Pneumonia in a Paso-Fino mare

A 5-year-old Paso-Fino mare was presented for severe respiratory distress. The mare had foaled 2 months prior to presentation. The horse was in poor body condition with a dull hair coat. A mild fever was noted during physical examination and increased bronchovesicular sounds were auscultated. Thoracic radiographs showed an interstitial pattern and an alveolar infiltrate with distinct air bronchograms. Moderate purulent inflammation with increased mucus was observed in tracheal wash fluid, but no infectious agents were identified. A bronchoalveolar lavage (BAL) contained a large amount of mucus and reactive mononuclear phagocytes with variable numbers of intracellular fungal organisms morphologically consistent with Pneumocystis carinii. The mare had undetectable levels of immunoglobulin M (IgM) and decreased IgG levels in the serum. Immunophenotyping revealed decreased expression of major histocompatibility complex (MHC) class II molecules. Moderate to marked hyperplasia of type II epithelial cells was present throughout histologic sections of lung, but the fungal organisms were not observed. A culture system has not been developed for diagnosis of P carinii infection. Instead, diagnosis of P carinii pneumonia is achieved by microscopic identification of characteristic morphologic features of the pathogen. Cytologic examination of BAL fluid is the preferred method used to diagnose human infection with P carinii. In humans, the diagnostic sensitivity of cytology is significantly higher than the sensitivity of histopathologic examination of lung biopsies. The difference in sensitivity between BAL cytology and lung histopathology may also apply to the diagnosis of P carinii pneumonia in horses.

Patient mortality of active pulmonary tuberculosis requiring mechanical ventilation

Mortality remains high among patients with pulmonary tuberculosis requiring mechanical ventilation (TBMV). This study was carried out to establish the mortality rates of TBMV and to identify factors that contribute to in-hospital mortality. From January 1996-April 2001, there were 825 patients with active pulmonary tuberculosis at the National Taiwan University Hospital, Taipei, Taiwan. Of these, 41 suffered acute respiratory failure and required mechanical ventilation in the intensive care unit (ICU). Of these 41 patients, 38 were followed up for 180 days. In-hospital deaths were documented in the medical records and all possible parameters contributing to mortality were collected. Of the 41 patients, 27 died in the hospital and 14 were discharged alive (in-hospital mortality rate 65.9%), with (mean +/- SD) 40.7 +/- 35.4 admission days before death. Of the 27 that died, 25 died during ICU admission and two died after being transferred to the ward. The mortality rate for the 180-day monitoring period was 79%. Factors contributing to in-hospital mortality included consolidations on chest radiographs and multiple organ failure. The mortality rate in the patients with pulmonary tuberculosis requiring mechanical ventilation is very high, with two factors affecting in-hospital mortality. These factors were multiple organ failure and consolidation on chest radiographs.

Severe community-acquired pneumonia with acute hypoxemic respiratory failure due to primary infection with Chlamydia pneumoniae in a previously healthy adult

Community-acquired pneumonia due to Chlamydia pneumoniae is associated with a benign clinical course. Severe, life-threatening pneumonia is rare and occurs only in immunocompromised hosts. We report a case of severe pneumonia complicated by acute hypoxemic respiratory failure due to primary infection with C. pneumoniae in a previously healthy 46-year-old woman.

Pneumocystis carinii pneumonia as a complication of bendamustine monotherapy in a patient with advanced progressive breast cancer

BACKGROUND

Bendamustine is an alkylator with anticipated antimetabolic activity. It has shown activity in malignant lymphoma, multiple myeloma, and breast cancer. Recognized side-effects are relatively mild with myelosuppression as the dose-limiting toxicity. The CD4/CD8 ratio may be reduced. To what extent the alteration of lymphocytes, especially CD4(+) lymphocytes, correlates with an increase in opportunistic infections cannot be definitively answered.

