[Patient with a lung abscess, primarily treated with drainage followed by antibiotics]. / Een patiënt met een longabces, primair behandeld met drainage en aanvullend met antibiotica.

A 45-year-old woman presented herself with coughing, nocturnal sweating, weight loss, and chest pain, left laterally. In the previous 5 months she had been treated twice with antibiotics due to a suspected pneumonia. With the help of a CT scan, 2 subpleural lung abscesses were diagnosed. The primary treatment was CT-guided drainage, as a result of which the largest abscess was emptied and a microbiological diagnosis could be established. Subsequently, the patient made a quick recovery with the help of specific antibiotics. It might be better to drain lung abscesses, especially subpleural ones, at an early stage rather than wait for the results of a trial treatment with antibiotics.

Chondrosarcoma of the lobar bronchus with prolonged postoperative survival.

Primary chondrosarcoma originating from the bronchus is very rare. We describe the case of a 71 year old man with a large chondrosarcoma originating from the left lower lobe bronchus. The tumour was resected and, in contrast to most patients with such tumours, this patient is well, without complaints or abnormalities on X-ray or computed tomographic (CT) scan, 3 yrs after surgery. Tumour characteristics, symptoms, diagnosis and treatment are discussed. Radical surgical resection is the treatment of choice.

Nedocromil sodium versus albuterol in the management of allergic asthma.

In a double-blind, double-placebo, randomized crossover study, we compared the effects of 6 wk of treatment with the anti-inflammatory drug nedocromil sodium (16 mg/day) with 6 wk of treatment with the bronchodilator drug albuterol (800 micrograms/day) in 29 adults with allergic asthma. After 3 and 6 wk of treatment with nedocromil sodium, patients were significantly less hyperresponsive to propranolol (p = 0.002 and p = 0.02) and almost significantly less hyperresponsive to histamine (p = 0.071 and p = 0.065). FEV1 and FVC percent predicted tended to be higher, morning PEF values increased significantly (p = 0.038 and p = 0.03), and diurnal and day-to-day PEF variation decreased (p = 0.03 and p = 0.093, p = 0.005 and p = 0.096, respectively) with nedocromil sodium treatment compared with albuterol treatment. Almost all symptoms (daytime and nighttime asthma, wheezing, shortness of breath) and the additional bronchodilator use were significantly reduced with nedocromil sodium treatment compared with albuterol treatment. Treatment with the anti-inflammatory drug nedocromil sodium was shown to be superior to treatment with the bronchodilator drug albuterol. The patient's clinical situation may deteriorate when beta 2-agonists are used continuously. Nedocromil sodium has good clinical effect, and it may serve as a first-line choice for antiinflammatory therapy in asthma.

Effects of budesonide and bambuterol on circadian variation of airway responsiveness and nocturnal symptoms of asthma.

Effects of the inhaled corticosteroid budesonide and the oral beta-agonist bambuterol on the nocturnal worsening of asthma were studied in patients with allergic asthma with a circadian peak expiratory flow variation greater than or equal to 15% (group 1, n = 8) and less than 15% (group 2, n = 9). Airflow limitation and airway responsiveness to histamine were measured during 24 hours after 4 weeks of treatment with (A) 0.4 mg budesonide at 8 AM and 8 PM, (B) 20 mg bambuterol at 8 PM, and (C) placebo, in a randomized, crossover design. Patients in group 1 had worse nocturnal symptom scores and a greater airway responsiveness than patients in group 2; in addition, patients in group 1 had a larger increase in responsiveness during the night (1.1 versus 0.6 doubling concentrations [DC]). Both budesonide and bambuterol improved responsiveness more at night than during daytime, thus decreasing circadian variation: at 4 AM, increases in PC20 were 2.0 DC after budesonide and 0.8 DC after bambuterol, compared with placebo. Bambuterol reduced circadian variation in FEV1, but in contrast to budesonide, did not improve 24-hour mean levels of FEV1 and PC20. Both drugs beneficially influenced nocturnal symptoms; the effects of budesonide were stronger than those of bambuterol. Our findings demonstrate that budesonide and bambuterol reduce nocturnal airway responsiveness and asthma symptoms and suggest a relationship between the degree of airway responsiveness and the presence of nocturnal symptoms of asthma.

An unusual cause of subcutaneous emphysema, pneumomediastinum and pneumoperitoneum.

A 62 year old female with subcutaneous emphysema, pneumomediastinum and pneumoperitoneum, was observed. Pneumothorax, however, was not present. Laparotomy revealed a large infiltrate in the left lower abdomen, which had penetrated the anterior abdominal wall. Microscopically, a recurrence of previously diagnosed vulval carcinoma was demonstrated. Despite intensive treatment the patient died two months later.

