Faculty Bibliography

Intravesical administration of bacillus Calmette-Guerin (BCG) is an effective treatment for superficial carcinoma of the bladder. The authors report a pulmonary complication characterized by miliary infiltration on chest roentgenogram and caseating granulomata on lung biopsy specimens. This case and three prior reports suggest that this complication may be a form of hypersensitivity rather than true BCG infection.

The authors report the case of a patient with a Hickman catheter that migrated into the lung parenchyma. The resultant inadvertent infusion of 5-fluorouracil caused necrotizing chemical pneumonitis. Possible mechanisms of catheter migration include the lateral orientation of the catheter tip and the partial thrombosis of the innominate vein and superior vena cava. The patient recovered but had residual contraction fibrosis of the right upper lobe of the lung

The present study was undertaken to clarify the role of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) in the diagnosis of pulmonary tuberculosis in patients at risk for human immunodeficiency virus (HIV) infection. We retrospectively identified 31 patients at risk for HIV who proved to have Mycobacterium tuberculosis on culture of at least one pulmonary specimen. All had pulmonary symptoms but initial sputum smears negative for acid-fast bacilli (AFB). All underwent fiberoptic bronchoscopy (FOB), including BAL and TBB; postbronchoscopy sputum was also collected in 19 patients. A specimen was considered to yield an immediate diagnosis when positive for AFB either on smear or histologic study; granulomas alone were considered positive when no other causes were identified. Overall, an immediate diagnosis was made by bronchoscopic specimens in 15 (48 percent) of 31 cases. TBB was the sole positive specimen in seven patients (23 percent). For comparison, similar specimens from 40 patients in whom M avium complex (MAC) grew on culture were also evaluated. An immediate identification of AFB was made in only four patients (10 percent). We conclude that the finding of AFB on staining of any pulmonary specimen is highly suggestive of tuberculosis, rather than MAC, and warrants institution of antituberculosis therapy. Of all bronchoscopic specimens, TBB provides the highest yield for an immediate diagnosis of tuberculosis

Gallium-67 localizes to the cellular fraction of bronchoalveolar lavage (BAL) fluid in patients with sarcoidosis, idiopathic pulmonary fibrosis, as well as normal subjects. To further study 67Ga disposition in BAL fluid, 11 patients with Pneumocystis carinii pneumonia (PCP) and 8 patients with a variety of other lung diseases, underwent BAL 24 hr after 67Ga injection. Compared to the non-PCP patients, PCP patients had high uptake gallium scans at 24 and 72 hr, and showed significantly increased radioactivity in both unfractionated lavage and in the acellular, supernatant fraction of BAL. The mean ratio of total supernatant/cell pellet radioactivity was also higher in patients with PCP (1.23 +/- 0.27 versus 0.24 +/- 0.05, p less than 0.01). Supernatant radioactivity correlated with the presence of neutrophil alveolitis, but not with BAL transferrin concentrations. We conclude that neutrophil alveolitis in PCP promotes 67Ga accumulation in the acellular fraction of BAL fluid. However, the high uptake 67Ga scans observed in PCP patients without neutrophil alveolitis suggest that the mechanism of pulmonary uptake of 67Ga is not fully elucidated by BAL fluid analysis alone

Spontaneous pneumothorax is a known complication of Pneumocystis carinii pneumonia (PCP) in patients with acquired immunodeficiency syndrome. From a series of 61 patients with PCP, we identified two cases, not associated with aerosolized pentamidine, that presented with spontaneous pneumothorax and cystic changes seen on chest radiographs. Bronchoalveolar lavage cell findings were remarkable for very elevated neutrophil counts in both cases, suggesting a possible inflammatory cause for the observed cystic changes.

To determine the excess mortality attributable to hospital-acquired bloodstream infections, we applied the acute physiology and chronic health evaluation (APACHE) II classification to 34 critically ill patients with this complication. The study included primary bloodstream infections, defined by a positive blood culture at least three days after hospitalization, in the absence of any other apparent source of infection. The most frequent blood isolates included Staphylococcus aureus (39 percent), Gram-negative rods (24 percent), and Candida albicans (15 percent); the spectrum of blood isolates suggested that most infections were related to intravascular catheters. In a control group of intensive care unit patients (n = 384), the death rate predicted by APACHE II was similar to the observed death rate (35.3 vs 37.8 percent). In a subgroup of control patients (n = 34), chosen for APACHE II scores that matched the patients with bloodstream infections, predicted and observed death rates were also similar (53.1 vs 52.9 percent). For patients with bloodstream infections, however, observed mortality (82.4 percent) significantly exceeded the predicted value (54.1 percent, p = 0.025). We conclude that critically ill patients who develop nosocomial bloodstream infections are at greater risk of death than patients with comparable severity of illness without this complication. The difference between the observed and predicted death rates, 28 percent, represents the excess mortality associated with bloodstream infection in critically ill patients

The Acute Physiology and Chronic Health Evaluation (APACHE) II classification, a measure of severity of illness in patients requiring intensive care, was devised before the rapid expansion of the acquired immunodeficiency syndrome (AIDS) epidemic. To determine the applicability of the APACHE II system to AIDS, we related observed in-hospital death rates to those predicted by APACHE II in 83 patients with AIDS. In a control group of patients without AIDS (n = 166) mean predicted and observed death rates (34.1 vs 31.3 percent) were similar. For the AIDS group overall observed mortality (63.9 percent) was significantly greater than that predicted by APACHE II (45.8 percent). The subgroup with Pneumocystis pneumonia requiring mechanical ventilation (n = 37) had an observed mortality (86.5 percent) that significantly exceeded the predicted value (44.3 percent), whereas all other AIDS patients (n = 46) showed similar predicted and observed death rates (47.0 vs 45.7 percent). APACHE II prediction of death rate also matched observed mortality in mechanically ventilated patients without Pneumocystis infection. The discrepancy between predicted and observed mortality in patients with Pneumocystis pneumonia requiring mechanical ventilation is most likely due to the lack of an APACHE II diagnostic category that accurately reflects the severity of this disease. A new diagnostic category that provides accurate outcome prediction in this patient group would form a basis for evaluation of new therapeutic interventions

A 37-year-old woman had pleuritic chest pain, dyspnea, and normal findings on chest roentgenogram. Lung scan showed markedly diminished perfusion to the right lung with a matched ventilatory defect. Further evaluation revealed a bronchogenic cyst. After resection, the lung scan was normal. To our knowledge, this is the first report of a bronchogenic cyst causing a reversible, unilateral ventilation-perfusion defect on lung scan.