Characteristics of low-risk patients hospitalized with community-acquired pneumonia.

BACKGROUND: Despite the wide distribution of different severity scoring systems for community-acquired pneumonia (CAP) patients, low-risk patients are frequently hospitalized, contrary to current recommendations. The aim of our study was to determine the rate, clinical characteristics, and outcome of low-risk patients with CAP admitted to our institution. METHODS: During an 18-month period, we prospectively screened all patients admitted to the Division of Internal Medicine with a presumptive diagnosis of CAP. Pneumonia Outcome Research Team (PORT) score and pneumonia severity index (PSI) were calculated for all patients during the first 24 h. RESULTS: A total of 591 patients had a diagnosis of CAP. Some 196 patients (33.1%) were low-risk (PSI class I, II), 98 (16.6%) intermediate (PSI III), and 297 (50.3%) high-risk patients (PSI IV, V). Patients in low-risk classes were younger (45.5+/-15.8 vs. 65.0+/-12.5 and 74.9+/-11.8 years, respectively, p<0.001) and had fewer background diseases. They had shorter hospitalizations than intermediate- and high-risk groups (4.4+/-3.2, 5.3+/-3.4, and 6.8+/-6.4 days, respectively, p<0.001). There was a significant difference in 30-day mortality between the different risk groups: 0% in the low-risk, 2.0% in the intermediate-risk, and 9.4% in the high-risk group (p<0.001). CONCLUSION: The considerable proportion of low-risk patients hospitalized due to CAP was found to be comparable to the stable 30% rate reported in the literature. We conclude that physicians tend to opt for a wide safety range when considering a CAP patient hospitalization, rather than make a decision based only on severity score calculation.

Pleural effusion associated with rheumatoid arthritis: what cell predominance to anticipate?

Pleural involvement is the most frequent manifestation of rheumatoid arthritis (RA) in the chest. We report here two patients who presented with large exudative pleural effusions and subsequently developed sero-positive RA. In both cases, the differential cell count of the pleural effusion suggested empyema. A literature review identified that RA-associated pleural effusion afflicts more men than women and 95% of the patients have high titers of rheumatoid factor (RF). In 46% of cases, RA-associated pleural effusion is diagnosed in close temporal relationship with the diagnosis of RA. The effusion is an exudate and is characterized by low pH and glucose level, and high lactic dehydrogenase (LDH) and cell count. At diagnosis there is a tendency for predominant neutrophils to occur consistent with an empyema and 7-11 days later, the cells in the pleural effusion are replaced by lymphocytes. Pleural effusion with predominant eosinophilia is rare. RA patients with acidic effusion and low glucose content with neutrophils predominance should be treated with thoracic drainage and antibiotics until an infection is ruled out. The histo-pathologic findings in pleural fluid of tadpole cells and multinucleated giant cells and the replacement of the mesothelial cells on the parietal pleural surface with a palisade of macrophage derived cells are described as pathogonomic for RA. Treatment with systemic steroids and intra-pleural steroids are effective in most cases.

Can the routine use of fluoroquinolones for community-acquired pneumonia delay the diagnosis of tuberculosis? A salutary case of diagnostic delay in a pilgrim returning from Mecca.

Guidelines advocate using fluoroquinolones as first-line treatment for community-acquired pneumonia (CAP). However, the use of fluoroquinolones in patients with undiagnosed tuberculosis may cause a delay in the diagnosis of tuberculosis and may also promote the development of resistance to these drugs if used as monotherapy in undiagnosed tuberculosis. We illustrate the former with the following case report of a patient who developed tuberculosis after a pilgrimage to Mecca.

Intradialytic hypercapnic respiratory failure managed by noninvasive assisted ventilation.

We report a hemodialysis patient with acute hypercapnic respiratory failure managed on noninvasive intermittent positive pressure ventilation and progressive metabolic acidosis. Dialysate bicarbonate concentration of 25 mEq/l was associated with exacerbation of metabolic acidosis, while higher dialysate bicarbonate concentration of 30 mEq/l induced a dangerous increase in PCO(2) level. Excessive bicarbonate buffering and CO(2) production induced by severe metabolic acidosis, malnourishment and tissue hypoxia, could explain inadequate correction of metabolic acidosis and worsening of hypercapnia in this patient. Our findings suggest the need for close monitoring of blood gases and cautious modulation of dialysate bicarbonate concentration in the presence of progressive metabolic acidosis in hypercapnic hemodialysis patients.

