Disseminated pneumocystosis presenting as a pleural effusion.

Extrapulmonary pneumocystosis recently has been reported in a number of tissues. Most cases occurred in patients receiving aerosolized pentamidine prophylaxis. We report a case of disseminated pneumocystosis presenting as a large pleural effusion without apparent lung involvement where Pneumocystis carinii was the only pathogen identified. The absence of parenchymal lesions on chest x-ray film, the lack of hypoxemia and the minimal uptake of gallium all argue against significant lung involvement. The patient was successfully treated with chest tube drainage, intravenous and inhaled pentamidine and orally administered dapsone and trimethoprim. The addition of inhaled pentamidine to intravenously administered pentamidine may have increased pleural fluid levels substantially and its use coincided with the patient's improvement.

Chylothorax as presenting manifestation of adenocarcinoma with probable gastric primary.

Chylothorax is an unusual complication of various malignant neoplasms, generally lymphomas. The few reported cases of chylothorax with gastric and other abdominal malignancies have involved large abdominal masses with prominent adenopathy and chylous ascites. We describe a patient in whom chylothorax was the presenting manifestation of an adenocarcinoma with probable gastric primary, developing prior to any clinical or radiologic evidence of tumor.

Role of special stains in the diagnosis of Pneumocystis carinii infection from bronchial washing specimens in patients with the acquired immune deficiency syndrome.

Fifty bronchial washing specimens from 36 patients with acquired immune deficiency syndrome (AIDS) were retrospectively reviewed to assess the sensitivity of the various special stains used to diagnose Pneumocystis carinii. In 76% of the cases, the Diff-Quik stain was positive; it was the easiest and most rapid of the special stains used. The sensitivity was increased to 92%, 96% and 100%, respectively, by also doing cresyl echt violet, Grocott's Gomori methenamine silver and both the cresyl violet and Grocott stains in addition to the Diff-Quik stain. We conclude that the Diff-Quik stain is a fairly reliable and rapid screening procedure for making the diagnosis of Pneumocystis infection in bronchial washings from AIDS patients. The routine Papanicolaou stain gave less sensitive results in the smears of the washing specimens, but does give a markedly improved yield in bronchoalveolar lavage specimens.

Utility of gallium67 scintigraphy and bronchial washings in the diagnosis and treatment of Pneumocystis carinii pneumonia in patients with the acquired immune deficiency syndrome.

Twenty patients with the acquired immune deficiency syndrome (AIDS) and suspected Pneumocystis carinii pneumonia were evaluated by gallium67 (Ga67 scintigraphy and fiberoptic bronchoscopy for initial diagnosis and response to therapy. Lung uptake of Ga67 was demonstrated in 100% of AIDS patients with P. carinii pneumonia, including those with subclinical infection. Fiberoptic bronchoscopy identified P. carinii in the bronchial washings of 100% of cases (19 patients), whereas only 13 of 16 (81%) patients had P. carinii in lung tissue obtained by transbronchial biopsy. Repeat fiberoptic bronchoscopy was performed in 16 of 20 patients. After 2 to 4 wk of therapy, P. carinii was identified in bronchial washings in 8 of 16 (50%) patients and in transbronchial biopsy in 1 of 10 (10%) patients examined. Bronchial washing has a higher yield than transbronchial biopsy in demonstrating P. carinii in patients with AIDS and may evolve as the procedure of choice in such patients. Based on the clinical course and results of Ga67 scintigraphy and fiberoptic bronchoscopy in AIDS patients with P. carinii pneumonia, optimal therapy may require at least 3 wk of treatment.

Primary Pseudomonas pneumonia in a previously healthy man.

A 29-year-old previously healthy man had a Pseudomonas aeruginosa pneumonia and bacteremia. Early recognition of the organism and institution of appropriate antibiotic therapy led to rapid clinical response and recovery. Although Pseudomonas is rarely the cause of pneumonia in a healthy host, it should be considered in the differential diagnosis.

Indications for transbronchial lung biopsy in the diagnosis of intrathoracic sarcoidosis.

80 patients in three different institutions underwent transbronchial lung biopsy (TBB) through a fiberoptic bronchoscope to confirm the diagnosis of sarcoidosis. A positive tissue diagnosis was obtained in 50 (75%) patients. The diagnostic yields in radiographic stage I, stage II and stage II sarcoidosis were 55% (12 of 22), 80% (33 of 41), and 82% (14 of 17), respectively. When the results in patients with stage I sarcoidosis were reviewed in conjunction with abnormalities on pulmonary function studies only reduced functional residual capacity (FRC) was found to be associated with increased diagnostic yield (80%) on TBB. We conclude that except for patients with radiographic stage I disease and normal FRC, TBB is the procedure of choice in patients with sarcoidosis when readily accessible extrathoracic abnormalities are not present.

Rapid development of massive pleural effusion in Legionnaires' disease.

The rapid development of a massive exudative pleural effusion was documented in a case of Legionnaires' disease. This clinical event can be considered an established though unusual feature of the widening clinical spectrum of infection by Legionella pneumophila.

Protein metabolism by rat lung: influence of fasting, glucose, and insulin.

We studied protein metabolism by rat lung slices. We found that phenylalanine is not metabolized to other substances by the lung and that the rate of incorporation of L-[U-14C]phenylalanine into protein, calculated using its intracellular specific radioactivity, reached a maximum within 20 min and remained stable for the rest of a 3-h incubation. The rate of protein degradation, determined using [12C]phenylalanine as a marker, was linear over a 3-h incubation. Fasting for 3 days slowed the increase in lung protein content of fasted compared to nonfasted rats; there was also a decrease in protein synthesis and an increase in proteolysis. In fed rats, glucose, insulin, and glucose plus insulin did not alter protein synthesis. Glucose, insulin alone, and glucose plus insulin decreased proteolysis. We conclude that the in vitro system reflected changes in the in vivo protein content of the lung. Fasting decreases protein synthesis and increases proteolysis. Glucose and insulin alone modulate protein metabolism in the lung by acting on the degradative rather than the synthetic process.