Simvastatin-diltiazem drug interaction resulting in rhabdomyolysis and hepatitis.

Simvastatin, a hydroxymethyl glutarate coenzyme A (HMG-CoA) reductase inhibitor, is a commonly used cholesterol lowering agent. The long-term safety profile of simvastatin, established over ten-years of clinical use, is excellent. Both rhabdomyolysis and hepatitis, however, are recognized toxic effects of this medication, and generally occur when the patients are taking more than 40 mg of simvastatin a day. Potent inhibitors of the cytochrome P450 3A4 (CYP3A4) enzyme increase the incidence of simvastatin toxicity. Calcium channel blockers are weak inhibitors of the CYP3A4 enzyme. Diltiazem is known to increase the serum concentration of simvastatin. Many patients who take both simvastatin and diltiazem require lower doses of simvastatin to achieve the recommended reduction in cholesterol. Since diltiazem is known to increase plasma levels of lovastatin, a similar phenomenon may occur with simvastatin. Our patient had been stable for three years on simvastatin therapy. His rhabdomyolysis and hepatitis coincided with the addition of diltiazem. This is the first report of the combined toxicities of rhabdomyolysis and hepatitis being induced by the addition of diltiazem to simvastatin therapy. This patient serves as a reminder to the clinician of the potential interaction of these two commonly used drugs.

Cat cuddler's cough.

Pasteurella multocida typically causes cutaneous infections in humans following animal bites or scratches. Primary pulmonary disease, however, can occur in humans after inhalation of airborne particles or by aspiration of colonized or infected nasopharyngeal secretions containing this organism. Symptoms of P. multocida pulmonary infection in humans are variable, ranging from cough with or without hemoptysis to severe prostration. P. multocida infection of the lower respiratory tree has a predilection for elderly patients with underlying lung pathology, especially chronic obstructive pulmonary disease and bronchiectasis. This report reminds the clinician that P. multocida can cause pulmonary infection in patients without underlying lung disease, and stresses the importance of careful history when presented with an indolent infection.

A rare cause of dyspnea and fibrocystic pulmonary disease.

Tracheobronchomegaly (TBM) is a disorder of the major airways characterized by an enlargement of the trachea and main stem bronchi. It is thought to result from a congenital connective tissue defect that results in the trachea and main bronchi becoming flaccid. Although TBM is considered rare, it may be more common than is generally recognized, and may be a seldom-diagnosed cause of chronic lung disease.

Influenza A pneumonia with rhabdomyolysis.

Influenza A pneumonia accounts for a significant number of the community-acquired pneumonias in the United States. While myalgia is a common complaint in influenza A infection, few cases of rhabdomyolysis associated with this virus have been described. Although it has been recently recognized that rhabdomyolysis complicating certain bacterial pneumonias has important prognostic implications, rhabdomyolysis in the setting of influenza A pneumonia does not appear to carry the same prognostic significance.

Spontaneous resolution of a giant pulmonary bulla.

Giant bullae occur most often in individuals who chronically inhale tobacco smoke. The natural history of these bullae is unpredictable, although the majority of them increase gradually in size and cause worsening respiratory function. Complete spontaneous resolution of a giant bulla is a rare occurrence, with only eight cases reported in English literature. Most of the cases of spontaneous resolution of giant bullae are thought to have resulted from an infectious process leading to closure of the communication between the airways and the bulla. However, resolution of a bulla has been associated with adenocarcinoma of the lung.

Noncaseating granulomatous disease in common variable immunodeficiency.

Patients with common variable immunodeficiency (CVID) are occasionally recognized to have a concurrent noncaseating granulomatous disease. The granulomatous disease (GD) associated with CVID shares many clinical properties typical of sarcoidosis. Some investigators speculate that the GD-CVID is actually sarcoidosis that is expressed atypically because of the patient's immunodeficiency. Clinical differences, however, have led other investigators to speculate that the GD-CVID is a distinct "sarcoid-like" granulomatous process.

Tracheal lipoma: a rare intrathoracic neoplasm.

Primary tracheal lipomas are extremely rare neoplasms. The typical patient is a middle-aged man with complaints of cough and shortness of breath. Often, the diagnosis is delayed, and patients are treated for asthma or bronchitis. The diagnosis of a tracheal lipoma is best approached by computed tomography (CT) and bronchofibroscopy. Tracheobronchial lipomas may be successfully excised endoscopically or by laser therapy. Open surgical resection is required when the lipoma extends extraluminally.

Outcomes of a postdischarge surveillance system for surgical site infections at a Midwestern regional referral center hospital.

BACKGROUND: Postdischarge surveillance has been reported in the literature as one method for detecting surgical site infections (SSIs) that more traditional methods of surveillance (review of readmission data, monitoring of microbiology, radiology, pharmacy antibiotic usage reports, and medical record review) fail to include. METHODS: This article describes a postdischarge surveillance program that used surgeon questionnaires and was implemented at a 225-bed Midwestern regional referral center hospital. Evaluation of the postdischarge program was accomplished by review of infection control program data for calendar years 1995 through 1997. RESULTS: Implementation of the postdischarge program resulted in an almost fourfold increase (in both 1995 and 1996) in SSI rates over the reported SSI rates if only traditional surveillance methods had been used. A majority of surgeons (79% in 1995 and 83% in 1996) had individual response rates of 80% or greater. In addition, implementation of the postdischarge program required only 3.5 to 4 additional hours per month. CONCLUSIONS: Results suggest that the postdischarge surveillance program identified SSIs missed by traditional surveillance methods, resulted in higher reported rates of SSI, was moderately to well accepted by surgeons, and was implemented with a minimum of organizational resources.

