Nontuberculous mycobacterial infection of the central nervous system in patients with AIDS.

Infections due to nontuberculous mycobacteria (NTM) are especially common in patients with AIDS. Meningitis due to NTM, however, is rare. A search for CSF cultures positive for NTM over the past 11 years at our hospital yielded 16 cases. Of these, 15 were caused by Mycobacterium avium-intracellular (MAI), and one was caused by M fortuitum. All patients with MAI infection had widespread dissemination and at least one risk factor for AIDS. Clinical features included weight loss, altered mentation, and seizures. Analysis of cerebrospinal fluid revealed a mildly elevated leukocyte count with lymphocyte predominance and normal protein and glucose values. All direct smears were negative for acid-fast bacilli. In-hospital mortality was 67%. The patient with infection due to M fortuitum had a preexisting diagnosis of AIDS and had a right upper lobe pneumonia and headaches. Cranial CT showed an enlarged infundibulum of the pituitary gland. Results of CSF analysis were essentially normal, and direct smears were negative. He left the hospital against medical advice. Our study indicates that the finding of MAI in the CSF in patients with AIDS is associated with an in-house mortality of 67% indicating a very poor prognosis.

Cardiopulmonary responses to continuous positive airway pressure in acute asthma.

The effects of nasal continuous positive airway pressure (CPAP) on expiratory flow, arterial blood gas tensions, cardiovascular status, and dyspnea were studied in 21 patients with acute asthma. Therapy consisted of the following CPAP sequence: 30 minutes at 5 cm H2O, 20 minutes at 0 cm H2O, 30 minutes at 7.5 cm H2O, and 20 minutes at 0 cm H2O. Six control patients were fitted with a CPAP mask but given no positive-pressure therapy. Significant reductions in respiratory rate occurred from a baseline of 22.0 +/- 1.0 to 19.8 +/- 3.8 breaths/min at CPAP 5 cm H2O and to 19.4 +/- 4.3 breaths/min at CPAP 7.5 cm H2O (P < .05). No significant change occurred in forced expiratory volume in 1 second (FEV1), heart rate, mean arterial blood pressure, or arterial blood gas tension with either level of CPAP. Dyspnea, as assessed by a breathlessness score, improved during CPAP therapy (P < .05). These levels of CPAP were tolerated without deleterious side effects. In comparison, the control group showed no change in heart rate, respiratory rate, or breathlessness score during the study period. These data show that application of CPAP in acute asthma reduces respiratory rate and dyspnea with no untoward effects on gas exchange, expiratory airflow, or hemodynamics.

Drug-resistant tuberculosis in an urban population including patients at risk for human immunodeficiency virus infection.

In the past 5 yr, an increased incidence of tuberculosis has been noted in the United States. Simultaneously, the population infected with human immunodeficiency virus-type I (HIV-I) and the number of cases of acquired immunodeficiency syndrome (AIDS) have increased. Selected areas of the United States have also reported increases in the frequency of drug-resistant isolates of Mycobacterium tuberculosis. Because our institution serves a population in which tuberculosis, AIDS, and drug resistant isolates of M. tuberculosis are frequently encountered, we sought to better define interrelationships among these factors by retrospectively reviewing the demographic, clinical, bacteriologic, and radiologic data for all adult patients in whom M. tuberculosis was isolated from a culture of respiratory-tract secretions during a 1-year period (June 1, 1988 to May 31, 1989). Two hundred forty-six patients were thus identified; 66.5% were U.S. born blacks, and 62.6% were 17 to 40 yr of age. Risk factors for HIV infection were present in 106 patients. The overall resistance rate (one or more drugs) = 30.9%, with primary resistance = 22.6% (35 of 155) and secondary resistance = 49.2% (29 of 59). In addition, 12 resistant isolates were found in 32 patients whose prior treatment status was indeterminate. Of the resistant isolates, 56.6% (43 of 76) were multiply resistant. Isoniazid resistance was noted in 90.7% (69 of 76) and rifampin resistance was noted in 50% (38 of 76) of the resistant isolates. No significant differences in the overall frequency of resistance were noted in patients at risk for HIV infection compared with those without these risks.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypertrophic osteoarthropathy associated with Pneumocystis carinii pneumonia in AIDS.

