Pulmonary dysfunction in 'freebase' cocaine users.

Of 19 consecutive smokers of cocaine, "freebase" cocaine users, admitted to a chemical dependence program, 12 (63%) had respiratory symptoms and ten (58%) noted dyspnea. Abnormalities of carbon monoxide diffusing capacity were also seen in ten of the subjects, although responses to steady-state exercise testing were normal in subjects undergoing exercise. We believe that freebase cocaine use frequently produces pulmonary gas exchange abnormalities that appear after relatively brief periods of abuse. These abnormalities may persist after cessation of freebase cocaine use. A history of this form of drug abuse should be sought when evaluating patients with appropriate symptoms or abnormalities of diffusing capacity.

Spontaneous pneumothorax in allergic bronchopulmonary aspergillosis.

A new roentgenographic finding of spontaneous pneumothorax occurred in a patient with well-advanced (stage V) allergic bronchopulmonary aspergillosis (ABPA). The pneumothorax responded to chest tube evacuation. Patients with well-advanced ABPA and severe chest pain should be carefully examined and treated for pneumothorax, to maintain as much functioning lung as possible.

Lack of usefulness of radiographic screening for pulmonary disease in asymptomatic HIV-infected adults. Pulmonary Complications of HIV Infection Study Group.

OBJECTIVE: To determine the use of chest radiographs in the screening of asymptomatic adults infected with the human immunodeficiency virus (HIV). METHODS: A prospective, multicenter study of the pulmonary complications of HIV infection in a community-based cohort of persons with and without HIV infection. The subjects included 1065 HIV-seropositive subjects without the acquired immunodeficiency syndrome at the time of enrollment: 790 homosexual men, 226 injection drug users, and 49 women with heterosexually acquired infection. Frontal and lateral chest radiographs were performed at 3-, 6-, and 12-month intervals, CD4 lymphocyte measurements at 3- and 6-month intervals, tuberculin and mumps skin tests at 12-month intervals, and medical histories and physical examinations at 3- and 6-month intervals. Pulmonary diagnoses that occurred within 2 months following each radiograph were analyzed and correlated with the radiographic results. RESULTS: Evaluable screening chest radiographs (5263) were performed in HIV-seropositive subjects while they were asymptomatic; of these, 5140 (98%) were classified as normal and 123 (2%) as abnormal. A new pulmonary diagnosis was identified within 2 months following a screening radiograph in 55 subjects. Only 11 of these subjects had abnormal radiographs; the sensitivity of the radiograph was 20%. The sensitivity was similarly low at baseline, within each transmission category, and in subjects whose CD4 lymphocyte counts were less than 0.2 x 10(9)/L (200/microL). The types of pulmonary diseases that occurred were similar in the subjects with normal and abnormal screening radiographs. CONCLUSION: Screening chest radiography in asymptomatic HIV-infected adults is unwarranted because the diagnostic yield is low.

Overall and cause-specific mortality in a cohort of homo-/bisexual men, injecting drug users, and female partners of HIV-infected men. Pulmonary Complications of Human Immunodeficiency Virus Infection Study Group.

OBJECTIVE: To study the overall and cause-specific HIV-related mortality in a cohort of HIV-seropositive subjects according to transmission category, race/ethnicity, sex and severity of immunosuppression. DESIGN: A cohort of 1129 HIV-seropositive homo-/bisexual men, injecting drug users, and female partners of HIV-infected men were enrolled at six centers in San Francisco, Los Angeles, Chicago, Newark, Detroit and New York between 1 November 1988 and 1 November 1989. Subjects were evaluated every 6 months at least until 31 March 1994. METHODS: The analyses of overall mortality for the subgroups of interest were performed with Kaplan-Meier plots and Cox proportional hazards models. Cause-specific analyses were performed on the primary cause of death using rates per 100 person-years of exposure. RESULTS AND CONCLUSIONS: Baseline severity of immunosuppression is the strongest predictor of mortality. There were no statistically significant differences in overall HIV-related mortality among transmission categories, race/ethnicity groups or sexes. There were differences, however, in cause-specific mortality among the different risk groups.

Accelerated development of pulmonary complications due to illicit intravenous use of pentazocine and tripelennamine.

