Heparin-induced hyperkalemia.

Heparin sodium is routinely used in the prophylaxis against deep venous thrombosis in medical and surgical patients. While most physicians are aware of heparin-induced thrombocytopenia and skin necrosis, the association of heparin and hyperkalemia is less well recognized. We present four cases in which the use of heparin was associated with hyperkalemia and discuss the pathophysiology. Our findings suggest that hyperkalemia can develop with the use of low-dose heparin, within seven days of initiating heparin therapy, and that patients with diabetes mellitus or chronic renal insufficiency are especially predisposed to this complication.

Thymic carcinoid with cutaneous hyperpigmentation.

Carcinoid tumors of the thymus gland have occasionally been associated with endocrine hyperfunction. A case of thymic carcinoid was initially observed as Cushing's syndrome and was also associated with marked hyperpigmentation. While the hyperpigmentation may be related to the excessively high levels of corticotropin, it is also possible that thymic carcinoids could produce melanocyte-stimulating hormone-like (or beta-lipotropin) material.

Nortriptyline-induced severe hyperventilation.

A 61-year-old man with end-stage renal disease developed severe hyperventilation following nortriptyline hydrochloride usage for depression. He required mechanical ventilation and paralysis to correct severe respiratory alkalosis. To our knowledge, nortriptyline usage has not been previously associated with hyperventilation.

Adult respiratory distress syndrome secondary to tularemia pneumonia.

Three patients with tularemia pneumonia developed adult respiratory distress syndrome and required positive end-expiratory pressure for adequate oxygenation. Rapid improvement was noted following appropriate antibiotic therapy, and mechanical ventilation was successfully discontinued after six to eight days.

Arrhythmogenic effects of orally administered bronchodilators.

The respiratory and circulatory effects of orally administered ephedrine sulfate, 25 mg, aminophylline, 400 mg, terbutaline sulfate, 5 mg, and placebo were evaluated in 20 patients with ventricular arrhythmia by a double-blind crossover method. The bronchodilator effect of terbutaline was similar to that of aminophylline over four hours but superior to ephedrine at the fourth hour. Both terbutaline and ephedrine exhibited chronotropic effects, with the effect of terbutaline greater than that of ephedrine at the fourth hour. The effect of aminophylline on heart rate did not differ from placebo. Only terbutaline was associated with an increase in ventricular ectopic beats. Ventricular tachycardia occurred in three patients treated with terbutaline and in one patient with ephedrine. There were no significant changes in blood pressure. Orally administered terbutaline should not be regarded as safer than orally administered ephedrine or aminophylline in patients with arrhythmias.

Effect of beta-blockade on right ventricular performance in patients with and without right ventricular dysfunction due to coronary artery disease.

To assess the effects of beta-blockade on right ventricular performance in patients with and without right ventricular dysfunction due to coronary artery disease, we performed radionuclide ventriculography on eight patients with normal right ventricular ejection fraction (RVEF greater than or equal to 35%) and 14 patients with mild to moderate right ventricular dysfunction (RVEF less than 35%) at rest. All patients had chronic stable angina pectoris, and nine patients had prior myocardial infarction. Radionuclide ventriculography was performed on placebo and during clinical beta-blockade (heart rate, 50 to 60 beats per minute and less than or equal to 20% increase in heart rate over baseline during stage I treadmill exercise, Bruce protocol) with the oral, cardioselective beta-blocking agent, betaxolol. The resting RVEF (mean +/- 1 SD) was 33% +/- 7% on placebo and 34% +/- 7% during clinical beta-blockade. Mean exercise RVEF was 40% +/- 8% on placebo and 39% +/- 8% during clinical beta-blockade. These differences were not statistically significant. Resting left ventricular ejection fraction ranged from 22% to 60% (mean, 42% +/- 8%). On placebo, one of eight patients with a resting RVEF greater than or equal to 35% had a normal exercise RVEF response (greater than or equal to 5% increment) whereas nine of 14 patients with resting RVEF less than 35% had normal exercise response. The discordant relationship between baseline RVEF and exercise response on placebo became less marked during clinical beta-blockade. We conclude that beta-blockade does not produce significant deterioration of right ventricular systolic function or right ventricular reserve either in patients with normal or in those with mild to moderately impaired resting right ventricular systolic function.

The Guillain-Barré syndrome: pulmonary-neurologic correlations.