[Specialty clinics--gain or loss?].

We evaluated the significance of first visits to our pulmonary clinic with regard to diagnosis and treatment by reviewing records of 287 new referrals by medical care providers (Sept. 1998-Feb. 1999). At the first visit the diagnosis was changed in 30%, and treatment in 40%. These are minimal figures because evaluation had not been completed nor the diagnosis determined in all cases, while further investigation and follow-up continued. In light of these findings, we believe that recent pressure on primary care physicians to avoid referrals to specialty clinics would result in short-term savings, but in the long term, would increase expenses and diminish quality of care. It is important to consider ways to maximize the interaction between the primary care physician and the specialist to maintain quality of care and decreases costs.

Cancer incidence and risks in selected agricultural settlements in the Negev of Israel.

Medical staff of two Negev kibbutzim invited epidemiologists to help them investigate cancer rates among their members. Our objectives were (a) to determine whether the cancer rate in the kibbutzim was elevated or abnormal and (b) to determine the role of agricultural and other relevant exposures if cancer incidence was elevated. We validated cases of cancer by kibbutz records and by surveying other information; we computed expected values on the basis of the age-sex-calendar period and site-specific cancer incidence rates reported by the Israel Cancer Registry for the entire population; and we compared the data for the 2 kibbutzim with data derived for similar age and sex groups in 2 other kibbutzim, which were assumed not to have increased cancer rates. In addition, we planned and conducted a case-referent study, including the design, pretest, and use of questionnaires, including data about lifetime exposures (i.e., type of work and its duration, agricultural and industrial chemicals, smoking and alcohol use, demographic variables, health experiences, and family history). In only one of the kibbutzim, for which high cancer rates were suspected, was there significant excess for all sites in persons who were less than 40 y of age. In one of the "comparison" kibbutzim, we found increased cancer rates overall. Much of the excess in the high cancer kibbutzim was in hematological cancer (i.e., leukemia and lymphoma). Multiple years of work in fields, orchards, and landscape, as well as orchard work that commenced before 1960, were associated with increased risk of cancer (p < .08). We also found an association between cancer rate and numbers of industrial chemicals used (p < .08). Pipe and cigarette smoking were also associated with increased cancer incidence. In the multivariate analysis, the association with calendar year in which orchard work was started and multiple exposures to industrial chemicals was stronger than associations noted in the univariate analyses. Although duration of agricultural work or multiple industrial exposures were clearly associated with increase in cancer risk, we were unable to identify the causal role of specific agent(s). Nonetheless, educational programs for cancer prevention can be based, in part, on the results of such a study.

Herbicide (Roundup) pneumonitis.

A case of acute intoxication presented as toxic pneumonitis after exposure to Roundup (glyphosate) (Solaris Group, Monsanto; San Ramon, CA) herbicide in an agriculture worker. The correct etiologic factor causing this specific clinical picture was identified only 2 weeks later, after a thorough occupational history was taken and meticulous delineation of the working conditions and exposures of the involved worker were made. As a rule, occupational related diseases are not readily elucidated by nonoccupational physicians. However, most acute intoxication events are first encountered by such physicians. In these situations, rapid and comprehensive evaluation is necessary in order to clearly identify the causative agent(s) and to initiate the appropriate treatment. Consulting occupational physicians at this early stage may facilitate early and accurate diagnosis.

[Spontaneous internal jugular vein thrombosis complicating chronic pulmonary disease].

Spontaneous internal jugular thrombosis is a rare vascular disorder. It usually occurs as a result of external pressure due to a tumor, infection or as a result of damage to the vessel wall after trauma or central venous catheterization. We report a 35-year-old woman who suffered from severe pulmonary hypertension due to chronic cystic lung disease. She was admitted due to sudden, severe, right-sided neck pain. Internal jugular occlusion by a thrombus was demonstrated by ultrasound and CT-scans but no apparent cause was found. We postulated that the important factors in the development of her thrombosis were stasis due to pulmonary hypertension and high blood viscosity.

Pleural empyema caused by Leuconostoc spp.

A rare case of pleural empyema caused by Leuconostoc spp. is reported. The patient was treated successfully with clindamycin. To our knowledge this is the first reported case of pleural empyema caused by Leuconostoc spp. In a patient with characteristic predisposing factors, such as a serious underlying disease, previous vancomycin therapy and thoracic access device. Our case illustrates that Leuconostoc spp. can cause pleural infection as further evidence of its human pathogenicity.