To gain information concerning the natural history and prevalence of pulmonary gas exchange abnormalities resulting from intravenous drug abuse, 45 intravenous drug users were studied. Twenty subjects used a mixture of the synthetic opiate pentazocine and the antihistamine tripelennamine, which, under the street name T's and B's, has become very popular in some urban areas as an available substitute for heroin. Compared with the 19 heroin addicts studied, the pentazocine and tripelennamine users had a significantly shorter mean duration of intravenous drug abuse (2.7 +/- 0.4 years versus 7.6 +/- 0.9 years, p less than 0.01), a greater frequency of respiratory symptoms (75 percent versus 36 percent, p less than 0.05), a significant reduction in the mean diffusing capacity of the lung for carbon monoxide (58.4 +/- 3.3 percent predicted versus 75.5 +/- 5.6 percent predicted, p less than 0.01), and abnormal responses to submaximal steady-state exercise testing. The intravenous use of pentazocine and tripelennamine and probably most other drug preparations intended for nonparenteral use represents a particularly noxious form of drug abuse that may lead to early respiratory complications in a large proportion of users.

Obtaining permission for an autopsy: its importance for patients and physicians.

This paper reviews the importance, benefits, and methods of increasing autopsy percentages. Its focus is on specific procedures for obtaining autopsy consent, particularly in terms of addressing the problems that most often interfere with obtaining permission for postmortem examination. Techniques for handling various misconceptions about autopsies are discussed. These guides for postmortem-related discussions with families will lead to improvement in overall physician performance and satisfaction.

Fiberoptic bronchoscopy in the evaluation of lung abscesses.

To define the results of flexible fiberoptic bronchoscopy (FFB) in patients with lung abscess and to characterize those patients most likely to have an underlying carcinoma, we retrospectively studied the records of 52 consecutive patients undergoing FFB at our institution between 1975 and 1982. Nineteen patients (36.5 percent) had an associated bronchogenic carcinoma (group 1); 33 (63.5 percent) had no malignancy (group 2). The FFB aided in diagnosing 73.7 percent of group 1 patients, but added no information in group 2 patients. Group 1 and 2 patients differed significantly with respect to prevalence of systemic symptoms (15.8 percent vs 51.5 percent, p less than 0.01); predisposition to aspiration pneumonia (26.3 percent vs 60.6 percent, p less than 0.01); mean presenting white blood cell count (10.9 vs 14.2, p less than 0.05); mean oral temperature at presentation (37.5 vs 38.3 degrees C, p less than 0.05); and the prevalence of extensive infiltrates on the initial chest roentgenogram (17.0 percent vs 83.6 percent, p less than 0.05). Based on these data, we believe that by carefully considering the available clinical information, it is possible to identify those patients whose lung abscesses are likely to be related to bronchogenic carcinoma. Such individuals should be promptly evaluated. It is not necessary, however, to routinely order bronchoscopy for all patients with lung abscess.

Endobronchial polyposis following smoke inhalation.

A 50-year-old fireman was found to have multiple endobronchial polyps when investigated for hemoptysis two months after acute thermal inhalation injury. Biopsy was obtained and the histology demonstrated benign granulation tissue. The polyps spontaneously regressed, without specific treatment, six months after the accident. Tracheal bronchial polyposis appears to be another complication of heat and smoke inhalation.

Amiodarone-induced pneumonitis. Assessment of risk factors and possible risk reduction.

Problems with pulmonary toxicity have emerged as a potentially limiting factor for amiodarone use. We prospectively studied 33 subjects treated with amiodarone for refractory arrhythmias. Serial clinical, radiographic and pulmonary function tests were correlated with the dose and duration of amiodarone treatment to define: a) prevalence of lung toxicity, b) subgroups of patients at particular risk for toxicity, c) potential interaction between amiodarone dose and toxicity. Considering all subjects, no significant change in lung volumes or airflow indices were noted; carbon monoxide diffusing capacity (DCO) underwent a mean reduction of 20.3 percent during treatment. Symptoms of possible pulmonary toxicity occurred in 27.3 percent of subjects. No type or degree of pretreatment cardiopulmonary dysfunction predicted lung toxicity. However, maintenance dose was correlated with toxicity; patients treated with doses of less than or equal to 400 mg per day from the start of treatment had insignificant reductions in DCO and did not develop symptoms.