Hypertrophic osteoarthropathy (HOA) is a systemic disorder primarily affecting the bones, joints, and soft tissues and developing in association with another disease process. Acute pyogenic pulmonary processes (empyema, lung abscess) are occasionally accompanied by transient HOA, but reversible HOA has not previously been reported in the setting of PCP in AIDS.

Reversible pulmonary uptake and hypertrophic pulmonary osteoarthropathic distribution of technetium-99m methylene diphosphonate in a case of Pneumocystis carinii pneumonia.

Diffuse pulmonary deposition of [99mTc]methylene diphosphonate (MDP) as well as abnormalities characteristic of hypertrophic pulmonary osteoarthropathy have been observed in a patient with Pneumocystis carinii pneumonia (PCP). The findings of the bone scan together with those in the corresponding scintigraphy, and roentgenograms of the chest and skeletal structures are presented. Parallel reversal of [67Ga]citrate and [99mTc]MDP pulmonary uptake with specific treatment for and clinical resolution of PCP implies a causal relationship.

Management of tuberculous pericarditis.

The cases of 17 patients with tuberculous pericarditis were reviewed. Thirteen patients had effusive pericarditis, and 10 had surgical drainage of the effusion. No deaths were due to pericardial tamponade; this appears to be related to earlier recognition of major pericardial effusions by echocardiography. In 2 patients clinical evidence of pericardial constriction developed while they were on a regimen of therapy, and in another 2 patients, echocardiography revealed pericardial thickening after resolution of the effusion. A pericardial window is recommended for the short-term management of patients suspected of having tuberculous pericarditis with a major pericardial effusion by echocardiography. If a thickened pericardium is found during the window procedure, early pericardiectomy is strongly encouraged.

Nonbronchoscopic lung lavage for diagnosis of opportunistic infection in AIDS.

Thirty patients known to have or suspected of having acquired immunodeficiency syndrome (AIDS) were evaluated for opportunistic pulmonary infection using a double lumen lavage catheter (DLL). Lavage specimens obtained were cytocentrifuged and initially stained by the Papanicolaou technique as a means of rapid evaluation for Pneumocystis carinii. If no opportunistic organism was identified, the patient underwent further diagnostic investigations. In 18 patients receiving mechanical ventilatory support, the procedure was performed via the endotracheal tube. Twelve patients who were less severely ill underwent the procedure via the transnasal route. In 43 percent (13/30), opportunistic infections were diagnosed by DLL. Twelve had P carinii, one of whom had cytomegalovirus and another of whom had Herpes simplex viruses, and one with Toxoplasma gondii. Thus, the sensitivity for all opportunistic infections was 86 percent (12/14). The volume of fluid recovered averaged 93 percent of that instilled. There was no significant difference between prelavage and postlavage PaO2. In this group of patients, double lumen lavage obviated the need for more invasive and expensive procedures.

Value of bronchoalveolar lavage in the diagnosis of pulmonary infection in acquired immune deficiency syndrome.

Seventy five patients with pulmonary disease and suspected acquired immune deficiency syndrome (AIDS) underwent fibreoptic bronchoscopy with bronchoalveolar lavage. Of 54 cases of Pneumocystis carinii pneumonia, 53 (98%) were diagnosed by bronchoalveolar lavage. Complications were recorded in 12 instances and included pneumothorax in two and transient increase in fever and hypoxaemia in the remainder. Bronchoalveolar lavage is a safe, easy, and effective procedure for diagnosing pneumocystis pneumonia in patients at high risk of AIDS and should be done routinely when fibreoptic bronchoscopy is performed in such patients.

