Pseudallescheria boydii lung infection in an immunocompetent adult, difficulties in diagnosis and management.

Pseudallescheria boydii and its asexual state Scedosporium apiospermum is a well known opportunistic pathogen among immunocompromised patients. However it is rare in immunocompetent patients. The optimum management of this infection is still not clear. The new azoles may show better efficacy than amphotericin B and additional surgery may play a pivotal role. We report a case of Pseudallescheria boydii lung infection in an immunocompetent patient who had an old tuberculous cavity and presumed inhalational exposure. The case highlights difficulties in diagnosis which complicates the selection of antifungal agent/s and the need for aggressive surgical debridement.

Utility of bronchoalveolar lavage in the diagnosis of pulmonary infections in immunosuppressed patients.

AIM: To evaluate the utility of bronchoalveolar lavage (BAL) in immunocompromised patients. MATERIAL AND METHODS: We studied BAL cytology and microbiological culture in 16 kidney transplant recipients (Group A), 14 dialysis patients (Group B) and eight HIV positive patients (Group C) suspected of having pulmonary infections. A group of 21 individuals without pulmonary diseases were studied as controls. RESULTS: A comparison of the cytological profile in controls and study groups showed that percentages of lymphocytes and neutrophils were significantly increased in all three patient groups as compared to controls, BAL bacterial cultures were positive in 4, 3 and 4 cases of Group A, B and C, respectively. Direct examination of BAL cytosmears helped in detecting cytomegalovirus inclusions, acid fast bacilli and Pneumocystis carinii in 3, 2 and 5 cases of Group A, B and C, respectively though microbial cultures were negative. The sensitivity of BAL cytology was found to be 76.3%, whereas that of microbial culture was only 31.5%. The diagnostic yield of BAL was 68.75%, 71.42% and 100% in the Groups A, B and C, respectively, while it was 76% when all three groups were considered together. BAL cytology yielded the diagnosis in 47.36% of cases, a combination of BAL cytology and culture in 23.68% and culture alone in 5.3% of cases. CONCLUSIONS: BAL is useful relatively non-invasive investigative tool in the rapid diagnosis of infections in immunocompromised patients. BAL cytology was found to be more useful than microbial cultures.

The Mantoux test in the diagnosis of genital tuberculosis in women.

OBJECTIVE: To analyze the usefulness of the Mantoux test in the diagnosis of genital tuberculosis in women of childbearing age. METHOD: In this report, the investigators studied the ability of a tuberculosis (TB) Mantoux test to diagnose pelvic tuberculosis. A positive TB Mantoux test was clearly defined. The positive control group was of 100 women treated for TB (study group C). The negative control group was of 100 postpartum women (study group B). The study group was 100 infertile women undergoing laparoscopy, in some of whom the diagnosis of TB was made (study group A). RESULT: The Mantoux test had a sensitivity of only 55% and a specificity of 80% in women with laparoscopically diagnosed tuberculosis. Pelvic focal reaction was absent in all groups including infertile women with a positive Mantoux test. CONCLUSION: Mantoux test has limited utility in diagnosing active genital tuberculosis during the childbearing age. However, in infertile women with positive a Mantoux test, laparoscopy may be advocated early.

Anaesthetic management of bilateral alveolar proteinosis for bronchopulmonary lavage.

The most hazardous manifestation of pulmonary alveolar proteinosis is progressive hypoxia for which bronchopulmonary lavage (BPL) is the single most effective treatment. Unfortunately this procedure under general anesthesia itself increases the risk of hypoxia due to the need for one lung ventilation. It was therefore considered interesting to report the successful anaesthetic management of a patient with pulmonary alveolar proteinosis for Bronchopulmonary lavage.

Pneumocystis carinii pneumonia in human immunodeficiency virus infected patients in Bombay: diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy.

We report Pneumocystis carinii pneumonia (PCP) diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy in three out of five human immunodeficiency virus (HIV) positive adult patients presenting with interstitial pneumonitis. One of these patients was serologically positive for HIV at the time of presentation and the remaining two patients were detected to be HIV positive on follow up after the diagnosis had been established. All the three patients were treated with co-trimoxazole. One patient recovered and was discharged; another patient improved with treatment but died after jugular vein cannulation and the third patient succumbed to cryptosporidial diarrhoea. The remaining two patients with non-specific interstitial pneumonitis treated with prednisolone and bronchodilators were recovered and were discharged from the hospital.

PIP: In developing countries, the proportion of Pneumocystis carinii pneumonia (PCP) cases, compared to other opportunistic infections associated with AIDS, is low partly because of underdiagnosis. PCP cases are reported that were diagnosed by bronchoalveolar lavage (BAL) cytology and transbronchial lung biopsy (TBLB) in 3 out of 5 HIV-positive adult patients presenting with interstitial pneumonitis at the Department of Chest Medicine, KEM Hospital, Bombay. One of these patients was serologically positive for HIV at the time of presentation and the remaining 2 patients were detected to be HIV-positive on follow-up after the diagnosis had been established. All patients had elevated erythrocyte sedimentation rate. CD4+ lymphocyte analysis was done in 1 patient and revealed 360 CD4+ cells/cu. mm. BAL cytology using Giemsa stained smears confirmed the presence of cysts diagnostic of Pneumocystis carinii. TBLBs of the 3 patients who revealed P. carinii in their BAL fluid also evinced foamy intra-alveolar eosinophilic exudates, and the GMS stain showed the presence of ovoid or cup-shaped structures consistent with P. carinii within these exudates. Biopsies from the 2 PCP-negative, HIV-positive patients showed evidence of interstitial pneumonitis. All 3 patients were treated with cotrimoxazole (20 mg/kg body weight). Only 1 patient recovered and was discharged; another patient improved with treatment and was started on cefotaxime (50 mg/kg body weight) and amikacin (15 mg/kg body weight), but died after jugular vein cannulation. The third patient developed cryptosporidial diarrhea and died. The remaining 2 PCP-negative patients with nonspecific interstitial pneumonitis treated with prednisolone and bronchodilators recovered and were discharged from the hospital. BAL cytology and TBLB were useful tools in detecting PCP, one of the few treatable AIDS-related infections.

