Faculty Bibliography

Pulmonary infiltrates in the patient with acquired immunodeficiency syndrome (AIDS) may be associated with a spectrum of unusual neoplastic and infectious process. Transbronchial biopsy frequently reveals the cause of these infiltrates; however, when transbronchial biopsy is nondiagnostic or contraindicated, or if the patient fails to improve after a diagnostic transbronchial biopsy, further investigation is warranted to direct appropriate therapy. Efficacy of 23 open-lung biopsies in 19 AIDS patients with pulmonary infiltrates was evaluated to define the indications for and the diagnostic yield of open-lung biopsy. Pulmonary infiltrates were recognized for a mean duration (+/- standard error) of 16 +/- 2 days before open-lung biopsy and were associated with fever and cough. These patients did not have prior transbronchial biopsy, and open-lung biopsy was diagnostic in all of these. Prior transbronchial biopsy performed in the remaining 16 patients was nondiagnostic in 10. Open-lung biopsy was diagnostic in 70% of these patients (Pneumocystis carinii pneumonia, 2 patients; Kaposi's sarcoma, 3 patients; Kaposi's sarcoma and Legionella pneumophila, 1 patient; cytomegalovirus, 1 patient). The other 6 patients having a previous diagnostic transbronchial biopsy failed to improve with therapy, and open-lung biopsy resulted in a therapeutic change in 67% of these patients. Two deaths were attributable to open-lung biopsy in patients with postoperative thrombocytopenic hemorrhage. Open-lung biopsy should be performed in AIDS patients when transbronchial biopsy is nondiagnostic or contraindicated, or in patients who fail to improve with appropriate therapy after diagnostic transbronchial biopsy, especially in patients with Kaposi's sarcoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Diffuse pulmonary infiltrates and acute respiratory compromise frequently occur in patients with cancer who are undergoing chemotherapy, and treatment remains controversial. We initiated a prospective randomized trial in 22 nonneutropenic patients to compare the efficacy of immediate open lung biopsy with that of empirical trimethoprim-sulfamethoxazole and erythromycin therapy with delayed open lung biopsy if no clinical improvement occurred after 4 days of therapy. Diagnoses included non-Hodgkin's lymphoma (15 patients), T-cell lymphoma (2), acute lymphoblastic leukemia (3), Hodgkin's disease (1), and breast cancer (1). The median age was 40 years, and fever (18) and tachypnea (13) were the most frequent signs. Median room air arterial oxygen tension in 18 hypoxic patients was 53 mm Hg; 19 patients had diffuse pulmonary infiltrates. Eight of the 10 patients randomized to empirical antibiotic therapy showed improvement after 4 days. The 2 patients whose condition did not improve and who underwent delayed open lung biopsy had Pneumocystis carinii pneumonia. One of them did show improvement, and the other died of respiratory failure. Time to clinical resolution in the 9 surviving patients was 14 days; 4 required prolonged ventilation (longer than 24 hours). Findings for the 12 patients randomized to immediate open lung biopsy were P. carinii pneumonia in 7 and nonspecific pneumonitis in 5; there were 3 deaths related to open lung biopsy. Time to resolution in the surviving patients was 13 days for those with P. carinii pneumonia and 5 days for those with nonspecific pneumonitis; 7 required prolonged ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective serial evaluation in 19 patients with soft-tissue and osteogenic sarcomas was performed to determine whether computerized tomography (CT) or conventional linear tomography (LT) detected pulmonary metastases earlier. Analysis of the metastatic nodules was performed radiographically with histologic confirmation by obtaining serial CTs and LTs followed by metastasectomy. Nodules were classified as stable, growing, or developing and by detection on CT and/or LT. CT was the first positive study in a significantly greater number of patients (13 CT, 1 LT; P less than .005), and CT detected the nodules earlier than LT (56 CT first v 7 LT first; P less than .0001). Ninety of 166 nodules resected were detected by CT, LT, or both (54%). The median size of metastatic nodules documented at surgical exploration and first detected by CT was significantly smaller than that first detected by LT (7.6 mm for CT v 13.2 mm for LT; P less than .05). Of 55 histologically documented metastases detected initially either by CT or LT, CT was markedly superior to LT with 50 (91%) first detected only by CT (P less than .001). These data reveal that CT detects more pulmonary metastases earlier than LT and that developing or growing nodules in patients with sarcomas are usually metastases. Decisions regarding metastasis resection in sarcoma patients, therefore, should be based primarily on CT findings

Although an aggressive form of Kaposi's sarcoma often develops in patients with the acquired immunodeficiency syndrome, most patients die due to opportunistic infections rather than the direct effects of this tumor. Because Kaposi's sarcoma has caused pulmonary dysfunction in a number of our patients, we attempted to characterize features of pulmonary dysfunction induced by Kaposi's sarcoma. In 66 patients with Kaposi's sarcoma treated between 1982 and 1984 there were 30 episodes of pulmonary dysfunction that resulted in a biopsy. Six episodes were due to pulmonary Kaposi's sarcoma alone, and 6 additional episodes were due to Kaposi's sarcoma and associated opportunistic infections. Clinical and radiologic features of pulmonary Kaposi's sarcoma an infection were indistinguishable. Pulmonary Kaposi's sarcoma could only be documented in large tissue sections available from open-lung biopsy or autopsy samples. Because chemotherapy or radiation therapy appears to provide palliation, clinicians should recognize Kaposi's sarcoma as a cause of pulmonary disease in patients with the acquired immunodeficiency syndrome