Cefuroxime axetil in acute purulent exacerbations of chronic bronchitis.

51 hospitalised patients with acute purulent exacerbations of chronic bronchitis were treated for ten days with two daily 1 g doses of the orally absorbed pro-drug cefuroxime axetil. However, some patients were still infected with Haemophilus influenzae or Branhamella catarrhalis at follow-up, and sputum purulence remained. Clinical results were "excellent" or "good" in 60% of the evaluable patients one week after the end of the treatment. Mean peak serum concentrations averaged 12.8 mg/l with mean peak sputum concentrations of 1.8 mg/l. The MIC90 value for H. influenzae was 4 mg/l. Three patients discontinued cefuroxime because of unwanted gastrointestinal drug effects, and three because of insufficient improvement. These results do not suggest that this compound is indicated for such patients.

The quinolones in chronic bronchitis.

Results are presented from 186 hospitalized patients treated for acute purulent exacerbations of chronic bronchitis with orally administered ciprofloxacin (80 patients), enoxacin (26 patients), ofloxacin (30 patients) or pefloxacin (50 patients). In general, good clinical results were observed in 50-70% of the patients treated, most failures being due to relapses or reinfections with Streptococcus pneumoniae or Pseudomonas aeruginosa. Studies on blood and sputum concentration suggested that gastro-intestinal absorption was not always satisfactory. Unwanted drug effects were noted with all agents studied, generally presenting as stomach pain, nausea, hallucinations, or dizziness. Most adverse drug reactions were seen with enoxacin, often but not always during concomitant treatment with theophylline.

[New oral quinolone compounds in chronic bronchitis]. / Neue orale Chinolon-Verbindungen bei chronischer Bronchitis.

Clinical, microbiological and pharmacokinetic results are presented from studies in 186 patients treated with the new quinolone antimicrobial agents enoxacin, pefloxacin, ciprofloxacin or ofloxacin. Almost all had been admitted to hospital for acute purulent exacerbations of chronic bronchitis, associated mainly with Haemophilus influenzae, Streptococcus pneumoniae, Branhamella catarrhalis or Pseudomonas aeruginosa. The H. influenzae and B. catarrhalis strains were generally very sensitive to the quinolones and sputum concentrations of 1.3 to 4.5 mg/l exceeded the MICs (geometric mean values 0.07 to 0.44 mg/l) by a factor of more than 10. In contrast, P. aeruginosa was slightly less sensitive (geometric mean MICs 0.4 to 4.4 mg/l) and S. pneumoniae much less so (with geometric mean MICs between 0.84 and 6.7 mg/l) and a number of treatment failures were noted with these organisms. Various unwanted drug effects (mostly upper gastro-intestinal) were seen, particularly with enoxacin. The best clinical results were observed with ofloxacin, even with once daily dosage, but the results with the other quinolones could only be described as moderate.

Pefloxacin in acute exacerbations of chronic bronchitis.

Forty-three patients admitted to hospital with acute purulent exacerbations of chronic bronchitis were treated with 400 mg pefloxacin twice daily for ten days. The first 20 patients were given the first dose of the drug as a 60 min intravenous infusion. Serum and sputum concentrations of pefloxacin were measured microbiologically at intervals on the first treatment day and the sputum was cultured before, during, and after the course of pefloxacin. Two patients died from unrelated causes during the follow-up and one refused to continue treatment. All strains of Haemophilus influenzae and Branhamella catarrhalis were eradicated at end-of-treatment but eight strains of Streptococcus pneumoniae and three of Pseudomonas aeruginosa were cultured and the sputum remained purulent despite the pefloxacin. Peak serum concentrations averaged approximately 4.5 mg/l after the infusion and 5 mg/l on oral administration, the corresponding sputum concentrations being 3.8 and 4.6 mg/l, respectively. MICs for H. influenzae were 0.06 mg/l, or less. Mode MICs for the pre- and post-treatment strains of Str. pneumoniae were 4 and 16 mg/l, and the corresponding values for Ps. aeruginosa were 2 and 16 mg/l. The poor results in pseudomonas and pneumococcal infections could largely be explained by the degree of resistance among these organisms.

Aztreonam in patients with acute purulent exacerbations of chronic bronchitis: failure to prevent emergence of pneumococcal infections.