Pulmonary embolism in younger adults.

To test the hypothesis that the clinical presentation and outcomes are different when pulmonary embolism occurs in younger (age 18 to 40 years) as compared to older (age greater than 40 years) adults, 40 younger patients were compared with older patients. No risk factors could be identified in 28 percent of the younger group. Normal physical examinations were more common (58 vs 28 percent, p = 0.01) among younger as compared with older adults. Hypoxemia was absent in 29 percent of the younger and 3 percent of the older group (p = 0.004); P(A-a)O2 was significantly lower among younger patients even after controlling for age. Mortality was decreased sevenfold (2.5 vs 18 percent, p = 0.03) among younger patients. These data indicate that pulmonary embolism tends to have a subtle presentation in younger adults. When diagnosed and treated, the mortality rate is substantially less among younger as compared with older patients.

The clinical spectrum of Staphylococcus aureus pulmonary infection.

Staphylococcus aureus causes serious pulmonary infections in adults. Prior descriptions of this entity have depended on diagnosis of expectorated sputum cultures that are often contaminated. To better characterize this infection, we retrospectively reviewed the medical records of 31 adults with S aureus pulmonary infection diagnosed by culture specimens uncontaminated by the upper respiratory flora. Our results support the concept that S aureus pulmonary infections usually occur in older adults (sixth decade or older) with concomitant illnesses that are typically nosocomial. However, in contrast to previous reports, the chest roentgenograms in these patients typically showed multilobar infiltrates (60 percent), predominantly in the lower lobes (64 percent), and often bilateral (48 percent). Pleural involvement (48 percent) was more common than previously reported, and abscess formation (16 percent) occurred infrequently. Sputum cultures were found to be sensitive but nonspecific diagnostic tools. Despite antibiotic therapy, reinfection occurred in 10 percent of patients and the mortality rate was 32 percent.

Performance of an algorithm to detect Pneumocystis carinii pneumonia in symptomatic HIV-infected persons. Pulmonary Complications of HIV Infection Study Group.

STUDY OBJECTIVES: To determine whether an algorithm consisting of a chest radiograph and the diffusing capacity of the lung for carbon monoxide (D(LCO)) is effective in detecting Pneumocystis carinii pneumonia (PCP) in symptomatic HIV-infected persons; and to establish a benchmark for future comparisons of alternative algorithms. DESIGN: Prospective, 64-month study. SETTING: Multicenter, ambulatory care. PATIENTS: 306 HIV-infected subjects enrolled in the Pulmonary Complications of HIV Infection Study who developed 467 episodes of new or worsening respiratory symptoms. MEASUREMENTS: Chest radiography followed by D(LCO) measurement, if the radiograph was normal or unchanged. RESULTS: An algorithm combining a chest radiograph followed by a D(LCO) measurement, if the radiograph was normal or unchanged, was effective and detected abnormalities that led to a diagnosis of PCP in 78 of 80 evaluable episodes (97.5%). The radiograph (specific parenchymal abnormality, number of lung zones involved) and the D(LCO) (degree of decrease, degree of decrease from baseline) also provided additional information on the probability of PCP. CONCLUSIONS: In symptomatic HIV-infected patients suspected of having PCP, the diagnostic evaluation should begin with a chest radiograph, followed by a D(LCO) measurement, if the radiograph is normal or unchanged. If both of these tests are normal, it may be reasonable to conclude the evaluation rather than to proceed on to additional testing. This algorithm can serve as a benchmark for future comparisons.

Risk factors and outcomes associated with identification of Aspergillus in respiratory specimens from persons with HIV disease. Pulmonary Complications of HIV Infection Study Group.

