Blood and alveolar lymphocyte subsets in pulmonary cytomegalovirus infection after lung transplantation.

BACKGROUND: Cytomegalovirus (CMV) pneumonitis has been shown to be associated with lymphocytic alveolitis after lung transplantation. In the present study, we investigated a series of bronchoalveolar (BAL) and blood samples, collected in the absence of rejection or acute infectious episodes. in order -1: to evaluate intra-alveolar cell population changes concomitant with CMV replication and -2: to reappraise the value of cell population analysis in the management of patients after lung transplantation. METHODS: We used flow cytometry to investigate modifications of lymphocyte subpopulations related to pulmonary cytomegalovirus infections in blood and BAL samples from a series of 13 lung transplant recipients. After exclusion of samples obtained during pulmonary rejection, bronchiolitis obliterans or acute bacterial infection, 48 blood and BAL samples were retained for analysis: 17 were CMV positive by shell-vial assay and 31 were CMV negative in blood and BAL. RESULTS: Our results demonstrate that pulmonary CMV infection is associated with a significant increase in the total lymphocyte population in BAL samples, but with minor modifications of the various lymphocyte subpopulations and a significantly higher absolute number of B lymphocytes in blood samples. CONCLUSIONS: Cytomegalovirus pulmonary infection is accompanied by only minor changes in BAL lymphocyte subpopulations. The study of BAL lymphocyte subpopulations therefore appears to be of limited clinical value in the diagnosis of pulmonary CMV infection. However, increased blood B-lymphocytes seems to be a clinical feature associated with CMV infection.

[Intralobar sequestration of the lung in an adult (type 1 of pryce). Treatment by coil embolization]. / Séquestration pulmonaire intralobaire de type pryce 1 chez l'adulte. Vaso-occlusion par spires métalliques.

A 34 year old patient presented with recurrent hemoptysis. A chest radiograph was normal. Helical CT angiogram of the chest with tridimensional reconstructions demonstrated an intralobar pulmonary vascular sequestration Pryce I-type of the right lower lobe. The angiography confirmed the diagnosis showing a large feeding artery arising from the coeliac trunk. An embolization of the feeding artery using metallic coils was performed. Transient pulmonary infarction occurred immediately after treatment. At two years follow-up, the patient remains asymptomatic. Percutaneous embolization of this rare pulmonary vascular malformation is an alternative to surgical treatment.

Nebulized cyclosporine in the rat: assessment of regional lung and extrapulmonary deposition.

BACKGROUND: Nebulized cyclosporine (CsA) has been shown to limit lung allograft rejection as well as intramuscular (IM) CsA, with limited blood diffusion. The present study determined the pharmacokinetic parameters of nebulized CsA, by the assessment of regional lung deposition and extrapulmonary diffusion of CsA. METHODS: CsA was given either by IM injection (10 mg/kg) or by aerosol (at 10 and 25 mg/kg doses); 70 rats were killed at 25 and 50 min, and at 2, 4, 6, 8, 12, 24, or 48 hr after CsA administration. CsA levels were measured in the whole lung, in central and peripheral parts of the lung, in whole blood, kidney, and heart. The areas under the concentration time curves (AUCs) were determined. RESULTS: In blood, kidney, and heart, CsA levels were significantly higher for IM than for aerosol administrations at 10 and 25 mg/kg doses. In the whole lung, the AUC was greater for the aerosol route at 25 mg/kg doses (588 ng x hr/mg) than for the low-dose (200 ng x hr/mg) or IM administration (200 ng x hr/mg). The central to peripheral index of CsA (ratio of AUC central/peripheral part of the lung) was not significantly different for both aerosol administrations (0.63 and 0.69, respectively) and for the IM route (0.81). CONCLUSIONS: Nebulized CsA allows better pulmonary concentration than IM administration, with equivalent central and peripheral deposition whatever the mode of administration, and results in lower levels in blood, kidney, and heart.

[Report of 2 cases of pleural recurrences of surgically treated bronchogenic carcinoids. Diagnostic and therapeutic problems]. / A propos de 2 récidives pleurales de carcinoïdes bronchiques opérés. Problèmes diagnostique et thérapeutique.

Recurrence after surgery for bronchial carcinoid tumors is very uncommon in cases of typical tumors and occasionally seen in cases of atypical tumors. We observed two cases of recurrence in an unusual location, the pleura. Somatostatin analog and MIBG scinigrams were useful for diagnosis. Treatment required surgical excision of the relapsing tumor, cytoreductive hepatic surgery or hepatic arterial chemoembolization for liver metastases, chemotherapy, interferon, radionuclide therapy, and somatostatin analogs for carcinoid syndrome.

