Legionella pneumophila lung abscess associated with immune suppression.

Legionella species are a common cause of community-acquired pneumonia, infrequently complicated by cavitary disease. We describe Legionella pneumophila pneumonia and abscess formation in an immunosuppressed patient receiving corticosteroid therapy for metastatic breast carcinoma. The predisposing role of corticosteroids is discussed and the management of this complication is reviewed.

[IgA vasculitis secondary to Klebsiella pneumoniae infection]. / Vascularite à IgA satellite d'une pneumopathie abcédée à Klebsiella pneumoniae.

INTRODUCTION: IgA vasculitis is a leucocytoclastic vasculitis of small vessels with immune deposits of IgA. It tends to occur in a post-infectious context, though the pathogenic agent is rarely found. OBSERVATION: We report, for the first time, the case of an 81-year old patient who presented with an acute IgA vasculitis with cutaneous and joint involvement during a Klebsiella pneumoniae respiratory infection. Remission of vasculitis was observed after antibiotic therapy alone. CONCLUSION: This observation reminds us of the need to search carefully for any pathogenic agent that may be driving IgA vasculitis as this may be important both for understanding aetiology and for treatment.

MTB-specific lymphocyte responses are impaired in tuberculosis patients with pulmonary cavities.

OBJECTIVE: Tuberculosis (TB), an infectious disease caused by the bacillus Mycobacterium tuberculosis (MTB), is a global health problem. Because the failing immune response in the lung can lead to formation of a pulmonary cavity, this study was designed to clarify MTB-specific lymphocyte responses in TB patients with pulmonary cavities. METHODS: We utilized culture filtrate protein 10 (CFP-10) and early secretory antigenic target 6 (ESAT-6) as immunogenic MTB antigens following overnight stimulation of peripheral blood mononuclear cells (PBMCs). By flow cytometry, we then dissected CD4+ and CD8+ T lymphocytes secreting intracellular cytokines of IFN-γ and TNF-α to assess the local immune response of TB patients with pulmonary cavities compared with those having other radiological infiltrates. RESULTS: As expected, after 16 h of ex vivo activation using both ESAT-6 and CFP-10, the proportions of CD4+IFN-γ, CD4+TNF-α, CD8+TNF-α, and CD8+IFN-γ cells were all markedly increased in 46 patients with TB when compared with 23 household contacts. However, the IFN-γ and TNF-α responses of both CD4+ and CD8+ T lymphocytes were found to be relatively lower in 18 patients who had pulmonary cavities when compared with 28 patients who had radiological infiltrates. Moreover, patients with cavities had higher absolute numbers of neutrophils than patients with infiltrates. Further analysis indicated an inverse correlation between neutrophil counts and the proportions of IFN-γ-secreting T cells. CONCLUSION: MTB-specific lymphocyte responses are impaired in TB patients with pulmonary cavities that are likely to play an important role in the pathogenesis of cavitary TB.

Surgery of a nocardia lung abscess presenting as a tension pyopneumothorax.

While some cases of nocardial pneumonia develop secondary empyema, tension pyopneumothorax is a very rare and lethal complication. A 74-year-old man who exhibited thrombocytopenia during steroid therapy for autoimmune hepatitis, presented to our department with a nocardial tension pyopneumothorax. He underwent a left lower lobectomy after chest drainage, and was discharged without any complication other than reoperation to remove a postoperative hematoma.

Invasive fungal laryngopharyngitis resulting in laryngeal destruction with complete laryngotracheal separation: Report of a case.

As the treatment of hematopoietic cancers evolves, otolaryngologists will see a higher incidence of opportunistic infections. We discuss a case of invasive fungal disease that invaded the larynx, pharynx, trachea, and pulmonary parenchyma after chemotherapy. The patient, a 46-year-old woman, presented 1 week after undergoing induction chemotherapy. Her initial symptoms were odynophagia and dysphagia. Despite encouraging findings on physical examination, her health rapidly declined and she required an urgent tracheotomy and multiple operations to address spreading necrosis. Because of her inability to heal, she was not a candidate for laryngectomy, so she was treated with conservative management. The patient was then lost to follow-up, but she returned 5 months later with laryngeal destruction and a complete laryngotracheal separation. While noninvasive fungal laryngitis is routinely encountered, its invasive counterpart is rare. The literature demonstrates that some cases completely resolve with medical therapy alone but that surgery is necessary in others. We recommend surgical debridement of all necrotic tissue.