Study of respiratory failure in organophosphate and carbamate poisoning.

OBJECTIVE: To study the clinical profile and cholinesterase levels of subjects of organophosphate and carbamate poisoning and to identify those subjects who would require ventilatory support. DESIGN: Prospective, observational study. SETTING: Intensive care unit of a tertiary care urban hospital. SUBJECTS: Fifty-two patients admitted with a diagnosis of organophosphate or carbamate poisoning. OUTCOME MEASURES: Subject survival and ventilator requirement. INTERVENTION: Treatment with atropine and pralidoxime and mechanical ventilation for patients with respiratory failure. Clinical features were monitored at every stage, and blood for plasma and red blood cell cholinesterase levels was collected on admission. RESULTS: According to the ingested poison, subjects were divided into four groups: organophosphates (13 subjects), mixed organophosphate and carbamate (18), carbamates (13), and a fourth miscellaneous group (8). Dyspnea and vomiting were the most common symptom and miosis and cyanosis were the most frequently observed signs. Plasma and red cell cholinesterase levels were lowest in the mixed poison group and highest in the carbamate group. Twenty-seven subjects developed Type I respiratory failure and 7 had Type II respiratory failure. Mechanical ventilation was required in 31 subjects. Overall 33 subjects survived. A scoring system, on a point scale of 16, was developed using miosis, unconsciousness, fasciculations, and plasma cholinesterase levels to predict ventilator requirement. CONCLUSION: This study helps to identify at an early stage those patients with organophosphate or carbamate poisoning who would ultimately require ventilatory support. We found miosis, unconsciousness, fasciculations, and a low plasma cholinesterase level to be of greatest predictive value.

Exudative pleural effusions in patients over forty years of age--an analysis of seventy-six patients.

A prospective study of 76 consecutive patients over the age of 40 years, with exudative pleural effusion, was undertaken to determine the common causes of such a clinical condition. Malignant pleural effusions were the most common in this series, found in 49 patients (64.47%), all but one being metastatic from elsewhere. Forty were secondary to a carcinoma of the bronchus, 3 from carcinoma of the breast, 1 each from carcinoma of the ovary, oesophagus, and larynx; lymphoma accounted for the remaining 2. Infective causes accounted for 24 of the effusions (31.57%). Of the infections, tuberculosis was the most common, accounting for 17 of the 24. Other infective causes included bacterial empyemas in 4, ruptured amoebic liver abscess in 2, and actinomycosis in 1. Pancreatitis, pulmonary thromboembolism, and a post-cardiotomy syndrome were diagnosed in 1 patient each, while the diagnosis remained unknown in the remaining 5 patients. In 2 patients the diagnosis was made on autopsy.

Anti-inflammatory action of steroid inhalers.

With mucosal inflammation contributing to the pathogenesis of asthma, it is increasingly accepted that long term steroid inhalers may induce remission in chronic long standing asthmatics. The present study involved 44 stable asthmatics who were randomly given either beclomethasone dipropionate inhaler (50 ug) 2 puffs qds or salbutamol inhaler (100 mcg) 2 puffs tds in addition to their oral bronchodilators. Pulmonary function testing, bronchoalveolar lavage and complete blood count were done at basal and weekly intervals and at the end of the study. The absolute eosinophil count showed a significant drop in the beclomethasone group as compared to the salbutamol group. Serial lung functions showed a significant improvement in the pre-bronchodilator PEFR and the pre-bronchodilator FVC in the beclomethasone group as compared to the salbutamol group. There was no significant change in the lavage eosinophil count pre and post-bronchodilator in both groups. Steroid inhalers are thus useful in long term management of bronchial asthma especially with respect to reducing bronchodilator requirement.

Assessment of exercise tolerance in chronic bronchitis and interstitial lung disease.

Cardiopulmonary exercise testing has a definitive place in objective evaluation of the subjective sensation of breathlessness. In the present study 21 patients with COPD, 10 with ILD and 17 normals were subjected to stage 1 exercise testing and correlations were sought between Vo2 and work, FVC, FeV1, Ve, respiratory rate and tidal volume and between VCO2 and work. In COPD and ILD the Vo2 correlated with work, Fev1, Fvc and Ve whereas in normals it correlated with the VE but not with the FeV1 and FVC. In COPD VO2 correlated with TV though this was not the case in ILD. Thus stage 1 exercise testing can be a useful additional method to assess the disability in COPD and ILD although differentiation between these two respiratory diseases on basis of exercise testing alone may not be possible.

Percutaneous visceral pleural biopsy with fenestrated cup biopsy forceps.

When there is an exudative pleural effusion often both the parietal and the visceral pleura are affected, but the usual practice is to perform a percutaneous parietal pleural biopsy alone for diagnosis. Percutaneous visceral pleural biopsy was carried out in 20 patients with exudative pleural effusions with fenestrated cup biopsy forceps. In all 20 biopsies pleural tissue was obtained and it was diagnostic in 19 cases. The procedure is painless and appears safe.