Exudative polyserositis and acute respiratory failure following praziquantel therapy.

Praziquantel is recommended as the drug of choice for all forms of schistosomiasis. We report the first case (to our knowledge) of exudative effusive polyserositis following treatment of schistosomiasis with this drug. This involved pleura, pericardium, and peritoneum and was associated with acute respiratory failure. The latter preceded the appearance of pleural effusions. We present a brief review of the literature and attract attention to the need for close observation of patients with schistosomiasis who are treated with praziquantel.

The "lung shift" in treated schistosomiasis. Bronchoalveolar lavage evidence of eosinophilic pneumonia.

There is conflicting and incomplete information in the literature on the pulmonary reaction which can occur following treatment of schistosomiasis. We examined the pulmonary function, bronchoalveolar lavage profile, and lung histopathology of a patient with pneumonia and peripheral eosinophilia following oxaminquine chemotherapy for intestinal Schistosoma mansoni infection. Spirometry revealed restrictive rather than obstructive impairment, and lavage showed eosinophil prominence which was also seen in the interstitial and alveolar-filling process in transbronchial biopsies.

Adult respiratory distress syndrome and disseminated intravascular coagulation complicating heat stroke.

Fifty two consecutive patients with heat stroke were examined for evidence of adult respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC). Twelve patients were found to have ARDS (incidence of 23 percent) of whom nine (75 percent) died. All of these 12 patients had DIC as compared to only one among the 40 patients without ARDS. Review of the evidence in literature linking ARDS and DIC and our own observations in this study lead to the conclusion that the coagulopathy may be an essential mediator of lung damage in heat stroke and is a reliable marker of its occurrence. This suggests the possibility that screening of heat stroke victims for DIC may identify patients at increased risk of developing overt ARDS and allow early institution of measures which may possibly improve survival.

The annual risk of tuberculosis infection used as predictor of the future incidence of smear-positive cases.

It has been estimated that in underdeveloped countries every 1% annual risk of tuberculosis infection results in an incidence of 50 per 100,000 smear-positive cases. However, workers had theoretically speculated that the incidence would be about one-third less in countries with good medical facilities. I decided to test the latter theory in the city of Riyadh (capital of Saudi Arabia) which enjoys a high standard of living, easy access to medical facilities, and free treatment. I calculated the annual risk of infection (using the standard tables developed by the TSRU of the International Union Against Tuberculosis) from a nationwide survey of tuberculin reactivity that was conducted in 1987-1988. The annual risk was found to be 0.5% in the whole of Saudi Arabia as well as the city of Riyadh. Accordingly, the incidence of smear-positive cases should have been 25 per 100,000 in an underdeveloped community (0.5 x 50 = 25). However, the actual incidence of smear-positive cases in Riyadh was found to be only 15.2 per 100,000 in 1991-1992. This supports the theoretical speculation that the incidence, as predicted from annual risk of infection, is about one-third less in wealthy communities with adequate access to medical care. If this finding is confirmed, it could have two applications: First, the annual risk of infection could be used to predict the future incidence of smear-positive cases in high risk groups in wealthy countries, like immigrants from the third world, and foresee in advance what impact they will have on active tuberculosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Alpha 1-antitrypsin serum levels in widespread bronchiectasis.

This study found significantly higher serum levels of alpha 1-antitrypsin (alpha 1-AT) in 35 patients with widespread bronchiectasis compared with healthy controls. The results are in contradiction with a previous study and four case reports which found an association between alpha 1-AT deficiency and bronchiectasis. However, the validity of the association has been questioned in the literature on the grounds that most of the patients in those reports had other possible aetiologies for their bronchiectasis. We believe the raised level of alpha 1-AT in our patients represents a non-specific acute phase response to bronchial infection. Further studies are needed to clarify whether bronchiectasis, like emphysema, can be a manifestation of alpha 1-AT deficiency.

Tuberculin survey in the Eastern Province of Saudi Arabia.

We present the results of the Mantoux test (5 units tuberculin) survey in the Eastern Province of Saudi Arabia, which was conducted as part of a nationwide epidemiological survey of tuberculosis. A total of 1105 subjects were screened out of whom 630 gave a history of BCG vaccination in the past and 363 were BCG-negative. Among BCG-negative children aged 5-14 years, only 5% had a positive Mantoux, a rate lower than most Third World countries but higher than developed countries were under 2% of children are tuberculin reactors. This calls for continuation of free treatment of active cases and increased efforts towards screening of contacts. The results also vindicate the current policy of giving BCG vaccine at birth and probably indicates the need to revaccinate at school leaving age, in accordance with WHO recommendations. Tuberculin reactivity rose steeply with age (32% at age 15-24 and 72% at age 45-64 years) indicating the presence of a large pool of subjects at risk of breaking into active disease. Finally, 71% (201/283) of children aged 5-14 years who had received BCG vaccine at birth, reacted negatively to the Mantoux test. This supports the findings of previous studies that in the majority of subjects, BCG-induced tuberculin sensitivity fades a few years after vaccination.

"Aerosol-in-bag" administration of inhaled bronchodilators.

Many patients fail to use metered dose inhalers (MDI) correctly even after receiving tuition, as the technique requires hand-lung coordination, and breath-holding. The article describes the various Auxiliary Delivery Systems designed to circumvent the problem, compares them with MDI, and reports a new "Aerosol-in-Bag" method which is home-made, easy for the patient to assemble, and hardly adds to the cost of the MDI. It could be particularly useful in third-world countries where cost and availability are serious considerations. The new method was found to be as effective as a correctly used MDI, in spite of its extreme case of use, as it requires no coordination or special breathing techniques.

Sarcoidosis presenting as recurrent left laryngeal nerve palsy.

A patient with sarcoidosis presented with hoarseness caused by mediastinal lymph nodes compressing the left recurrent laryngeal nerve. The response to corticosteroids was dramatic and complete.

Resistance to antituberculosis drugs in Riyadh, Saudi Arabia.

The prevalence of resistance to antituberculosis drugs in Riyadh was found to be 21.3%, while the rate of primary drug resistance was 11.5%. Resistance to isoniazid was the most common (19.4%) followed by rifampicin and streptomycin. The prevalence of primary and acquired rifampicin resistance was 3 and 33.7% respectively. The majority of isolates from patients with acquired resistance to rifampicin were resistant also to isoniazid.

Management of post-tuberculous complex aspergilloma of the lung: role of surgical resection.

Of 14 patients with complex aspergilloma complicating healed tuberculosis, 12 underwent lobectomy or pneumonectomy for recurrent haemoptysis. No deaths occurred, though one patient needed re-exploration for bleeding. There was no postoperative worsening of dyspnoea despite a mean forced vital capacity (FVC) of 60% predicted for the patients undergoing surgery and of 20% predicted for two patients with severe restrictive defects, perhaps owing to the fact that there was little or no function in the resected part of the lung, as shown by preoperative isotope ventilation-perfusion scanning, and that patients were under the age of 50 and generally fit. There has been no recurrence of haemoptysis during follow up, which has been from 12 to 33 months. Surgical resection, provided that cases are carefully selected, offers the best chance of cure with low mortality and morbidity.