Successful Treatment of Combined Aspergillus and Cytomegalovirus Abscess in Brain and Lung After Liver Transplant for Toxic Fulminant Hepatitis.

Invasive aspergillosis is one of the most important and fatal complications after liver transplant, especially in patients with involvement of the central nervous system. We present a case of a patient who developed cerebral and pulmonary aspergillosis, coinfected with cytomegalovirus, after liver transplant for toxic fulminant hepatitis. The patient was treated successfully with neurosurgical intervention and voriconazole. Voriconazole is considered more effective in cerebral aspergillosis than other anti-fungal agents due to the greater penetration into central nervous system and higher cerebrospinal fluid and brain tissue levels.

Corticosteroids and malnutrition. Aspergillus lung abscess in an asthmatic child.

An adolescent developed invasive pulmonary aspergillosis in the limited form of a lung abscess. She had a weak immunologic response to the infection. Her depressed immunity was the result of prolonged corticosteroid therapy, compounded by malnutrition. In spite of this and other complications of corticosteroids, she made a full recovery from the fungal infection following treatment with amphotericin B and surgical excision of the lung abscess.

The pulmonary nodule after lung transplantation. Cause and outcome.

In the immunocompromised patient, the pulmonary nodule remains a diagnostic and therapeutic challenge. We studied the incidence, cause, diagnosis, and therapy of pulmonary nodules after lung transplantation (LTx). Eight out of 64 patients (12.5%) developed pulmonary nodules after a median follow-up of 5.8 months (range, 1 to 10 months). The median age was 30.5 years (range, 21 to 62 years). Solitary pulmonary nodules (n = 2) disappeared spontaneously within 3 weeks and were suspected to be of infectious origin. The cause of multiple nodules (n = 6) was posttransplant lymphoproliferative disorder (PTLD [n = 3]), aspergillosis (n = 2), and abscesses caused by Pseudomonas aeruginosa and Staphylococcus aureus (n = 1). After an initial chest radiograph, CT with fine-needle biopsy was the most valuable diagnostic tool. In six patients, nodules resolved within 10 weeks (median, 8 weeks). Two patients, however, died of sepsis (P aeruginosa and S aureus and Aspergillus, respectively). The differential diagnosis of pulmonary nodules after LTx primarily comprises PTLD and infection (bacterial or fungal). To improve the outcome, early, aggressive treatment is mandatory; therefore, serial CT scans are strongly recommended to be part of the diagnostic armamentarium in LTx recipients.

Rare, suppurative pulmonary infection caused by Nocardiopsis dassonvillei recognized by glycolipid markers.

An opportunistic actinomycete was isolated as the only etiological agent of a severe, suppurative pulmonary infection. The strain was rapidly recognised as Nocardiopsis by the taxonomically important and immunologically active glycolipid markers (G1 and G2). Identification of the clinical isolate, from a group of actinomycetes mainly known as soil habitants, was definitely proved by chemotaxonomic studies (cell wall/sugar, phospholipid and fatty acid types) as well as by genomic data (GC content, DNA-DNA reassociation). The level of DNA-DNA homology of the clinical actinomycete, in comparison with other reference members of this genus, revealed the highest (88%) relatedness to Nocardiopsis dassonvillei. The results confirmed the value and generic specificity of glycolipid markers from Nocardiopsis, the first time used for rapid recognition of a clinical strain causing a nocardiosis-like disease.

Lung abscess in adults: clinical comparison of immunocompromised to non-immunocompromised patients.

Information related to the clinical characteristics and isolated microbes associated with lung abscesses comparing immunocompromised (IC) to non-immunocompromised (non-IC) patients is limited. A retrospective review for 1984-1996 identified 34 consecutive adult cases of lung abscess (representing 0.2% of all cases of pneumonia), including 10 non-IC and 24 IC patients. Comparison of age, gender, tobacco use, pre-existing pulmonary disease or recognized aspiration risk factors were not significantly different between the two groups. Upper lobe involvement accounted for the majority of cases, although multi-lobe involvement was limited to IC patients. There were no differences in the need for surgical intervention, and mortality was very low for both groups. Anaerobes were the most frequent isolates for non-IC patients (30%), whereas aerobes were the most frequent isolate for IC patients (63%). Importantly, certain organisms were exclusively isolated in the IC group and multiple isolates were obtained only from the IC patients.Thus, comparing non-IC to IC patients, clinical characteristics may be similar whereas important differences may exist in the microbiology associated with lung abscess. These findings have important implications for the clinical management of these patient groups, and support a strategy to aggressively identify microbial agents in abscess material.