CASE REPORT

The patient, female, aged 48 years, was suffering from an advanced progressive breast cancer. After initial treatment with several chemotherapies, a cytotoxic therapy was initiated, with bendamustine (150 mg/m(2)) administered on two consecutive days and repeated every 4 weeks. After five courses, the patient developed Pneumocystis carinii pneumonia (PCP), disclosed in the bronchoalveolar lavage. While receiving bendamustine therapy, the CD4(+) and CD8(+) lymphocyte counts in the peripheral blood were determined by flow cytometry. The next-to-normal CD4/CD8 ratio before therapy (0,82) had decreased to 0,05 during the therapy mainly due to a decline of CD4(+) lymphocyte. The patient was seronegative for human immunodeficiency virus. In spite of high-dose intravenous trimethoprim/sulfamethoxazole and methylprednisolone application, the patient died of a respiratory failure 3 days after PCP was diagnosed.

CONCLUSION

Bendamustine is capable of inducing a reduction in CD4(+) lymphocyte counts causing a severe T-lymphocyte-mediated immunosuppression. Measuring CD4(+) lymphocyte counts may be helpful in determining the risk of PCP in patients treated with bendamustine.

Septic shock secondary to scrub typhus: characteristics and complications

Scrub typhus is an acute febrile illness caused by infection with Orientia tsutsugamushi transmitted by the bite of larval trombiculid mites (chiggers). A prospective study was conducted in septic shock patients in Maharat Hospital, Nakhon Ratchasima Province, Thailand, from 12 November 2001 to 5 January 2002. Of the 51 septic shock patients studied during the 7 week period, 18 (35.3%) were found to have evidence of scrub typhus infection; 3 patients (16.7%) died. In this study, septic shock caused by Orientia tsutsugamushi is the most prominent (35.3%) in endemic area of scrub typhus. Scrub typhus with septic shock patients results in organ failure: respiratory failure, DIC were predominant, followed by renal and hepatic involvement. Two deaths were due to respiratory failure and one death was as a result of combined respiratory and renal failure. Fever was the most common symptom, followed by headache, myalgia and dyspnea; lymphadenophathy and eschar are common signs. Laboratory findings revealed that almost all of the patients had a mild leukocytosis, reduced hematocrit and thrombocytopenia; SGOT, ALP, direct bilirubin (DB), total billirubin (TB), BUN, Cr were elevated; hypoalbuminemia was noted. Urinalysis showed that 88.9% of the patients had albuminuria. 77.8% of patients had abnormal chest X-rays.

Invasive pulmonary aspergillosis resulting in respiratory failure during neutrophil recovery from postchemotherapy neutropenia in three patients with acute leukaemia

Respiratory failure is a severe complication of invasive pulmonary aspergillosis (IPA). Its pathogenesis is not well understood. We herein describe three cases of subacute respiratory failure that occurred during the recovery phase of neutropenia following induction chemotherapy for acute leukaemia with IPA. In each case, severe neutropenia (19-85 days), high-grade fever, severe anaemia, the use of granulocyte-colony-stimulating factor and increasing infusion volume were noted. As the neutrophil count was recovering, the shadows on the chest X-ray expanded with progressing hypoxia. We should pay attention to the respiratory failure during the recovery phase of neutropenia in patients with IPA.

Clinicopathological and immunohistochemical features of the severe pulmonary form of leptospirosis

Four cases of severe pulmonary form of leptospirosis (SPFL) are described. In all four of these blood culture proven cases, there was severe pulmonary injury characterized by alveolar hemorrhage and acute respiratory failure. Three patients died in less than 48 hours after onset of the first respiratory signs. Leptospiral antigen detection in lung tissues was positive by immunoperoxidase in all three of these cases, suggesting that the microorganism exerts a local direct destructive action. Patients with SPFL should be carefully monitored, as the abrupt onset of severe alveolar hemorrhage can lead to respiratory insufficiency and death. The authors emphasize the importance of radiological findings and blood gas analysis for prompt clinical diagnosis, and suggest that corticosteroids, associated with antibiotics, early respiratory support, and platelet transfusions are useful as an attempt to prevent further development of SPFL.

[The first heart-lung transplantation in a Hungarian patient with cystic fibrosis]

INTRODUCTION

Progressive lung disease and respiratory insufficiency is the leading cause of early death for patients with cystic fibrosis.

METHOD

Successful heart-lung transplantation was performed in the 24 years old man with cystic fibrosis for end stage lung diseases and for concomitant dilatative cardiomyopathy.

