Faculty Bibliography

The effects of exposure to the environment around the World Trade Center after the attack of September 11, 2001, are not fully described. We evaluated 240 police first-responders; respiratory symptoms occurred in 77.5% but resolved or improved in around three fourths of subjects by the time of their evaluation (mean 69 days after the attack). Cough was the most common symptom (62.5%). Spirometric abnormalities were mild and occurred in 28.8%. Independent risk factors for abnormal spirometry were previous pulmonary disease or symptoms (adjusted odds ratio, 2.76) and intensity of exposure (AOR, 2.32). Previous pulmonary conditions were associated with obstructive defects (P<0.002). Exposure intensity was associated with a lower forced vital capacity (P<0.03) and a higher prevalence of abnormal spirometry (P<0.03). Officers with dyspnea, chest discomfort, or wheeze were more likely to have abnormal spirometry (P=0.04). A significant minority of officers had symptoms a few months after the exposure. Long-term effects of this respiratory tract exposure will need additional evaluation.

The spectrum of pulmonary manifestations in patients infected with human immunodeficiency virus (HIV) is broad, including many infectious and noninfectious complications. In the evaluation of an HIV-infected patient with diffuse pulmonary disease a definitive diagnosis is preferred over empiric therapy in most patients. Patients with focal consolidation usually receive empiric treatment for community-acquired pneumonia, with nonresponders undergoing additional diagnostic testing. Bronchoscopy remains a cornerstone in the diagnostic evaluation. A multilobar bronchoalveolar lavage (BAL) is usually sufficient for the diagnosis of Pneumocystis carinii pneumonia (PCP) and avoids the additional complications of hemorrhage and pneumothorax associated with transbronchial biopsy (TBBX). However, TBBX improves the sensitivity for diagnosis of tuberculosis and fungal pneumonias and is necessary to confirm invasive aspergillosis. Definitive criteria for diagnosis of cytomegalovirus pneumonitis have yet to be established, although bronchoscopic specimens usually are used. Tissue confirmation with TBBX is required for the diagnosis of noninfectious disorders such as non-Hodgkin's lymphoma and lymphocytic and nonspecific pneumonitis. Bronchoscopic visualization of typical lesions often is sufficient for the presumptive diagnosis of Kaposi's sarcoma (KS) although the diagnostic yield is enhanced by the detection of human herpes virus 8 in BAL samples.

BACKGROUND:Respiratory failure (RF) in ALS typically occurs as a late manifestation. While there are uncommon patient reports of early RF, most had moderate limb and bulbar weakness. DESIGN/METHODS/METHODS:We reviewed clinical and laboratory data from 3 patients with ALS, early RF, and minor motor signs. RESULTS:Patients were male, ages 62, 75 and 80 years. The patients presented with 6 months to 2 years of exertional and nocturnal dyspnea, daytime hypersomnolence, limb fatigability, and weight loss. Exam showed tachypnea, slight distal limb weakness, and hyperreflexia. All three patients had prominent fasciculations, insomnia, supportive EMG findings, FVC (32-74% predicted), PO2 (50-80 mmHg), PCO2(52-76 mmHg) and required BiPAP (Bi-level positive airway pressure). One patient had a reduced FEV1/FVC of 0.55 and a 15% increase in FEV1 post-bronchodilator suggesting concurrent chronic obstructive pulmonary disease (COPD). However, his P(A-a)O2 was only 7 mmHg suggesting COPD was not the major factor causing respiratory failure; his extreme hypercapnea could not be explained by ALS or COPD alone. CONCLUSIONS:ALS may present with unexplained RF, or sleep disturbance resembling sleep apnea, without significant bulbar or limb weakness. In our experience, such patients are elderly with dyspnea, fasciculations, and other minor motor signs: the Dyspnea-Fasciculation Syndrome. Concurrent COPD may augment the effect of ALS, resulting in earlier RF. FVC may be relatively preserved, despite hypercapnia.

Bronchoscopy has played the central role in defining the spectrum of pulmonary disorders that occur in patients with HIV infection. Transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL) both have high yields in the diagnosis of Pneumocystis carinii pneumonia (PCP) and other infections. Paradoxically, despite our knowledge and experience using bronchoscopy, controversy still exists regarding whether to attempt to make a bronchoscopic diagnosis in most patients with suspected PCP who have negative sputum studies or whether to administer initial empiric therapy and reserve invasive diagnostic techniques for patients who have a response. I prefer establishing a diagnosis as soon as possible because bronchoscopy is safe and because the patient may not have PCP and may become too ill to have bronchoscopy after a few days of ineffective therapy. A second controversy relates to the necessity of including routine TBB in addition to BAL during bronchoscopy. Although biopsies increase the risk of pneumothorax and hemorrhage, they add to the diagnostic yield in PCP and other infections. They are also necessary to provide tissue specimens for diagnosing noninfectious pulmonary disorders such as Kaposi's sarcoma and lymphocytic and nonspecific pneumonitis.

OBJECTIVES/OBJECTIVE:To examine ICU admission rates and diagnoses of patients with HIV infection and to determine the outcomes of different critical illnesses. DESIGN/METHODS:Consecutive enrollment of patients admitted to the ICU with confirmed HIV infection or an AIDS-defining diagnosis. SETTING/METHODS:Medical ICU of an urban teaching hospital. PATIENTS/METHODS:65 adult patients with documented HIV infection or AIDS-defining disorder. INTERVENTIONS/METHODS:Standard care. RESULTS:In 1 year, there were 1,550 hospital admissions for patients with HIV infection, and 65 (4.2%) were admitted to the ICU. The mortality rate of patients admitted to the ICU was 51%; 35 (54%) were admitted with respiratory failure, 22 of whom had Pneumocystis carinii pneumonia (PCP). Sixteen patients with PCP required mechanical ventilation, and 13 (81%) died despite treatment with adjunctive corticosteroids. Other causes of respiratory failure included bacterial pneumonia, pulmonary tuberculosis, adult respiratory distress syndrome, and pulmonary Kaposi's sarcoma. Overall, 22 of 35 (63%) patients with respiratory failure died in the hospital. Thirty patients (46%) were admitted because of sepsis, neurologic disease, congestive heart failure, hypotension, or drug overdose. These patients had a mortality rate of 37%. Prior antiretroviral and anti-Pneumocystis prophylaxis did not influence outcome, but a body weight of 10% or more below ideal at the time of admission predicted poor survival. CONCLUSION/CONCLUSIONS:There is a diverse range of indications for critical care in patients with HIV infection. Although respiratory failure due to PCP was the most common reason for admission to the ICU, it accounted for only 34% of the cases. The prognosis of PCP in patients who require mechanical ventilation despite adjunctive corticosteroid treatment is poor.

We reviewed 18 cases of histoplasmosis in patients at risk for the acquired immunodeficiency syndrome seen at two New York City hospitals in the past 3 1/2 years. Seventeen patients were Hispanic, including 13 born in Puerto Rico and three in South America. Clinical presentation was subacute, with high fever, weight loss, and mild respiratory symptoms with well-maintained gas exchange. Five patients had normal chest roentgenograms. The most common chest roentgenographic abnormality was diffuse small nodules. A rapid diagnosis was established histologically in 72 percent of patients, most commonly by transbronchial lung biopsy; cultures were positive in 94 percent of patients while serology was positive in five of six patients. Mycobacterium tuberculosis was a concurrent, often unrecognized, pathogen in six cases. Most patients responded to amphotericin therapy. Histoplasmosis may represent an early sign of altered host immunity in the acquired immunodeficiency syndrome.