STUDY OBJECTIVES: To examine the significance of previously suggested risk factors and assess outcomes associated with Aspergillus identification in respiratory specimens from HIV-seropositive individuals. DESIGN: This was a nested case-control study. Patients who had Aspergillus species identified in respiratory specimens were matched at the time of study entry 1:2 with control subjects according to study center, age, gender, race, HIV transmission category, and CD4 count. SETTING: The multicenter Pulmonary Complications of HIV Infection Study. PARTICIPANTS: HIV-seropositive study participants. MEASUREMENTS AND RESULTS: Between November 1988 and March 1994, Aspergillus species were detected in respiratory specimens from 19 (1.6%) participants. The rate of Aspergillus identification among participants with CD4 counts <200 cells per cubic millimeter during years 2 through 5 after study entry ranged from 1.2 to 1.9%. Neutropenia, a CD4 count <30 cells per cubic millimeter, corticosteroid use, and Pneumocystis carinii infection were associated with subsequent identification of Aspergillus in respiratory specimens. Cigarette and marijuana use, previously suggested risk factors, were not associated with Aspergillus respiratory infection. A substantially greater proportion of patients with Aspergillus compared with control subjects died during the study (90% vs 21%). Excluding four cases first diagnosed at autopsy, 67% died within 60 days after Aspergillus was detected. CONCLUSIONS: Although Aspergillus is infrequently isolated from HIV-infected persons, the associated high mortality would support serious consideration of its clinical significance in those with advanced disease and risk factors.

Nonspecific airway hyperresponsiveness in HIV disease. Pulmonary Complications of HIV Infection Study Group.

OBJECTIVES: HIV disease is frequently complicated by episodic acute bronchitis, suggesting the presence of chronic bronchial inflammation. To further examine this concept, we investigated the possible association of nonspecific airway hyperresponsiveness (AHR) and HIV disease. DESIGN: Methacholine inhalation challenge studies were performed on 66 HIV-seropositive and 8 HIV-seronegative members of the Pulmonary Complications of HIV Infection Study Cohort. AHR was defined as 20% or more decline in FEV1 from the postdiluent value after inhalation of 125 or less cumulative breath units. The prevalence of AHR in HIV-seropositive cohort members was compared with that in matched control subjects who had undergone methacholine challenge testing for two unrelated studies. Demographic, behavioral, and clinical features in HIV cohort members with and without AHR were contrasted. The relationship between AHR and the occurrence of episodic airway disease or symptoms suggestive of airway disease was examined. RESULTS: AHR was not more prevalent in HIV-seropositive cohort members than control subjects (19.3% vs 12.9%; p > 0.1). Within the cohort, AHR was detected more frequently in members with than without a history of asthma (60% vs 16%; p < 0.05). A greater proportion with than without AHR had 1 or more episode of pneumonia within 2 years (46% vs 9%; p < 0.01), 1 or more asthma episode during the study period (39% vs 1.9%; p < 0.001), or wheeze noted during clinic visits (62% vs 17%; p < 0.01). The proportion that experienced acute bronchitis did not differ in the two groups. CONCLUSIONS: This study suggest that HIV-infected persons do not have increased prevalence of nonspecific AHR. In HIV disease, AHR is associated asthma, but not episodic acute bronchitis. Thus, the possibility that airway injury without demonstrable AHR might complicate HIV disease remains.

Use of preventive interventions by persons infected with type-1 human immunodeficiency virus (HIV-1). The Pulmonary Complications of HIV Study Group.

Measures aimed at preventing complications and slowing progression of type-1 human immunodeficiency virus (HIV-1) can potentially reduce morbidity. Although little is known about the use of such measures, such data are critical for program planning. This study was performed to quantify the frequency and patterns of use for such interventions. We enrolled 1,171 persons infected with HIV, but without an acquired immunodeficiency syndrome (AIDS) defining diagnosis, in a multicenter prospective study of the pulmonary complications of HIV infection. Participants were homosexual/bisexual men, injection drug users (IDUs), or female sexual contacts of HIV-infected men. Centers were university-based and geographically dispersed across the United States. Standardized questionnaires were administered on entry and at three-month or six-month intervals; we correlated use of general and HIV-related preventive measures before entry and during the first three years in study with clinical/epidemiologic characteristics. Overall use of preventive interventions was low; only one third of study entrants had used such measures. Use was greatest among those with advanced HIV infection, but only half used preventive measures on entry; IDUs were less likely than homosexuals to use these services. Although use of interventions such as anti-Pneumocystis and antiretroviral agents increased during study participation, general measures such as pneumococcal vaccine and tuberculosis prophylaxis were used by less than 30% of those eligible for use. Among IDUs, cumulative use of these measures remained below 20% during the first three years of this study. We conclude that HIV-infected persons underuse preventive interventions, particularly general measures.(ABSTRACT TRUNCATED AT 250 WORDS)

The physician's role in tuberculosis prevention.