Cytologic diagnosis of Pneumocystis carinii infection by bronchoalveolar lavage in acquired immune deficiency syndrome.

Twenty-six patients with pulmonary infiltrates and suspected acquired immune deficiency syndrome (AIDS) underwent 29 fiberoptic bronchoscopies, including bronchoalveolar lavage. Seventeen of the 18 patients (94.4%) shown to have Pneumocystis carinii pneumonia were diagnosed by examination of the bronchoalveolar lavage specimen. Minor complications occurred in 7 of 29 total bronchoscopies and included transient fever and hypoxemia. Bronchoalveolar lavage is a safe, easy and effective procedure for making the diagnosis of P. carinii pneumonia in patients at high risk for AIDS and should be included routinely when performing fiberoptic bronchoscopy.

Mortality in sarcoidosis. A changing pattern of the causes of death.

Forty-one deaths occurred among 1,090 patients with the clinical diagnosis of sarcoidosis between 1960 and 1977. Thirteen patients died of causes unrelated to sarcoidosis, whereas death was related to sarcoidosis in 28 patients (68%). The most prevalent lesion leading to death was advanced pulmonary involvement (22/28 patients or 78%) with various late complications: cardiorespiratory failure, gram-negative pneumonias, fungal infections. The average clinical course among these 22 patients was 10 years from the onset of the disease. The average age at death was 39 years. Patients who died of central nervous system and cardiac sarcoidosis were younger, and their clinical course was shorter. Subclinical sarcoidosis does not seem to affect life span. Autopsy in 25 patients showed systemic sarcoid lesions in all, including asymptomatic patients and those presenting with clinical manifestations limited to the CNS and the heart. The discrepancy implies difficulty in making the diagnosis, and suggests the need of intensive diagnostic work-up. Improved medical therapy, particularly the control of infections and management of cardiorespiratory failure, has resulted in a protracted clinical course and a changing pattern of the causes of death in sarcoidosis.

Pulmonary sarcoidosis: roentgenographic, functional, and pathologic correlations.

Discrepancies were observed between functional (PFT), chest roentgenographic, and open lung biopsy findings (granulomata, interstitial pneumonitis, angiitis, and fibrosis) in 81 patients with clinical diagnosis of sarcoidosis. A combination of normal PFT and Type 1 roentgenographic findings (hilar lymphadenopathy) was associated with minimal lung lesions without fibrosis. Type 1 findings alone did not preclude extensive lesions or fibrosis. Advanced roentgenographic and PFT abnormalities correlated with the presence of extensive lung lesions. The pulmonary diffusing capacity correlated best with specific and overall lung pathology, and roentgenographic types. Only this test differentiated the extent of granulomata and the roentgenographic types. Moderate degrees of other pathologic changes were not distinguished by any other PFT. Degrees of overall lung pathology correlated with an individual PFT and most significantly with overall PFT (p less than 0.001). Serial studies of PFT are a practical and valuable means for assessment of the disease process in sarcoidosis.

Double-blind, controlled study of clemastine fumarate, chlorpheniramine and placebo in patients with seasonal allergic rhinitis.

A whole body plethysmograph (body box) equipped with a flow meter (see Figure 1) was used for objective quantification of the effects of single doses of clemastine fumarate 2.68 mg, chlorpheniramine 4 mg and placebo in a double-blind study of 48 patients with seasonal allergic rhinitis. This technique offers an objective means of assessing drug effects on nasal congestion and obstruction. Before the development of whole body plethysmography, only subjective assessments of antihistamines' effects on nasal blockage or congestion were available. These subjective reports usually noted that nasal blockage or congestion was refractory to antihistamines or minimally relieved by them. However, in this study, nasal and oral airway resistances, each measured by whole body plethysmography, were lowered by clemastine fumarate and chlorpheniramine. These results were corroborated by the patients' and physician's assessments of changes in symptom severity and the physician's evaluation of intranasal photographs taken for each patient. Oral airway resistance of patients treated with clemastine fumarate was improved to a significantly greater extent than in patients receiving placebo. At two hours post-drug, patients receiving clemastine fumarate usually showed a greater response in most assessments than those receiving chlorpheniramine, and the trend of most comparisons was clearly in favor of clemastine fumarate. Patients in all three treatment groups experienced drowsiness but both incidence and severity were lower with clemastine fumarate.