Surgery for lung abscess in immunocompetent and immunocompromised children.

PURPOSE: The aim of this study was to evaluate the surgical management results of lung abscess in immunocompetent and immunocompromised children. METHODS: Surgery was performed on 30 children with lung abscess or necrotizing pneumonia refractory to medical treatment in a 12-year period. Of them, 23 were immunocompetent, and 7 were immunocompromised. Pulmonary resection was performed including unilateral lung in 28, bilateral in 2, and 2 lobes in 6. Concomitant decortication was performed in 18 (78.2%) immunocompetent patients. RESULTS: Increased incidence of surgery for lung abscess was caused mainly by drug-resistant and fungal infection. Surgery was performed commonly for bacterial lung abscess on patients less than 5 years old and fungal lung abscess on adolescence. A multiple small abscess was the predominant type of abscess in immunocompetent patients, whereas 2-lobe involvement tended to occur in immunocompromised patients. Fungal lung abscess tended to occur on left lung and in female patients. Left lower lobe was involved most commonly in both groups of patients in which majority need lobectomy. Immunocompromised patients required a more extensive pulmonary resection. There were 3 postoperative complications (morbidity of 10.2%) with no postoperative mortality. Length of postoperative hospital stay ranged from 6 to 85 days with average of 18.4 days. CONCLUSIONS: The incidence and pattern of lung abscess that required surgery between immunocompetent and immunocompromised children were different. A more aggressive, extensive surgical procedure is preferable for immunocompromised patients, and the surgical results were comparatively excellent to immunocompetent patients. However, the prognosis of immunocompromised children depends on their underlying disease process.

[Pulmonary abscess and pleural empyema caused by Legionella pneumophila in kidney transplant recipient]. / Absceso pulmonar y empiema pleural por Legionella pneumophila en un paciente trasplantado renal.

A kidney transplanted patient developed a nosocomial pneumonia and pleural empyema due to Legionella pneumophila. Despite erythromycin and rifampin treatment the patient died. The diagnosis was made by direct fluorescent antibody staining of pleural fluid.

[A case of lung abscess with elevated serum levers of sialyl Lewis X-i (SLX) and CA 19-9].

A case of lung abscess of the felt lower lobe in a 19-year-old woman with elevated serum levels of Sialyl Lewis X-i (SLX) and CA 19-9 is reported. Completing the lobectomy, serum SLX level returned to the normal range within a week postoperative day. Serum CA 19-9 level also decreased at half life of 2 weeks to the normal range within 6 weeks postoperative day. Laboratory examination demonstrated high levels of these antigens in abscess fluid. Histologically, the abscess was revealed to be associated with a markedly dilated bronchus with hyperplastic bronchial glands, and there was no evidence of malignancy. Immunohistochemical examinations using monoclonal antibodies against human SLX and CA 19-9 showed highly positive reaction with those antigens in both goblet cells in bronchial epithelia and the mucous cells in bronchial glands.

[Role of the immunoglobulin coat in the process of microorganism phagocytosis]. / O roli immunoglobulinovogo pokrova v protsesse fagotsitoza mikroorganizmov.

Comparative electron microscopic examinations of staphylococcus aureus under different conditions (in a pulmonary abscess of a patient, in a short-time contact with serum and blood cells of a donor, and experimental infection of white mice) revealed dissimilar possibilities of formation of an immunoglobulin coat on the surface of bacterial cell wall. Upon a short-time contact of S. aureus with human blood serum in vitro an immunoglobulin coating appeared on the bacterial cell wall. In control experiments with staphylococci killed with glutaraldehyde and treated with methycilline the possibility of formation of microcapsule by staphylococci was excluded. No immunoglobulin coating was detected in a protracted suppurative process. In the pulmonary abscess, different gram-positive and gram-negative bacteria were found.

[Immunostimulant preparation made from the antigens of opportunistic microorganisms in the treatment of inflammatory lung diseases]. / Immunostimuliruiushchii preparat iz antigenov uslovno-patogennykh mikroorganizmov pri lechenii vospalitel'nykh zabolevanii legkikh.

