Faculty Bibliography

Over 91,000 cases of AIDS have been reported in United States, and it has been estimated that more than 1 million individuals are currently infected by the human immunodeficiency virus (HIV). The disease is growing most rapidly among intravenous drug abusers and minority patients. This accentuates some medical and ethical problems. Chief among these are the availability of competent care for patients and the willingness of physicians to treat these patients, issues related to HIV testing and counseling, patients' rights regarding the extent of treatment that should be given and access to and participation in clinical trials

Severe Pneumocystis carinii pneumonia (PCP) necessitating mechanical ventilation has been associated with a high mortality rate in several previous studies. This has discouraged physicians from recommending, as well as patients from accepting, mechanical ventilation when respiratory failure developed. Analysis of 19 records of patients with first episode PCP who were intubated and received mechanical ventilation showed a mortality of 57.8%. A constellation of clinical and laboratory findings was found that identified those patients more likely to survive, including a shorter duration of symptoms prior to admission, better arterial oxygenation on admission, deterioration of respiratory status soon after bronchoscopy, decrease in serum lactic acid dehydrogenase and rapid improvement in arterial blood gas determinations after institution of mechanical ventilation. Mean survival for the group that recovered from PCP after mechanical ventilation was not different from that of other patients with PCP who did not require mechanical ventilation. Thus, patients at risk for PCP should be advised to present to medical facilities as soon as symptoms of this disease develop and, when appropriate, should be encouraged to undergo intubation with respiratory support if it becomes necessary

We conducted a randomized, double-blind, placebo-controlled trial to test the efficacy of the 14-valent pneumococcal capsular polysaccharide vaccine in 2295 high-risk patients (patients with one or more of the following: age above 55 years and the presence of chronic cardiac, pulmonary, renal, or hepatic disease, alcoholism, or diabetes mellitus). Seventy-one episodes of proved or probable pneumococcal pneumonia or bronchitis occurred among 63 of the patients (27 placebo recipients and 36 vaccine recipients). Vaccine-serotype Streptococcus pneumoniae strains were recovered in association with 11 infections in the placebo group and 14 infections in the vaccine group. Pneumococcal infections occurred most frequently among patients with chronic pulmonary, cardiac, or renal diseases. Among vaccine recipients who subsequently had vaccine-type pneumonia or bronchitis, the majority did not make or sustain serum antibodies against their infecting organism in concentrations that were twice as high as the base-line values, or more than 400 ng of antibody nitrogen per milliliter, although their base-line levels were higher than those in subjects in whom infection did not develop. We were unable to demonstrate any efficacy of the pneumococcal vaccine in preventing pneumonia or bronchitis in this population. Our data suggest that chronically ill patients, who are most susceptible to infection, may have an impaired immune response to the pneumococcal vaccine

Severe hemorrhagic pancreatitis developed in a patient with the acquired immunodeficiency syndrome (AIDS) during pentamidine isethionate treatment for Pneumocystis carinii pneumonia. Despite prompt withdrawal of administration of the drug, the patient died of complications of pancreatitis. Pentamidine is known to be toxic to pancreatic islet cells, causing both hypoglycemia and hyperglycemia in clinical use. However, it rarely causes symptomatic pancreatitis. A review of the literature indicates that this is the second report of fatal pancreatitis associated with pentamidine therapy