Double-blind, controlled study of clemastine fumarate, chlorpheniramine and placebo in the symptomatic treatment of seasonal allergic rhinitis in desensitized and nondesensitized patients.

In double-blind trials clemastine fumarate 2.68 mg. chlorpheniramine 4 mg and placebo were randomly assigned to two groups of patients with seasonal allergic rhinitis. Thirty-nine desensitized patients were given one of the three test drugs in a parallel design; 67 nondesensitized patients each received two of the three drugs in a crossover design. Assessment of drug activity in each study was by whole body plethysmography and intranasal color photography as well as by subjective methods. Objective measurements showed clemastine fumarate was significantly superior to placebo and often better than chlorpheniramine in decreasing true nasal resistance and relieving nasal congestion. High placebo responses characterized the subjective evaluations, although the active drugs were clearly better. Responses varied somewhat between desensitized and nondesensitized patients. The number of reports of sedative effect, high in all groups, seemed to be more closely related to these antihistamine conditioned patients than to activity of the drugs themselves, based on previous reports of low sedation with clemastine fumarate. The techniques described proved very useful in distinguishing relative activity of antihistamines. Clemastine fumarate, the new antihistamine studied, appears to offer certain advantages over the older drug, chlorpheniramine.

A comparative study of subcutaneously administered terbutaline and epinephrine in the treatment of acute bronchial asthma.

Terbutaline, a new bronchodilator drug reported to have selective affinity for beta 2-adrenergic receptors, was compared with epinephrine in the treatment of 49 adult subjects with acute bronchial asthma. Under double-blind conditions, 24 subjects received 1.0 mg of terbutaline sulfate, and 25 subjects received 0.5 mg of epinephrine hydrochloride subcutaneously. Spirometric measurements, heart rate, and blood pressure, as well as subjective responses, were recorded prior to, and then at 5, 15, 30, 60, and 120 minutes after administration of the drug. The results indicate that terbutaline is an effective bronchodilator drug in subjects with acute asthma; however, the heart rate rose significantly after administration of terbutaline, with a maximal increase of 25 percent above control. Review of the literature reveals that tachycardia is a consistent finding when subcutaneous doses of terbutaline in excess of 0.25 mg are administered. Stimulation of beta 1-adrenergic receptors in the heart appears to be the most important factor involved in this response. A lesser cardioaccelerator effect was observed after administering epinephrine in a dose producing an equivalent degree of bronchodilatation.

Cardiovascular effects of benzquinamide in man.

Benzquinamide HCl, a new antiemetic agent, was studied in twelve healthy volunteers. Each subject received intravenously both benzquinamide (0.7 mg/kg) and placebo in a randomized, double-blind crossover manner. Cardiac output and arterial pressure, arterial blood gases, respiration (tidal volume and rate), and oxygen consumption were measured twice before drug administration and at 5, 10, 20 and 30 min after injection. Intra-arterial pressure increased significantly (P less than 0.005) at 5 min (12.6%) and 10 min (8.6%) following benzquinamide. Likewise, peripheral vascular resistance increased significantly (P less than 0.005) at 5 min (14.3%) and 10 min (8.8%) post-injection. Cardiac output, stroke volume and heart rate remained essentially unchanged. A significant increase (P less than 0.025) in respiratory rate was observed at 10 min (8.7%) and 20 min (12.6%) following benzquinamide. Values for the arterial Po2, Pco2, and pH showed no significant changes. It is considered that the effect of benzquinamide in increasing intra-arterial pressure is due to the increased peripheral vascular resistance.