Hypersensitivity reaction to azathioprine.

Adverse drug reactions can vary from a simple rash to anaphylactic shock. While certain medications including the penicillins are well known to cause such reactions, other drugs are not as commonly recognized. Azathioprine hypersensitivity reactions tend to be benign and self-limiting with cessation of drug ingestion. We report a patient who had a hypersensitivity reaction to azathioprine, which manifested as distributive shock that mimicked sepsis. We also reviewed the English language literature for risk factors for a hypersensitivity reaction to azathioprine and its possible mechanism.

Thoracic actinomycosis and human immunodeficiency virus infection.

Despite the impairments of cellular and humoral immunity that accompany the acquired immunodeficiency syndrome, there has not been increased evidence of thoracic actinomycosis. We report on a patient with the human immunodeficiency virus (HIV) infection who had pulmonary actinomycosis. We review the current ideas regarding this unusual pulmonary pathogen and offer possible explanations for its rare appearance in the HIV population.

Delayed onset of pseudomembranous colitis after rifampin therapy.

Rifampin therapy is an infrequently reported cause of pseudomembranous colitis. A low index of suspicion may account for this lack of recognition. Awareness of this potentially hazardous complication of rifampin therapy is encouraged, especially since increasing numbers of patients infected with the human immunodeficiency virus, who may have diarrhea from other etiologies, require rifampin therapy.

Nutritional status and mortality in respiratory failure caused by tuberculosis.

A retrospective analysis of the records of all patients admitted to the intensive care unit with respiratory failure and nonmiliary tuberculosis was conducted to determine variables that might be predictive of survival. Nutritional status, as reflected by the patient's serum albumin and hemoglobin, were the best predictors of survival and were more helpful than the widely accepted APACHE II scoring system. This observation suggests that early and aggressive attention to improving the patient's nutritional status may be as important as effective antitubercular therapy and mechanical ventilation in salvaging these individuals.

Hepatocellular carcinoma presenting as a mediastinal mass.

We present a patient with hepatocellular carcinoma with systemic hematogenous metastases, but without parenchymal pulmonary involvement. Thoracic imaging revealed prominent mediastinal involvement. This pattern of hepatocellular tumor spread is unique.

Abnormal pulmonary function and juvenile onset diabetes mellitus.

The metabolic and microcirculatory abnormalities associated with insulin-dependent diabetes mellitus involve most organ systems, including the lung. The adverse effects of diabetes mellitus on the function of the respiratory system are minor compared to the morbidity sustained by the cardiovascular, renal, neural, and ophthalmic systems. Nevertheless, physicians should be aware that some indices of pulmonary function may be abnormal in diabetic patients, independent of the more commonly recognized respiratory risk factors.

Dissecting aortic aneurysm mimicking massive pulmonary embolism.

The finding of a massive unilateral segmental defect with normal ventilation upon lung scanning does not always secure the diagnosis of acute pulmonary embolus. We present a patient whose ventilation-perfusion lung scan suggested a significant embolic phenomenon, but who was subsequently found to have compression of her right pulmonary artery by a dissecting aortic aneurysm. Conditions that present with a unilateral perfusion defect merit further evaluation with pulmonary arteriography.

Juvenile laryngeal papillomatosis: a new complication.

Extension of juvenile papillomas to the lung parenchyma is unusual. When it occurs, the patient's prognosis worsens because these lesions destroy lung tissue as they grow. Respiratory complications eventually occur in the presence of multiple nodular and cystic lesions due to the attendant parenchymal destruction. We have observed that pneumothorax can occur after the development of cystic pneumatoceles, presumably from the ball valve effect of a nodular lesion (Fig 3).

Cardiac arrhythmias during performance of the flow-volume loop.

The purpose of our study was to determine the frequency of cardiac ectopy during the performance of flow-volume loops. The performance of an adequate flow-volume loop entails significant shifts in intrathoracic pressure and oxyhemoglobin saturation that could heighten myocardial arrhythmogenicity and lead to increased cardiac ectopy. Forty-two male patients referred for performance of flow-volume loops were studied with an ambulatory cardiac monitor and an arterial oxyhemoglobin saturation monitor during the performance of three flow-volume loops before and after administration of an aerosolized, selective beta 2-agonist. For comparison, the 60 min prior to and after completion of the loop testing was monitored with the continuous cardiac monitor. The frequency of cardiac ectopy was determined in four patient populations delineated by the presence or absence of cardiac, pulmonary, or cardiopulmonary disease. Each group was further divided based on the occurrence of arterial oxyhemoglobin desaturation during the performance of the flow-volume loop. We found that, despite the presence or absence of underlying cardiopulmonary disease or the occurrence of oxyhemoglobin desaturation during flow-volume loop performance, the number of cardiac ectopies diminished significantly during loop performance when compared with the 60-min study period prior to testing. This is in contrast to what had been reported previously. We conclude that the flow-volume loop is safe to perform in the general population, including those individuals with an increased risk of arrhythmias such as those with cardiac or pulmonary disease.