[Resistance to penicillin G and Streptococcus pneumoniae infection at the Hôpital Foch, Paris, France, in 1995]. / Résistance à la pénicilline G et infection à Streptococcus pneumoniae, en 1995 à l'Hôpital Foch, Paris, France.

UNLABELLED: Decreased susceptibility to penicillin G of pneumococcal strains is continuously increasing in France. OBJECTIVE: We assessed effect of resistance to penicillin on therapeutic management and mortality in adults with pneumococcal pneumonia in our hospital. METHODS: This one-year retrospective study (1995) included patients with proven pneumococcal infection (positive blood culture, pleural fluid, or specimens from the lower respiratory tract). Strains of Streptococcus pneumoniae were screened for susceptibility to antimicrobial agents. Resistance to penicillin G was defined as a minimal inhibitory concentration > or = 0.12 microgram/ml. Age immune and nosocomial status, first and second line antibiotherapy and death were compared according to the strains susceptibility to penicillin G. A p value below 0.05 was statistically significant. RESULTS: In 15 cases a pneumococcal strain susceptible to penicillin G was isolated while 23 patients were infected with a strain with a decreased susceptibility to penicillin G. Age was significantly higher in the latest group (61.6 versus 54.7 years) while no difference was noted between the 2 groups according to immune and nosocomial status, therapeutic management and death. DISCUSSION: Resistance to penicillin did neither appear to increase mortality nor to influence therapeutic management in patients with pneumococcal infection.

Preparation of high-risk patients for major thoracic surgery.

For a least a decade, many patients have benefitted from new indications of major thoracic surgery owing to improvements in the surgical and anesthetic procedures of thoracic surgery. Identification of risk factors of perioperative morbidity and mortality becomes of paramount importance when trying to lesson the postoperative mortality rate to 1% or less. The careful assessment of the candidates for thoracic surgery with a multidisciplinary approach is the cornerstone of such an objective. The lower mortality rate should be achievable with a preoperative preparation of the patients of a rehabilitation and nutritional program and a pharmacologic treatment optimization.

Accelerated obstructive pulmonary disease in HIV infected patients with bronchiectasis.

Human immunodeficiency virus (HIV) infection has been associated with a wide spectrum of pulmonary disease. We report three HIV-seropositive patients with rapidly worsening airway obstruction associated with bronchiectasis. All subjects (age range 33-39 yrs) were cigarette smokers. Two had previously used intravenous drugs. The CD4 lymphocyte count ranged 40-250 cells x mm(-3). All individuals had complained of increasing dyspnoea for 3-6 months. Within 1 yr, they all developed severe airway obstruction with a decrease in both forced expiratory volume in one second (FEV1) and ratio of FEV1 to forced vital capacity (FEV1/FVC) to less than 60% of predicted value, and a decrease in mean forced expiratory flow at 25-75% of the forced vital capacity (FEF25-75) to less than 35% of predicted value. Computed tomography of the chest disclosed bilateral dilated and thickened bronchi. No classical causes of genetic or acquired bronchiectasis were identified in our patients. Recurrent bacterial bronchitis occurred in the follow-up period of the three patients. In conclusion, unusually rapid airway obstruction associated with bronchiectasis should be added to the wide spectrum of respiratory complications of human immunodeficiency virus infection.

Lymphocytic alveolitis after primary HIV infection with CMV coinfection.

Herein is a report of an adult case of primary HIV infection with cytomegalovirus coinfection causing cough, fever, and lymphocytic alveolitis. Primary HIV infection has not been previously reported as a cause of lymphocytic alveolitis.

Predictive value of cytomegalovirus DNA detection by polymerase chain reaction in blood and bronchoalveolar lavage in lung transplant patients.

BACKGROUND: Despite promising results, the efficacy of polymerase chain reaction (PCR) for clinical management of cytomegalovirus (CMV) infection in transplanted patients is still controversial. METHODS: A prospective study of CMV detection, with concurrent shell vial cultures and PCR in blood and bronchoalveolar lavage (BAL), was conducted in 13 lung transplant recipients, monitored for 15 months (range: 1-42 months). CMV DNA was detected by PCR amplification of a 406-bp fragment in the Us region and a 290-bp fragment in the immediate early region of the viral genome. RESULTS: When comparing PCR to viral culture, the sensitivity and specificity of CMV DNA detection were 100% and 65.7% in blood (n=122) and 100% and 75% in BAL (n=104). The positive and negative predictive values of PCR for a forthcoming diagnosis of CMV infection were 50% and 97% in blood, and 67% and 85% in BAL. Seventeen CMV infections were evaluated at the end of treatment: when PCR was still positive either in blood or BAL, CMV infection relapsed within 35+/-5 days; when PCR was negative, CMV infection relapsed after 142+/-57 days (P=0.01). CONCLUSIONS: Negative CMV detection by PCR strongly advocates against a forthcoming CMV infection. PCR assay seems to be a good predictor for early recurrence of CMV infection, and would be useful for monitoring the response to antiviral therapy.