The results of the trial of an immunostimulating preparation, consisting of Klebsiella pneumoniae, Proteus, Escherichia coli and Staphylococcus antigenic complexes, on 20 patients with acute pulmonary abscess and bronchiectasis are presented. The preparation was introduced subcutaneously in 5 injections. The preparation was found to have low reactogenicity, and in the course of immunotherapy the manifestations of systemic and local reactions became considerably less pronounced. Immunotherapy produced a good curative effect, objectively manifested by a decrease in coughing and in the amount of sputum gradually changing its character. After the fourth and fifth injections the patients no longer ejected purulent sputum. Fluoroscopic examination revealed a considerable decrease in the size of the pathological focus. The preparation stimulated immunological reactions, and immunization resulted in a considerable increase in the titer of antibodies to all components of the combined preparation, as well as in an increase in the number of functionally active T-lymphocytes, in the blood of the patients.

[Immunological indices and the acid phosphatase activity of the blood serum in patients with suppurative and destructive complications of acute pneumonia during the treatment/process]. / Nekotorye immunologicheskie pokazateli i aktivnost' kisloi fosfatazy syvorotki krovi u bol'nykh s gnoino-destruktivnymi oslozhneniiami ostroi pnevmonii v protsesse lecheniia.

The content of T and B lymphocytes, IgA, IgM and IgG as well as blood serum acid phosphatase (AP) activity were examined in 55 patients with purulent destructive complications of acute pneumonia. The patients were distributed into 2 groups depending on the disease gravity. The patients with a grave disease showed the depression of T and B immunity systems, marked deficiency of serum IgA, IgM and IgG. The percentage and absolute number of O cells was increased according to the disease gravity. In second group patients with a less graver disease, the reduction in the analogous immunity indicators was statistically insignificant. The disease ran the gravest course (with the development of pulmonary and extrapulmonary complications) in subjects with chronic alcoholism. The level of AP was the highest in disseminated destructive process and in diseases complicated by pleural empyema. During the convalescence, the AP activity descended, however it remained higher than normal in the presence of residual dry destructive cavities.

[The activation mechanisms in cytomegalovirus infection]. / O mekhanizmakh aktivatsii tsitomegalovirusnoi infektsii.

Antibodies to cytomegalovirus class IgG and IgM and level of tumor necrosis factor (TNF) in the serum were measured in 81 patients with severe surgical infections. In patients with acute lung abscess TNF level was twice higher and activation of cytomegalovirus infection (specific IgM) was three times more frequent than in patients with infectious endocarditis. The conclusion is made that severe surgical infections inducing progressive immunodeficiency create conditions for activation of latent viral infections, cytomegalovirus, in particular). Recommendations on prevention of hemotransmissible cytomegalovirus infection are presented.

[The efficacy of the natural antibacterial preparation chlorophyllypt in the combined treatment of acute lung abscesses]. / Effektivnost' prirodnogo antibakterial'nogo preparata khlorofillipta v kompleksnoi terapii ostrykh abstsessov legkikh.

The complexity of the treatment of acute suppurative pulmonary diseases has been aggravated recently by the growth of microbial resistance to antibiotics and enhancement of the allergy incidence among the population. This circumstance restricts the use of antibiotic on a broad scale in clinical practice and makes the researchers go in studies of adequate substitutes. In the given case, use was made of chlorophyllipt. It was given to patients by intravenous drip in the form of a 0.25% solution based on saline twice a day. To increase local deposition of the administered antimicrobial drug in the affected area, interstitial electrophoresis was employed. In the patients' group on chlorophyllipt, the clinico-laboratory and x-ray parameters returned to normal earlier. Chlorophyllipt was noted to produce an immunocorrective action characterized by the normalization of the absolute count and percentage of E-RFC and theophylline-resistant-RFC. This action could not be observed in the patients' group receiving only antibiotics.

[Immunological reactivity of patients with suppurative lung diseases and the effectiveness of immunocorrective therapy]. / Immunologicheskaia reaktivnost' u bol'nykh nagnoitel'nymi zabolevaniiami legkikh i éffektivnost' immunokorrigiruiushchei terapii.

Patients with acute lung abscesses and bronchiectatic diseases manifested deep changes in the immune responsiveness, which were largely of compensatory (elevation of IgA content to over 2 mg/ml), immunosuppressive (decrease of lymphocyte blast transformation with PHA down to 52.2 and 48.6%) or autoimmune (increase of spontaneous lymphocyte blast transformation up to 8%) character. In patients with acute lung abscesses, the indicators enumerated tended during treatment toward normalization which was not over in the majority of them by the discharge from hospital. In patients with bronchiectatic disease, that tendency was observable only after additional treatment with immunocorrective drugs (levamisole, splenin).