RESULTS

Six months following the operation the patient returned to full-time his job, and leads an active life like other fellow-men of his age.

CONCLUSIONS

The attention is called with this case report to a rarely necessary intervention available for Hungarian patients as well. The criteria of the lung transplantation in cystic fibrosis, the preoperative screening and the tasks of the postoperative care are summarised.

[Respiratory distress due to pulmonary hemorrhage in leptospirosis]

Two patients who lived in Buenos Aires suburbs died from leptospirosis in July 2000 and March 2001. They developed a nonspecific febrile illness followed by hemorrhagic pneumonia and respiratory distress in absence of typical manifestations such as jaundice, nephropathy, thrombocitopenia or hemorrhages in other organs. In the house and surroundings of one patient rodents were captured and three strains of leptospira, serogroup Icterohaemorrhagiae were isolated. Laboratory guinea pigs were inoculated and they were sacrificed as soon as respiratory symptoms appeared. Necropsy showed primary lung injury, which was similar to the histopathological lesions found in one of the patients. Neither jaundice, nor renal damage was found. Pericardiac hemorrhages were considered as a possible cause of cardiopulmonary collapse. This clinical form has not been reported previously in this region, where conditions are indeed suitable for the human illness to appear.

Defining severe community-acquired pneumonia

Based on the recognition of the main pathophysiologic features of pneumonia and currently available data on prognosis and clinical severity assessment, key points for a definition of severe pneumonia are as follows: 1. Independent predictors of pneumonia severity are factors reflecting acute respiratory failure and severe sepsis or septic shock. 2. In view of the dependence of the development of acute respiratory failure on pulmonary comorbidities, radiographic extension may prove to be an additional independent predictor of severe respiratory compromise. 3. Vital sign abnormalities other than acute respiratory failure and severe hypotension may be independent predictors of severity, particularly in patients presenting in early and asymptomatic stages of severe sepsis. 4. Several pathogens have been shown to have adverse prognostic potential. Because the cause is unknown at the initial evaluation, however, pathogens cannot form part of the criteria for the initial severity assessment. 5. Because pneumonia is a dynamic process, any assessment of severity takes place at an arbitrary point of disease evolution. It would be desirable to define a set of parameters reflecting initial severity as well as a state of increased risk for early deterioration toward severe pneumonia. 6. Severity stratification within the population of patients with severe pneumonia may open the prospect of identifying patients who may have the greatest benefit from intensive care.

Respiratory failure caused by tuberculous pneumonia requiring extracorporeal membrane oxygenation

While a common pathogen, Mycobacterium tuberculosis (TB) pneumonitis is only rarely reported as a cause for respiratory failure in developed countries. We report an adolescent with TB pneumonitis and respiratory failure requiring extracorporeal membrane oxygenation (ECMO) with eventual survival. With the incidence of TB rising globally, TB should be suspected and treated as early as possible. ECMO should be considered as a treatment option if conventional ventilatory support is inadequate. ECMO survival with TB pneumonia and anti-TB antimicrobial therapy is possible.

Delayed treatment contributes to mortality in ICU patients with severe active pulmonary tuberculosis and acute respiratory failure

OBJECTIVES

To clarify the patterns of pulmonary tuberculosis (TB) that should result in a high index of suspicion, to increase the chances of early therapy and to identify predictors of 30-day mortality.

PATIENTS AND METHODS

Retrospective, 7-year study in two medical intensive care units (ICUs). All patients admitted with pulmonary TB were enrolled. Clinical and laboratory data at admission and events within 48 h of admission were collected. Predictors of 30-day mortality were identified by univariate and multivariate analysis.

RESULTS

The study included 99 patients with a median age of 41 years. Immunodeficiency was present in 60 patients, including 38 with AIDS. Fifty-nine patients had pulmonary TB alone, 22 also had extrapulmonary TB and 18 had miliary. All 99 patients were admitted for acute respiratory failure, some also with shock (20), neurologic disorders (18) or acute renal failure (10). Mechanical ventilation was needed in 50 patients; 22 patients met criteria for acute respiratory distress syndrome (ARDS). The 30-day mortality rate was 26.2%. Four factors independently predicted mortality: a time from symptom onset to treatment of more than 1 month (OR, 3.49; CI, 1.20-10.20), the number of organ failures (OR, 3.15; CI, 1.76-5.76), a serum albumin level above 20 g/l (OR, 3.96; CI, 1.04-15.10), and a larger number of lobes involved on chest radiograph (OR, 1.83; CI, 1.12-2.98).