Recurrent optic neuromyelitis with endocrinopathies: a new syndrome.

We report a new syndrome that we call "recurrent optic neuromyelitis with endocrinopathies" in eight Antillean women from Martinique and Guadeloupe Ocular involvement was either monocular or binocular, whereas myelopathy was acute or subacute. In seven patients, myelopathic symptoms recurred, and in six patients, visual problems recurred. Spinal cord involvement was a consistent band-like pseudo-syringomyelic dissociated sensory loss. All eight patients had endocrinopathies consisting of amenorrhea, galactorrhea, diabetes insipidus, hypothyroidism, or hyperphagia. Spinal cord MRI revealed cavitation-like images. Various immunosuppressant treatments had little effect on the uniformly deteriorating course, ending in blindness and paraplegia. Six patients died within 5 years of onset, and an autopsy in one patient showed multiple demyelinizing lesions of the spinal cord with thickened blood vessels walls without evidence of inflammation. These cases appear to constitute a syndrome distinct from MS and from classic Devic's syndrome, not only because of the association with endocrinopathies but because of the stereotypy of the recurrences, the absence of MRI lesions in the cerebral white matter, and the unusual image of cavitation of the spinal cord. The syndrome is also distinct from HTLV-I-associated paraparesis, which is endemic in the West Indies.

Systemic vasculitis and myelodysplastic syndromes. A report of two cases.

Two cases of systemic vasculitis associated with myelodysplastic syndromes are reported. Vasculitis may develop either before or after the diagnosis of a hematologic disorder, and it responds to treatment with high-dose corticosteroids.

[Pulmonary cryptococcosis during HIV infection. 15 cases]. / Cryptococcose pulmonaire au cours de l'infection à VIH. 15 observations.

We reviewed the records of 15 Human Immunodeficiency Virus (HIV) infected patients with pulmonary cryptococcosis (PC). PC was the first AIDS-defining manifestation in nine patients. HIV infection was identified simultaneously with the onset of PC in 4 patients. The CD4+ lymphocyte count was low in all cases (median, 24/m3). Chest radiography showed interstitial infiltrates in 13 instances, associated with pleural effusion in 5 cases and hilar adenopathy in 2 cases. In one case, chest-X-ray showed isolated pleural effusion and was normal in one patient. For 11 of 12 patients, bronchoalveolar lavage fluid culture was positive for Cryptococcus neoformans. Seven of 15 patients had evidence of extrapulmonary cryptococcal disease with positive cerebrospinal fluid culture. Serum cryptococcal antigen was detected in all 15 patients. Concomitant lung infection with Pneumocystis carinii was diagnosed in 4 patients. First-line regimen was fluconazole in 10 patients and amphotericin B in 4 patients. Fluconazole has been prescribed in 7 patients as a permanent suppressive therapy and should be continued indefinitely.

Comparison of jet and ultrasonic nebulizers for alveolar targeting of methylprednisolone.

The secondary systemic effects of oral corticosteroid therapy in chronic lung disease indicate the possible benefits of local therapy. The aim of this study was to show if alveolar targeting of a corticosteroid, methylprednisolone (MP), is possible, and to determine which type of nebulizer allows the most selective deposition into the alveoli. A jet nebulizer (Respirgard II) with 2 ml volume fill (R2), and an ultrasonic nebulizer (Ultraneb 99) with 4 ml volume fill (U4), were compared using a 40-mg dose of MP labelled 99Tcm human serum albumin. Particle size and MP-to-albumin binding were measured in the aerosol cloud. Each nebulizer was used in random order in five healthy volunteers. A dynamic posterior scan of 68 images of 15 s each was performed with a Gammatome II gamma camera during inhalation. Peripheral and central regions of interest were automatically defined with reproducible methods, and the peripheral-to-central ratio was used as a penetration index. Stomach and oropharynx activities were estimated on static anterior and static left lateral views, respectively, at the end of the examination. The mass median aerodynamic diameter (MMAD) was lower for R2 when unlabelled MP was used. The MMAD of MP+HSA was compatible with alveolar targeting. In the aerosol cloud, MP-albumin binding was 75% for R2 and 79% for U4. Peripheral and central activities at equilibrium (13-16 min) were higher with U4, but the penetration index was significantly higher with R2. Moreover, the stomach and oropharynx activities were significantly lower with R2.(ABSTRACT TRUNCATED AT 250 WORDS)