In a retrospective analysis of 40 hospitalized patients with the Guillain-Barré syndrome (GBS), we related the use and outcome of assisted ventilation to specific quantitative details of the neurologic illness. Two patients had an unusually prolonged course: they were ventilated for 374 and 396 days before successful weaning. The other 38 patients were similar in most respects to those in previously reported series. Sixteen ventilated patients were hospitalized 56.6 +/- 10.6 (mean +/- S.E.M.) days, were ventilated 27.9 +/- 6.5 days, and had primarily pulmonary complications. There were 4 deaths during ventilation, and 9 of 13 survivors (69%) had a short-term excellent functional neurologic outcome. Attention to the neurologic details of the course of illness may spare some patients from tracheostomy. Twenty-two patients not requiring respirator support suffered distinctly less severe neuromuscular impairment with minimal cranial neuropathy, had no occurrence of pneumonia, and were discharged after 19.1 +/- 4.6 days. Eighty-one percent had an excellent functional outcome. The wide range of manifestations and severity of patients with GBS requires the attending physician to be flexible in dealing with each case and not make management decisions arbitrarily, by reference to a hypothetical "typical case."

A prospective evaluation emphasizing pulmonary involvement in patients with mixed connective tissue disease.

Pulmonary involvement in mixed connective tissue disease (MCTD) is common, frequently severe, and is often clinically inapparent and variably responsive to corticosteroid/cyclophosphamide treatment. Serial pulmonary evaluation of patients with MCTD is important, since deterioration, as in the diffusing capacity over time, may alert the physician to the need for more invasive evaluation. Patients with a greater degree of overlap in rheumatological symptoms with an element of systemic sclerosis (PSS) may later develop severe disease. Nailfold capillary microscopy also may help in determining which patients will develop severe pulmonary involvement. Significant pulmonary hypertension occurs and cannot be accurately predicted on the basis of history, physical examination, pulmonary function tests, gallium scanning, or exercise testing. The characteristic pathological finding was intimal proliferation with medial muscular hypertrophy in the pulmonary arterioles. In contrast, pulmonary interstitial abnormalities were minimal, suggesting the proliferative vascular lesions are more closely associated with pulmonary hypertension in MCTD. Some patients develop rapidly progressive disease with varying response to corticosteroid and cytotoxic agents. More commonly, however, MCTD patients with long-term disabling disease, including pulmonary dysfunction, have had significant improvement with steroid and/or cyclophosphamide treatment, and clinical remission has occurred in 38% of the patients in this series.

Lymphomatoid granulomatosis presenting as central neurogenic hyperventilation.

A patient with lymphomatoid granulomatosis and focal transformation to lymphoma limited to the central nervous system presented with severe central neurogenic hyperventilation. The hyperventilation resolved as the underlying pathologic condition was treated with prednisone and cyclophosphamide.

Severe hypoxemia in farmer's lung disease with normal findings on chest roentgenogram.

A 33-year-old woman farmer developed an acute episode of fever, cough, and shaking chills with persistent shortness of breath. Her PaO2 was 51 with a restrictive pattern on pulmonary function. Her diffusion capacity was 36 percent of predicted. In spite of these abnormalities, she always had normal chest roentgenographic findings. Further studies, including a lung biopsy, led to the diagnosis of farmer's lung disease.

Bronchoalveolar lavage and technetium-99m glucoheptonate imaging in chronic eosinophilic pneumonia.

A patient with chronic eosinophilic pneumonia was evaluated using bronchoalveolar lavage, technetium-99m glucoheptonate, and transbronchial lung biopsy. Bronchoalveolar lavage revealed 43 percent eosinophils and correlated well with results of transbronchial lung biopsy. Technetium-99m glucoheptonate lung imaging demonstrated intense parenchymal uptake. After eight weeks of corticosteroid therapy, the bronchoalveolar lavage eosinophil population and the technetium-99m glucoheptonate uptake had returned to normal. We suggest that bronchoalveolar lavage, with transbronchial lung biopsy, is a less invasive way than open lung biopsy to diagnose chronic eosinophilic pneumonia. The mechanism of uptake of technetium-99m glucoheptonate in this disorder remains to be defined.

Bedside respiratory analysis by pocket computer.

A computer program is presented which analyzes acid-base and respiratory variables. This program's advantages include limited data input, hand-held portability, error identification, and succinct analysis statements. It is a useful adjunct to daily care of the critically ill.

A comparison of inhaled fenoterol and albuterol in asthma.

In 24 adult asthmatics the effects of clinically recommended doses of fenoterol (320 micrograms) and albuterol (180 micrograms) were compared to placebo in a double-blind, crossover trial. Bronchodilation in FEV1 was significantly greater than placebo for both active drugs: two hours on albuterol and five hours on fenoterol. Results of FEF25-75% were similar. There were no significant changes in pulse rate, blood pressure and electrocardiogram, but 11 patients had mild subjective side-effects on fenoterol.

Leiomyosarcoma in the mediastinum presenting as superior vena cava syndrome.