The acquired immune deficiency syndrome is characterized by the development of multiple recurrent opportunistic infections or unusual neoplasms in individuals with no prior history of immune suppression. This report summarizes the thoracic diseases encountered in such patients before after death and the role of diagnostic techniques currently used in the evaluation of thoracic disease in 15 patients with this syndrome. Efficacy of treatment was determined by correlation with postmortem findings in all patients. Pulmonary disease was present in all 15 patients and necessitated 23 transbronchial biopsies in 11 patients. Pneumocystis carinii pneumonia and cytomegalovirus pneumonia were the most common findings. Nine open lung biopsies in eight patients disclosed either Pneumocystis carinii pneumonia or Kaposi's sarcoma. Esophageal disease was present in four patients, and endoscopic evaluation demonstrated Candida esophagitis (two), esophageal Kaposi's sarcoma (one), and cytomegalovirus esophagitis and Kaposi's sarcoma (one). Mean time to death from diagnosis of acquired immune deficiency syndrome was 7.7 months, with respiratory insufficiency being the most common cause of death (9/15, 60%). Pneumocystis carinii pneumonia was successfully eradicated in 70% of the patients. Candida esophagitis was ameliorated in both patients with the disease. Unsuspected pulmonary Kaposi's sarcoma, cytomegalovirus pneumonitis, and other infectious pathogens were documented at autopsy. These data reveal that Pneumocystis carinii pneumonia and Candida esophagitis can be managed successfully in patients with acquired immune deficiency syndrome if appropriately diagnosed. The major cause of death in this series was pulmonary insufficiency, often the result of severe cytomegalovirus infection. Thoracic surgeons must continue to play an aggressive and important role in the early diagnosis and management of potentially treatable pulmonary and esophageal disease in these patients

We have used the St. Jude Medical cardiac valve prosthesis without postoperative anticoagulation in 34 children undergoing valve replacement since March, 1979. The 19 boys and 15 girls ranged in age from 9 months to 21 years. The valve replaced was mitral in 12 patients, aortic in 14, pulmonary in three, and both mitral and aortic in two. One patient had implantation of a St. Jude Medical valve in a pulmonary conduit, and a left-sided tricuspid valve was replaced in two children. There were three operative deaths, all in infants with complex disease. One patient died suddenly at home 5 weeks after valve replacement, probably of ventricular arrhythmia. During follow-up of 1 to 50 months, comprising 646 patient months, no thromboembolic complications have been observed. Although use of the St. Jude Medical prosthesis without anticoagulation is still investigational, our preliminary data suggest that the risk of thromboembolism in unanticoagulated children with this valve is not greater than that in anticoagulated adults. The results justify continuing investigation of the St. Jude Medical prosthesis in children without postoperative anticoagulation

The authors describe CT-guided percutaneous aspiration of 13 apparent mediastinal abscesses in 12 extremely ill patients, excluding the diagnosis in 3 and establishing it in 9. Six patients subsequently underwent percutaneous catheter drainage, facilitating elective surgery in 1 and proving curative in 5

From January 1972 to April 1982, 125 adults underwent operation for congenital heart disease at the Medical University of South Carolina. Age ranged from 18 to 73 years, with an average age of 31 years. A variety of defects were seen. Atrial septal defect (59 patients), ventricular septal defect (15 patients), patent ductus arteriosus (14 patients), tetralogy of Fallot (14 patients), and coarctation of the aorta (9 patients) were the most common. There were 48 men and 77 women in the study. Most patients presented with recent onset of dyspnea on exertion or at rest, but 16 patients were asymptomatic. Eight patients died after surgery for an overall operative mortality rate of 6 per cent. The most common postoperative complication was arrhythmia (13 patients, 10%). Despite recent advances in the diagnosis and treatment of congenital heart disease in infants, a significant number of patients apparently escape detection and first present with congenital heart disease as adults. Prompt diagnosis and surgical intervention will usually produce excellent results and relief of symptoms in these patients

The external pressure suit (MAST) is beneficial in hypovolemic shock by preventing lower extremity venous pooling. Previous data from this laboratory demonstrated that internal cardiac massage is significantly improved when combined with MAST. This study was designed to see if external massage (EM) could be similarly augmented by this device. Twenty anesthetized pigs underwent left thoracotomy and placement of a left atrial catheter for pressure determination and microsphere injection. A flow probe was placed around the aorta for measurement of cardiac output, axillary artery catheters were placed for blood pressure determination and microsphere sampling, and central venous pressure was monitored. Hemodynamic collection of microsphere injections was performed during resting conditions, during EM alone after electrically induced ventricular fibrillation, and during EM after inflation of the MAST suit. Significant increases in mean arterial pressure, systolic arterial pressure, and diastolic pressure were noted with EM and MAST suit inflation over EM alone. Left atrial pressure doubled during EM and MAST suit inflation. Cardiac output was not augmented by the inflation of the MAST. Myocardial blood flow and brain blood flow increased during EM and MAST, but renal blood flow decreased. These data suggest that unlike internal massage, cardiac output during EM and MAST is not improved by increased venous return and flow during EM may be due to a different mechanism than direct cardiac compression