Nonresolving pneumonia in steroid-treated patients with obstructive lung disease.

PURPOSE: To review autopsy-proven cases of opportunistic pneumonia and determine how many of these patients had received corticosteroid therapy for obstructive lung disease in order to define whether this therapy was the major risk factor predisposing to infection. PATIENTS AND METHODS: All autopsies performed at Winthrop-University Hospital over a 5-year period were reviewed, and 30 cases of opportunistic pneumonia were identified. In eight of 30 cases, corticosteroid therapy for chronic obstructive pulmonary disease (COPD) was the only identifiable risk factor for opportunistic infection. The other 22 patients had other well-defined risk factors for infection. Chart review of the eight patients with COPD was undertaken to define the clinical features of their infections. RESULTS: All eight patients had a progressive multilobar pneumonia that failed to resolve, either clinically or radiographically, despite the use of multiple broad-spectrum antibiotics. In four cases, the infection was community-acquired, while in the other four cases, it was nosocomial in origin. Despite the presence of a nonresolving pneumonia, opportunistic infection was generally not considered as a diagnostic possibility, with only one case being correctly diagnosed antemortem. Autopsy examination documented Aspergillus species as being responsible for six episodes of pneumonia, Candida albicans accounting for one episode, and cytomegalovirus accounting for one episode. CONCLUSION: Based on this experience, it is clear that corticosteroid therapy of COPD can lead to opportunistic pulmonary infection, in or out of the hospital. This diagnosis should be considered when patients receiving this therapy develop a pneumonia that fails to respond to broad-spectrum antibiotics.

"When the pneumonia doesn't get better".

Nonresolving pneumonia is a common and frequently misunderstood problem faced by the practicing pulmonologist. While radiographic resolution of most infections is relatively long and lags behind clinical signs of recovery, data suggest that a variety of host defense problems are a consequence of systemic illness and are often involved. When such factors are not implicated, other specific etiologies should be sought, including unusual organisms like mycobacteria, higher order bacteria, and fungi. Noninfectious causes for delayed resolution include neoplastic disease, immunologic disease, thromboemboli, and inhalation injuries. This article discusses the natural history of common pneumonias to establish the usual clinical limits of resolution and outlines a diagnostic strategy to use when these limits are exceeded.

Developmental retroperitoneal cysts of the pelvis. A review.

Retroperitoneal cysts have been classified into traumatic, infective, degenerative, neoplastic, and developmental, according to their origin. This paper focuses on the developmental variety of retroperitoneal pelvic cysts, particularly those of mesothelial, mesonephric, or paramesonephric origin. Their clinical presentations depend on their location; they may be mesenteric, parovarian, or vaginal. The pathogenesis and embryologic, diagnostic, and therapeutic aspects are reviewed and a case report is presented.