Comparison of medical v surgical treatment of major hemoptysis.

One hundred thirteen patients hospitalized with substantial hemoptysis were studied. Thirty-one patients underwent surgery and 82 were treated medically, and the two groups had similar diagnoses and bleeding patterns. There were four deaths in the surgical group and 18 deaths in the medical group. Of these, eight patients had a sudden first hemoptysis with instantaneous death. Ten patients had a terminal hemoptysis after prior bleeding, but nine of these patients had absolute contraindications for surgery. In 64 patients hemoptysis was controlled with medical treatment. Most patients showed a steady decrease of bleeding, with cessation of hemoptysis after four days. Our experience indicates that the majority of patients with serious hemoptysis can be successfully treated conservatively. Massive hemoptysis, aspiration, or recurrence of bleeding in and of themselves are not indications for surgery. Where the hemoptysis remains uncontrolled in spite of a trial of adequate medical care or where the aspiration is severe and progressive, surgery may be indicated and can be lifesaving.

Active tuberculosis undiagnosed until autopsy.

In this report 21 patients in whom tuberculosis was the primary cause of death, but which was not diagnosed until necropsy, are reviewed. Of the 21 deaths, 11 were due to pulmonary tuberculosis and 10 to miliary tuberculosis. Proper evaluation of the following factors might have led to the correct diagnosis in many of the patients: A family history of tuberculosis, prior pleurisy, a gastrectomy, diabetes mellitus or end-stage renal failure; all can be associated with an increased incidence of tuberculosis. A negative tuberculin skin reaction does not exclude the presence of active tuberculosis. In the search for Mycobacterium tuberculosis, the examination of just one or two sputum specimens is not an adequate bacteriologic investigation. A positive gastric smear can have diagnostic importance. Ascitic fluid findings can be characteristic of tuberculous peritonitis. A negative bone marrow aspirate for acid-fast bacilli does not exclude miliary tuberculosis. Significant anemia, high fever and leukopenia increases the possibility of tuberculosis. The persistence and/or progression of lung infiltration, irrespective of supposedly specific antibiotic therapy, strongly suggests tuberculosis. Miliary tuberculosis can present as an adult respiratory distress syndrome. All but one patient in this series had fever. the failure to diminish the pyrexia believed due to specific lung infections with presumably effective antibiotics, and the inability of therapy to control other conditions thought to cause the fever indicate the presence of tuberculosis. Tuberculosis, especially miliary disease, should be considered as a possible etiology of fever of unknown origin. If the diagnosis of tuberculosis is highly suggestive, even without bacteriologic confirmation, a therapeutic trial of antituberculosis drugs should be given.

Reversible roentgenographic progression in the initial treatment of pulmonary tuberculosis.

This report concerns 7 patients who developed progressive pulmonary infiltrates during initial treatment of pulmonary tuberculosis. These new areas evolved within weeks after initiation of therapy, they were not usually at the site of the original lesion, and they were noncavitary in nature. At the time of their appearance there was evidence of clinical improvement, the original lesions were unchanged or showed some radiographic improvement, and the results of sputum cultures were positive with organisms sensitive in vitro to the drugs being administered. There was no indication of any other etiology except tuberculosis for the progression. There were no other signs of failure of the drug regimen. With continuation of the initial chemotherapy, sputum conversion occurred and the radiographic response was excellent, with the areas of progression and the original lesions demonstrating resolution or stability.