Tuberculosis is not only treatable but preventable as well. A number of options exist for reducing the transmission of tubercle bacilli. Practitioners are in a position to intervene directly on behalf of their patients and indirectly by promptly reporting infectious patients to local public health authorities. A considerable body of information supports the use of isoniazid in persons who are infected by Mycobacterium tuberculosis and who also have readily identifiable characteristics that place them at increased risk for developing tuberculosis.

Tuberculosis. An epidemic in older adults.

The incidence of tuberculosis is disproportionately high in our elderly population. This group appears to be at high risk because many were infected early in life. Additional factors contributing to increased risk in the elderly probably include low clinical suspicion for tuberculosis in this age group, unusual or nonspecific clinical and roentgenographic presentations, difficulties in interpreting the tuberculin skin test, and the presence of associated illnesses that may lead to delay in diagnosis. Failure to diagnose tuberculosis in this population has important public health implications, particularly in nursing homes and long-term care facilities. Tuberculosis is usually easily diagnosed when suspected in elderly patients, and effective therapy is available for prevention and treatment of this disease. The special needs of old patients must be considered when these regimens are applied. Increased awareness of tuberculosis in the elderly is important for the success of strategies that have been developed to eliminate tuberculosis from the United States. As our population continues to age, physicians who treat the elderly must be vigilant in suspecting tuberculosis as a cause of illness in these patients.

Bacterial pneumonia associated with HIV-1 infection.

Bacterial pneumonia remains an important cause of treatable morbidity among HIV-1-infected persons. These pneumonias occur at all CD4 counts but are especially common as the HIV-1 infection progresses. Bronchopneumonia should be considered particularly in the setting of segmental or lobar consolidation associated with productive cough and fever. S. pneumoniae remains the most common pathogen causing bronchopneumonia. Because of the high rate of bacteremia, diagnosis may be facilitated by blood cultures. Treatment is similar to management of HIV-1-seronegative persons, although drug resistance against some bacteria may be an emerging problem. Several opportunities exist for prevention, and these should be pursued vigorously.

Tuberculosis. Part I.

Tuberculosis has been a disease of human beings for thousands of years. In recent times it has waxed to become the feared White Plague of the eighteenth and nineteenth centuries and waned under the impact of effective chemotherapy until its elimination seemed possible by the early twenty-first century. The resurgence of tuberculosis in the past 10 to 15 years, caused by unanticipated events such as the appearance of the human immunodeficiency virus and deteriorating social conditions, also brought with it the problem of multiple drug resistance. Control measures such as tuberculin skin testing, perhaps somewhat forgotten when tuberculosis seemed to be a disease of the past, again became first-line defenses against spread of the disease. Environmental controls must be well understood and used effectively. Diagnosis of tuberculosis requires knowledge of the strengths and shortcomings of the various diagnostic methods and experience in their use. Practitioners are cautioned to remember that no diagnostic method, by itself, can be relied on to confirm or rule out tuberculosis. Well-tested diagnostic methods of chest radiograph, tuberculin skin testing, smear, and culture have been recently supplemented by rapid diagnostic tests based on amplification of bacterial RNA and DNA. More invasive diagnostic methods are sometimes required to diagnose extrapulmonary disease. Two-drug up to seven-drug therapy may be indicated for a case of tuberculosis, depending on evidence of the presence of multiple drug resistance. Duration of treatment can range from 6 to 12 months, also depending on identification of drug-sensitive or drug-resistant organisms. Failure of compliance can be a significant problem in patients who are homeless, or drug abusers, or who for various reasons cannot or will not complete a course of therapy. Directly observed therapy is strongly recommended for these patients, and for assistance in its administration the physician must cooperate with the local or state health department. The health department also must be notified whenever a case of tuberculosis is identified.