Trimetrexate-leucovorin dosage evaluation study for treatment of Pneumocystis carinii pneumonia.

To determine the maximal tolerable dosage of trimetrexate for treatment of pneumocystis pneumonia, 25 patients were treated each day with 45 mg/m2 of trimetrexate and 80 mg/m2 of leucovorin; 10 received 60 mg/m2 and 80 mg/m2; 12 received 60 mg/m2 and 160 mg/m2; and 6 received 90 mg/m2 and 160 mg/m2, respectively. Leucovorin was increased twofold and trimetrexate reduced by 50% or suspended briefly for various levels of neutropenia and thrombocytopenia until blood counts increased. Dosage-modifying hematologic toxicity occurred in 12 (46%), 8 (80%), 9 (75%), and 4 (67%) patients with the respective groups. Cytopenias were in each case reversible and other toxicities were well tolerated. All survivors but one were able to receive a full 21 doses of trimetrexate. Twenty-four (92%), 10 (100%), 7 (58%), and 4 (80%) of patients in the respective groups survived. Thus, the 45 mg/m2/day dosage of trimetrexate with 80 mg/m2/day of leucovorin resulted in the least dosage-modifying toxicity and excellent efficacy. This combination should be selected for studies to compare trimetrexate with other therapies for pneumocystis pneumonia.

Chest roentgenogram in pulmonary tuberculosis. New data on an old test.

The utility of routine admission chest roentgenograms (CXRs) was evaluated in detecting pulmonary tuberculosis and the relationship between roentgenographic patterns and the likelihood of finding acid-fast bacilli (AFB) on sputum smear. Of 58 patients whose chief complaints were unrelated to pulmonary tuberculosis, the CXR suggested tuberculosis in 52 cases (90 percent). In 45 cases, the emergency room physician failed to elicit the patient's respiratory symptoms and did not consider tuberculosis as a diagnostic possibility. In 18 individuals, the diagnosis was missed in the emergency room because of failure to obtain a CXR. Among patients whose roentgenograms showed cavitation or extensive alveolar infiltrate, sputum smears showed AFB in 98 percent of cases. If alveolar infiltrate was absent, or if the roentgenographic pattern was not that of adult reactivation disease, sputum smears revealed AFB in only one half of the cases. We conclude that routine admission CXRs are useful in hospitals serving populations where tuberculosis is still common, and the probability of detecting AFB on sputum smear is greatly influenced by the roentgenographic findings.

Cutaneous ulcers in sarcoidosis.

We treated four patients with multisystem sarcoidosis and skin ulceration. Their cases are compared with those of patients previously described in the literature. Treatment for ulcerative sarcoid is also discussed.