A group of 36 patients, all requiring hospital admission because of acute purulent exacerbations of chronic bronchitis, were treated with 1 or 2 g intramuscular injections of aztreonam for ten days. Patients with Streptococcus pneumoniae infections were excluded from the study. Sputum cultures before treatment revealed the other usual respiratory pathogens but repeat cultures on days 3, 10 and 17 sometimes yielded Str. pneumoniae, occasionally combined with Haemophilus influenzae or Branhamella catarrhalis. Ten patients had to be given other antimicrobial agents for Str. pneumoniae infections which developed during the study or follow-up periods. Pseudomonas aeruginosa failed to respond well to aztreonam. All the H. influenzae strains were sensitive to aztreonam (MIC 0.25 mg/l, or less) but all strains of Str. pneumoniae were resistant (MIC greater than 32 mg/l). Ps. aeruginosa strains were moderately resistant (MIC generally 4-16 mg/l) and Bran. catarrhalis strains only moderately sensitive (MICs generally 0.5-4 mg/l). Peak serum concentrations averaging approximately 37 mg/l were observed after the 1 g injections (55 mg/l after 2 g) and the corresponding mean peak concentrations in the sputum were 1.3 mg/l and 2.5 mg/l, respectively. The penetration from blood to sputum was thus approximately 3.5% and 4.6% after the 1 g and 2 g doses. No unwanted local or general reactions were observed. The disappointing clinical results (only 23 out of 36 patients with excellent or good clinical results) one week after the end of the treatment were mainly due to the emergence of pneumococcal infections during (and immediately after) therapy. Considering that Str. pneumoniae is still one of the most important organisms associated with acute purulent exacerbations of chronic bronchitis, and that conventional sputum cultures may not always reveal its presence, there is considerable doubt if aztreonam has any place in the treatment, especially as the results in Ps. aeruginosa infections have also been much poorer than expected.

Ceftriaxone in acute purulent exacerbations of chronic bronchitis.

A group of 36 patients, admitted to hospital because of acute purulent exacerbations of chronic bronchitis, were treated with once daily injections of ceftriaxone for 10 days, 17 receiving 1 g injections and 19 patients 2 g doses. At the end of treatment (day 11) six patients remained infected (three with Branhamella catarrhalis and three with Pseudomonas aeruginosa) but during the 7 follow-up days 12 patients developed infections with beta-lactamase producing strains of Bran. catarrhalis, Ps. aeruginosa was cultured from 2 patients and Streptococcus pneumoniae from 3 more. Kinetic studies confirmed the long half-life of ceftriaxone (13 to 14 h in this patient group) and showed average peak serum concentrations of 31 mg/l after 1 g and 43 mg/l after the 2 g dose. The comparable sputum concentrations were 3.5 and 4.8 mg/l, respectively. However, four patients failed to show any ceftriaxone in the sputum despite simultaneous blood concentrations of between 32 and 50 mg/l and in two patients ceftriaxone only appeared in the sputum 12 h after the injection. All except one harboured beta-lactamase-producing Bran. catarrhalis in the sputum, and the possibility of breakdown of ceftriaxone by branhamella beta-lactamases is suggested.

Serum and sputum concentrations of enoxacin after single oral dosing in a clinical and bacteriological study.

Fifteen patients admitted to hospital with acute purulent exacerbations of chronic bronchitis were treated with enoxacin by mouth (three 200 mg capsules twice daily) for ten days. Sputum was cultured before, during and after the treatment course. Serum and sputum concentrations were measured microbiologically at intervals on the first treatment day. Blood was assayed before, and 1, 1 1/2, 2, 2 1/2, 3, 5 and 7 h after the first dose and purulent unhomogenized sputum was tested in samples collected 0-2, 2-4, 4-6 and 6-8 h after this dose. The highest concentrations in serum were usually noted 2 or 2 1/2 h after the medication and ranged from approximately 3 to 6 mg/l (average 4.08 mg/l). The highest sputum concentrations were generally found in the 2-4 or 4-6 h portions, and ranged from 2.2 to 6 mg/l (average 3.68 mg/l). The areas under the serum and sputum concentration-time curves were both calculated to be 17.03 mg/l.h (0-7 h values) whereas the projected 0-12 h values were 25.2 and 26.9 mg/l.h, respectively. The drug concentrations declined slowly in serum and sputum with half-lives of approximately 5 and 4 h. Penetration from blood to sputum as judged on peak to peak ratios was approximately 90%, whereas the AUC value ratios showed penetration ranging from 100 to 107.5%. Unfortunately, 9 of the 15 patients had to abandon the treatment (mostly on the third day) due to unwanted drug effects (principally nausea, but some patients had hallucinations, dizziness or epileptiform attacks) possibly related to interference with theophylline metabolism.