Faculty Bibliography

We prospectively evaluated 150 consecutive patients with Pneumocystis carinii pneumonia (PCP) as their sole initial manifestation of AIDS (group 1). Admission laboratory and radiographic criteria were analyzed for diagnostic and prognostic indicators and compared with those of patients presenting with non-PCP pulmonary manifestations of AIDS (group 2). Mean admission serum LDH level was 465 +/- 67 IU/L in PCP patients (group 1) and 211 +/- 28 IU/L in group 2 (p less than 0.01). Seventy-eight percent of PCP patients (117 of 150) survived. Comparing survivors with nonsurvivors, the mean admission LDH level was 394 +/- 45 vs 717 +/- 51 IU/L (p less than 0.01), and the mean P(A-a)O2 gradient was 42 +/- 6 vs 55 +/- 6 mm Hg (p less than 0.05). Serum LDH levels and P(A-a)O2 gradients have diagnostic and prognostic implications in patients with AIDS-related PCP

Consecutive gallium-67 scans (n = 237) of 180 human immunodeficiency virus-seropositive patients with suspected pulmonary infections were evaluated for intensity and pattern of gallium distribution. Scan findings were correlated with the history, chest radiographic findings, and clinicopathologic diagnoses. Pneumocystis carinii pneumonia (PCP) occurred significantly more often with heterogeneous diffuse uptake than with homogeneous diffuse uptake. Heterogeneous diffuse uptake had an 87% positive predictive value for PCP, which was higher than that of other patterns. Localized pulmonary uptake was most commonly due to bacterial pneumonia or PCP; ill-defined, perihilar uptake, to cytomegalovirus or PCP; and focal (lymph node) uptake, to tuberculosis or lymphoma. The positive predictive value of any pulmonary uptake for lung pathology was 93%, and the negative predictive value of a negative scan was 96%. These findings confirm the utility of gallium scanning in the detection of lung pathology related to acquired immunodeficiency syndrome, particularly PCP. Furthermore, identification of a diffuse pattern may permit the use of a less invasive test more specifically directed at the confirmation of a diagnosis of PCP

Thin (1.5- and 5.0-mm) section contiguous computed tomographic (CT) scans obtained through the basilar segmental bronchi in 31 patients were reviewed in order to delineate normal anatomy and common variations of lower lobe airways. In each case, the frequency with which individual segmental and subsegmental bronchi were seen was established, as were variations in branching patterns. All basilar segmental bronchi were identified except in one case in which images of the left lung were obscured due to respiratory and cardiac motion. In the right lung, a division into subsegmental bronchi was identified in 84 of 150 (56%) visualized segmental bronchi. Six separate patterns of basilar segmental subdivision were found. In the left lung, subsegmental bronchi were identified arising from 51 of 145 (35%) visualized segmental bronchi. Five separate patterns of bronchial subdivision were found in the left lung. It is concluded that thin-section CT allows precise identification of all basilar segmental bronchi and, consequently, can play a significant role in the cross-sectional evaluation of lower lobe bronchial and parenchymal abnormalities

This review provides an overview of the risk of nosocomial infection in the 'AIDS era.' Airborne spread of Mycobacterium tuberculosis from affected patients has re-emerged as a hazard to hospital personnel. The risk of acquiring clinical illness due to Pneumocystis carinii or cytomegalovirus is, in contrast, a function of the immunocompetence of the health care worker. Methods of transmission as well as the epidemiology of human immunodeficiency virus-related infection in the health care worker will be discussed. The increase in the number of immunocompromised patients (AIDS and non-AIDS) requires careful attention to infection control methodology with respect to the cleansing of the fiberoptic bronchoscope, the intensive care unit's respiratory equipment (such as mechanical ventilators and nebulizers), and the pulmonary function laboratory

The possible contribution of computed tomography (CT) in the management of patients with solitary pulmonary nodules (SPNs) or masses was reviewed retrospectively in 65 patients undergoing fiberoptic bronchoscopy (FOB). Nodules were evaluated by size, location, surface contour, and the presence in cross-section of a bronchus leading to or contained within the nodule or mass, a 'positive bronchus sign.' Thirty-five lesions were associated with a positive bronchus sign; 21 of 35 (60 percent) were diagnosed endoscopically, (p = .027); of 30 cases with a negative bronchus sign, only ten (30 percent) had a diagnosis made by FOB (p = .034). It is concluded that CT may be of use in the routine evaluation of pulmonary nodules, prior to bronchoscopy, especially in cases for which histologic evaluation is essential, especially to determine the presence or absence of a CT bronchus sign

Eighty-six [67Ga]citrate chest scans were performed in 71 adult patients with the acquired immunodeficiency syndrome. Forty-five of these patients also had Kaposi's sarcoma. Only 29 of 57 abnormal scans were correlated with abnormal chest radiographs. Chest radiographs were negative for 27 scans and unavailable for one. Several scan patterns were seen. Diffusely increased lung uptake was seen most commonly with Pneumocystis carinii pneumonia, but also other infections and noninfectious inflammatory conditions. Focal uptake corresponding to regional lymph node groups occurred most often with Mycobacterium avium-intracellulare but aslo with lymphoma. Localized intrapulmonary uptake was seen in bacterial pneumonias. Perihilar activity occurred in two cases. When chest radiographs were abnormal and 67Ga scans negative, the most common diagnosis was pulmonary Kaposi's sarcoma

To assess the role of open lung biopsy in patients with the acquired immunodeficiency syndrome (AIDS), we retrospectively reviewed the cases of 42 patients with AIDS who underwent this procedure for the diagnosis of pulmonary infiltrates. Four patients had no preceding bronchoscopy because the severity of the respiratory failure or abnormalities of coagulation precluded the safe performance of this procedure. Twenty-nine cases had a preceding nondiagnostic bronchoscopic procedure, and nine others underwent open lung biopsy because of progressive deterioration despite treatment for diseases diagnosed bronchoscopically. We found that open lung biopsy was likely to be useful diagnostically when bronchoscopy could not be safely performed or when a preceding bronchoscopic procedure was not diagnostic. Open lung biopsies done on patients whose condition continued to deteriorate despite treatment for disorders established bronchoscopically were not likely to yield information therapeutically useful. In only one of nine such cases was a new treatable diagnosis obtained (Legionella). The others showed either severe pulmonary fibrosis or persistence of the initial disease process diagnosed at the time of bronchoscopy

Pulmonary Kaposi's sarcoma is an unusual pre-mortem diagnosis in AIDS patients. During a four-year period, 318 patients with AIDS-associated Kaposi's sarcoma presented to New York University Medical Center; 19 patients were found to have pulmonary involvement. All 19 patients were homosexual men; 18 of these patients presented with cutaneous and/or visceral Kaposi's sarcoma. Seventy-nine percent of patients had previous or concurrent pulmonary opportunistic infections. Clinical presentation of pulmonary Kaposi's sarcoma was indistinguishable from opportunistic pneumonia with respect to symptoms, physical examination results, and laboratory findings. Chest roentgenograms revealed a typical nodular pattern in only five patients. In contrast to AIDS-associated opportunistic pneumonia, the yield from fiberoptic bronchoscopy (24 percent) and open lung biopsy (56 percent) was low. Pathologically, Kaposi's sarcoma of the lung is less cellular than the cutaneous lesion. It is focal and scattered throughout the pulmonary interstitium, which may explain the difficulty in pre-mortem diagnosis