Severe hemoptysis associated with pulmonary aspergilloma. Percutaneous intracavitary treatment.

Surgical therapy for massive hemoptysis associated with pulmonary aspergilloma carries a high morbidity and mortality in patients with limited pulmonary reserve. Bronchial artery embolization has proven ineffective in treating and in preventing recurrent episodes of hemoptysis in this group of patients. Over a four-and-one-half year period, we have successfully treated six episodes of acute hemoptysis in four patients using a percutaneously placed catheter and intracavitary instillation of amphotericin B, N-acetylcysteine, and aminocaproic acid. Advantages of this method of treatment for patients with severely compromised pulmonary reserve include: (1) no further loss of lung function; (2) ease and rapidity of catheter insertion; (3) prompt response to treatment; (4) relatively short hospitalization; and (5) ability to repeat the procedure in the same or another cavity if necessary.

Legionella pneumophila pericarditis proved by culture of pericardial fluid.

Serogroup 1 Legionella pneumophila was isolated from the pericardial fluid of a nonimmunosuppressed patient with pulmonary infiltrates, cardiac tamponade, and histologic evidence of pericarditis. This is the first reported case in which the association of L. pneumophila infection and pericarditis has been proved by growth of the organism from pericardial fluid. Physicians caring for patients with pericarditis of unknown cause should consider L. pneumophila in their differential diagnosis because special diagnostic efforts and relatively specific therapy are required for its optimal management.

Factors influencing theophylline serum protein binding.

We studied a number of influences on theophylline binding to serum proteins using equilibrium dialysis (37 degrees), a modified Krebs-Ringer bicarbonate buffer (pH 7.4), and 8-14C-theophylline with unlabeled theophylline (30 microgram/ml) added to sera from healthy subjects. Theophylline protein binding rose by 18.6% as pH rose from 7.0 to 7.8 (percent theophylline bound = 28.2 +/- 4.3 at pH 7.0 and 46.8 +/- 4.9 at pH 7.8, n = 5). Average theophylline binding to the proteins at 37 degrees in serum samples from 10 normal adults was 39.3 +/- 3.44%, which is 89.9% lower than the average of 48.2 +/- 3.74% for the same samples at 26 degrees. Theophylline binding was 6.1% higher with 0.1 mole/l phosphate buffer, pH 7.4, than with a modified Krebs-Ringer bicarbonate buffer, pH 7.4. Of the 19 drugs and metabolites tested for competition with theophylline for binding sites on serum proteins, 10 induced decreases in binding ranging from 6.8% in the case of furosemide to 18.3% for sodium salicylate. The latter was the only drug that induced a decrease in theophylline binding at concentrations that would be achieved in the therapy of same patients (i.e., patients on long-term salicylate therapy). All the other drugs that decreased theophylline binding did so at much greater concentrations than their usual therapeutic levels. The mean +/- SD of theophylline bound in 51 fresh serum samples from healthy adults was 48.6 +/- 10.2%; the pH of these specimens varied from 7.6 to 8.7. After adjusting pH to 7.4, theophylline binding was lowered to 37.6 +/- 4.5% and intersubject variability decreased. We recommend that the pH of serum specimens be adjusted to 7.4, or to the original pH of the blood specimen if it differs significantly from 7.4 (i.e., in acidotic or alkalotic patients). The wide range of reported values for theophylline binding to serum proteins in normal and asthmatic adults at least partly results from differences in the conditions used for the separation of free from bound drug.

Determination of theophylline and its metabolites by liquid chromatography.

A high pressure liquid chromatographic assay has been developed for the separation and quantitation of theophylline and its metabolites (1-methyl uric acid, 3-methyl xanthine, and 1,3-dimethyl uric acid), theobromine, and dyphylline in biological fluids, viz. human serum, urine, and saliva. The serum has been rendered protein-free by passage through a filter with a nominal molecular weight limit of 10,000. The filtrate is injected onto a reverse-phase column and the separation achieved by utilizing a polar mobile phase and dyphylline (dihydroxypropyl theophylline) as the internal standard. The results for two normal subjects are included to illustrate the applicability of the technique.

Chronic eosinophilic pneumonia followed by polyarteritis nodosa complicating the course of bronchial asthma. Report of a case.

The syndrome of pulmonary infiltrates with eosinophilia (PIE) occurs rarely in the asthmatic patient. An unusual case is presented in which progressive bronchoconstriction and exaggerated blood eosinophilia preceded the recognition of two seemingly unrelated diseases, each of which can independently result in hypereosinophilia and the PIE syndrome. In the male patient studied, the first illness, biopsy-proved chronic eosinophilic pneumonia, was responsive to corticosteroid therapy. Four uneventful years later, polyarteritis nodosa with eventual pulmonary involvement developed. A careful search for specific underlying pulmonary and systemic disease is in order when hypereosinophilia occurs in the clinically unstable asthmatic patient.

Kinetics of intravenous theophylline.

The pharmacokinetics of theophylline was studied in 6 normal, nonsmoking, adult male volunteers. A constant-rate intravenous infusion of 3.84 to 4.98 mg/kg of theophylline (as the ethylenediamine salt, aminophylline) was administered over 40 min. Serum theophylline concentrations were measured for 24 hr by means of a gas chromatographic method specific for theophylline. Within 30 min of an average intravenous dose of 4.4 mg/kg of theophylline, serum levels reached 10 microgram/ml. The highest serum level at the end of the infusion was 17 microgram/ml. The serum concentration-time data were fitted to a two-compartment open model and yielded a mean serum half-life (t1/2) of 11.02 hr, a value longer than those previously reported. Our results indicated that after the original loading dose of 4.4 mg/kg was infused for 40min, an immediate infusion rate of 1.40 mg/kg/hr (1.65 mg/kg/hr aminophylline) would be necessary to maintain a serum level of 10 microgram/ml.

Interference by butyl rubber stoppers in GLC analysis for theophylline.

During a study of the pharmacokinetics of theophylline using GLC analysis, unexpectedly high values occurred in a random manner. The cause of there abnormal values was investigated, and significant interference was observed when blood samples were drawn using evacuated glass tubes sealed with butyl rubber stoppers. In vitro tests using distilled water showed no apparent theophylline levels due to the additives in three commonly used tubes. However, when water was allowed to remain in contact with the butyl rubber stoppers for 1 min, an apparent theophylline content of as high as 5.5 mug/ml was observed. A contact time of 60 min resulted in apparent theophylline levels of as high as 52.3 mug/ml. It was concluded that a substance leached from the butyl rubber stoppers accounted for the spurious results.