal in bronchopulmonary Kaposi's sarcoma. We conclude that in symptomatic patients: (1) DTPA clearance measurements are useful for detecting lung disease when chest x-ray and/or PaO2 are normal and (2) a gallium scan is indicated to distinguish progressive Kaposi's sarcoma from a superimposed second process when radiological abnormalities of pulmonary Kaposi's sarcoma are present.

[Leukocyte migration inhibition test in drug-induced pneumonitis].

The leukocyte migration inhibition test (LMIT) was performed in 8 cases of presumed drug-induced pneumonitis. The drugs involved were amiodarone in 3 cases, methotrexate in 2 cases, and fenofibrate, nadolol, and gold salt, each in one case. The agarose microdroplet technique for photoelectric readings of leukocyte migration inhibition was applied in the presence of a wide range of drug concentrations. LMIT was found to be positive in 6 of the 8 cases (75%). The presence of a positive LMIT indicates the elaboration of leukocyte migration inhibitory factor. These results suggest that cell-mediated immunity may play a role in the pathogenesis of drug-induced pneumonitis and that LMIT may be useful for the detection of causative drugs in patients with this condition.

[Lymphocytic alveolitis in the early stages of HIV infection: correlation with biological and prognostic factors]. / Alvéolites lymphocytaires aux stades précoces de l'infection par le VIH: corrélations avec les facteurs biologiques de pronostic.

Broncho-alveolar lavage was performed to assess the degree of pulmonary lymphocytic alveolitis in 32 asymptomatic patients who were infected with the Human Immunodeficiency Virus (VIH). The patients were stages II and III of the CDC classification and the aim of the study was to determine the frequency, nature and prognostic role of the findings. 62.5% of the subjects (20/32) presented with a lymphocytic alveolitis which consisted predominantly of CD8 lymphocyte (64.3 +/- 3.5%), in the absence of an opportunistic infection or broncho-pulmonary tumours. Two sub-populations of alveolar CD8 were shown at comparable levels, a) sub-population CD8+D44+ (22.1 +/- 5%), in whom we showed the possession of cytotoxic activity in particular specific for VIH; b) sub-population CD8+CD57+ (19.6 +/- 3%) which we have shown to be capable in vitro of inhibiting the effector phase of cytotoxic activity of CD8+D44+ alveolar cells specific for VIH. In this group of 32 patients the occurrence of an alveolitis was not correlated with the usual prognostic factors of infection by VIH measured simultaneously with broncho-alveolar lavage (the level of CD4+ blood lymphocytes, and the beta 2-plasma microglobulins and the presence of p24 antigenaemia). In addition the level of CD4 lymphocytes supperior to 400/mm3 and of beta 2-microglobulins less then 3 mg/l whether a lymphocytic alveolitis was there or not confirmed the relatively poorly developed state of the VIH infection in these asymptomatic patients. Also the occurrence of a lymphocytic alveolitis did not seem to be linked to progression of the disease in the group of patients studied.(ABSTRACT TRUNCATED AT 250 WORDS)

[Should the extended evaluation of bronchial adenocarcinoma be different from that of non-small cell lung carcinoma?]. / Le bilan d'extension des adénocarcinomes bronchiques doit-il différer de celui des autres cancers bronchiques non à petites cellules (CBNPC)?

The records of 132 patients explored for initial evaluation of non-small cell lung cancer (NSCLC) were reviewed to find out whether the evaluation of extrathoracic extension could be influenced by anatomicopathological data. Brain, liver and bone metastases were found to be significantly more frequent in adenocarcinomas than in NSCLCs. This relative frequency was observed at all stages, including stages I and II as defined by computerized tomography of the chest, and in asymptomatic patients. We therefore recommend to evaluate fully the tumoral extension in patients with bronchial adenocarcinoma irrespective of its stage, and to do so even in the absence of clinical symptoms.

[Acute respiratory insufficiency caused by hyperinfestation with strongyloides. BALF diagnosis and favourable outcome]. / Insuffisance respiratoire aiguë liée à une anguillulose d'hyperinfestation. Diagnostic par LBA et évolution favorable.

Hyperinfestation with Strongyloides is a severe complication in immunodepressed patients. It may present with various clinical signs, notably acute respiratory failure. Diagnosis may be difficult, particularly when the strongyloidiasis is associated with septicaemia caused by Gram-negative organisms. We report a new case of hyperinfestation with Strongyloides in a patient treated for periarteritis nodosa. This case was remarkable on two scores: the diagnosis problem raised by the presence of intrapulmonary haemorrhages, and the favourable outcome of an acute and initially severe respiratory failure which had required assisted ventilation. The role played in the patient's cure by the doses of thiabendazole given and the duration of their administration is discussed.