The authors report a case of leiomyosarcoma in the mediastinum presenting with superior vena cava obstruction, and also demonstrate the aggressive nature of this tumor in spite of radiotherapy. Where technically feasible, surgery appears to be the treatment of choice. The pathologic and electron microscopic features of this tumor are also described.

Bronchiectasis: a cause of pulmonary symptoms in heroin addicts.

Extensive and severe bronchiectasis was found in 7 heroin-addicted individuals with pulmonary symptoms whose chest roentgenograms were not suggestive of severe airway disease. Abnormalities consisted of varicose and cylindrical alterations. Pulmonary function tests revealed airflow obstruction, decreased lung volumes, and diffusion capacity impairment. Arterial blood gas analysis demonstrated mild hypoxemia in all patients and chronic hypocapnia in 4. Serial pulmonary function tests in 2 patients revealed only modest improvement in the degree of airflow obstruction. The occurence of bronchiectasis appeared to be related to episodes of heroin-induced pulmonary edema and infection.

Bilateral diaphragmatic paralysis as a possible paraneoplastic syndrome from renal cell carcinoma.

Bilateral diaphragmatic paralysis is rare. We describe a patient with bilateral diaphragmatic paralysis who died 18 months after initial presentation and who was found to have renal cell carcinoma. At autopsy, no intrathoracic tumor was found that would explain the diaphragmatic paralysis. We believe that this may represent a paraneoplastic syndrome caused by renal cell carcinoma.

Sex hormones modulate the response of pulmonary perivascular inflammation to cyclophosphamide therapy in MRL/MpJ-lpr/lpr mice.

Responses of pulmonary perivascular infiltrates to immunosuppressive therapy with cyclophosphamide (CY) were evaluated in the MRL/MpJ-lpr/lpr (MRL/1) mouse, a model for the study of systemic lupus erythematosus. Male and female mice were divided into the following groups: controls injected with saline; intact mice receiving CY; castrated CY-treated mice; castrated, hormone implanted, CY-treated mice. CY treatment began at 30 days of age and animals were killed at 60 days of age. Lungs were fixed-inflated to 26 cm H2O pressure with glutaraldehyde-formaldehyde fixative. The pulmonary perivascular response to immunosuppressive therapy was graded depending on the extent of infiltrates surrounding 15 pulmonary vessels per animal. Intact males treated with CY alone had almost complete clearing of perivascular infiltrates, whereas intact females did not respond to therapy. Castrated CY-treated males showed a decreased response to CY compared to intact CY-treated males. Castrated, estradiol-implanted males had no response to CY therapy. Estradiol interfered with the therapeutic response to CY in male MRL/1 mice.

Pulmonary inflammation in autoimmune MRL/Mp-lpr/lpr mice. Histopathology and bronchoalveolar lavage evaluation.

Early detection of lupus pneumonitis is difficult because it requires lung biopsy. The authors describe here in detail the age-related histologic changes in pulmonary inflammation, the age-related changes in bronchoalveolar lavage (BAL), and the effect of cyclophosphamide (8 mg/kg) on pulmonary inflammation and bronchoalveolar lavage in MRL/Mp-lpr/lpr mouse, an animal model of systemic lupus erythematosus. To assess the evolution of pulmonary inflammation and response to cyclophosphamide therapy, they compared the age-related progression of pulmonary inflammation with sequential changes in BAL cell populations in this autoimmune mouse model. A striking similarity was noted between age-related changes in pulmonary inflammation and lymphocyte counts in BAL. A trend to reduction in histologic evidence of inflammation was reflected by lymphocytes in BAL in cyclophosphamide-treated (8 mg/kg/day) males but not in females. There was a striking sex-related difference in that the histologic evidence of pulmonary inflammation and bronchoalveolar lavage lymphocyte count in cyclophosphamide-treated males was significantly lower than cyclophosphamide-treated females of the same age.

The effect of terbutaline on cardiac function in patients with stable chronic obstructive lung disease.

The effect of 0.25 mg of terbutaline sulfate, a beta 2-adrenergic agent, on the right and left ventricular ejection fractions (RVEF and LVEF, respectively) was studied in 30 patients with severe stable chronic obstructive pulmonary disease (COPD) with a mean forced expiratory volume in 1 s of 0.79 +/- 0.06 L. All bronchodilator therapy was withdrawn 48 hours before the study. The ECG-synchronized gated equilibrium radionuclide ventriculography showed decreased RVEF in 27 patients and LVEF in 16 patients. Both the RVEF and LVEF significantly increased after the terbutaline injection; this increase was noted both in patients with normal and decreased ejection fractions. We conclude that the increase in ejection fractions after terbutaline injection may contribute to the good clinical response to this drug seen in patients with severe stable COPD even though the bronchodilator effect may be minimal.