CONCLUSION

Delayed clinical suspicion and treatment of active pulmonary TB with respiratory failure may contribute to the persistently high mortality rates in ICU patients with these diseases.

Diphtheritic polyneuropathy: clinical analysis of severe forms

BACKGROUND

Diphtheritic polyneuropathy (DP) is a dangerous complication of diphtheria, especially its severe forms with bulbar, respiratory tract, and circulatory disturbances. However, the clinical picture of severe forms of DP is practically unknown.

OBJECTIVE

To investigate the clinical features and peculiarities of the course of severe forms of DP.

PATIENTS

Thirty-two patients with severe forms of DP.

RESULTS

The first symptoms of DP developed in most patients 3 to 5 weeks after the onset of diphtheria. The cranial nerves were involved in all patients, most frequently nerves IX and X (32 patients); VII (28 patients); III, IV, and VI (27 patients); and XI (27 patients). One third of the patients had quadriplegia. The remaining patients had quadripareses. Of the 32 patients, 24 underwent artificial ventilation. All patients had sensory signs, proprioceptive more often than superficial. Autonomic disturbances were observed also in all patients. Only 2 of the 32 patients died.

CONCLUSIONS

A direct indication for tracheotomy and artificial ventilation in patients with DP is a decrease of the vital capacity of the lungs below the traditional 16 mL/kg body weight or the development of the paralytic closure of the larynx against the background of the increasing weakness of the respiratory muscles. Characteristic of severe forms of DP is the phenomenon of the oppositely directed change in the neurological symptoms in the second month of the disease: the restoration of the function of the cranial nerves against the background of the further increase of the motor disturbances in the extremities and trunk. Special attention and care should be taken of patients during the period of the appearance of the episodes of vascular collapses-between the fourth and seventh weeks of DP.

Aspergillus bronchitis causing atelectasis and acute respiratory failure in an immunocompromised patient

Aspergillus tracheobronchitis is an uncommon clinical form of invasive aspergillosis with fungal infection limited entirely or predominantly to the tracheobronchial tree. We report a case of Aspergillus fumigatus bronchitis, diagnosed by fiberoptic bronchoscopy, with fungal growth completely occluding the left main bronchus leading to lung collapse and acute respiratory failure in a 60-year-old male with erythroleukemia and profound granulocytopenia.

Quantitative pathology of inhalational anthrax I: quantitative microscopic findings

Forty-one cases of documented inhalational anthrax from the Sverdlovsk epidemic of 1979 traced to release of aerosols of Bacillus anthracis at a secret biologic-agent production facility were evaluated by semiquantitative histopathologic analysis of tissue concentrations of organisms, inflammation, hemorrhage, and other lesions in the mediastinum, mediastinal lymph nodes, bronchi, lungs, heart, spleen, liver, intestines, kidneys, adrenal glands, and central nervous system. These data were correlated with clinical, epidemiologic, and demographic data. The patients' courses, with a variable incubation period and short nonspecific course (4 days before hospitalization) with rapid demise (1 day of hospitalization before death), correlated with systemic bacterial infection and lesions. Bacillus anthracis were identified in all cases in which there was no antibiotic treatment or there was treatment for fewer than 21 hours. The lesions that were the most severe and apparently of longest duration were in the mediastinal lymph nodes and mediastinum. There and elsewhere, peripheral transudate surrounded fibrin-rich edema; necrosis of arteries and veins was the most likely source of large hemorrhages displacing tissue or infiltrating tissue, respectively; and apoptosis of lymphocytes was observed. Respiratory function was compromised by mediastinal expansion, large pleural effusions, and hematogenous and retrograde lymphatic vessel spread of B. anthracis to the lung with consequent pneumonia. The central nervous system and intestines manifested similar hematogenous spread, vasculitis, hemorrhages, and edema. These pathologic findings are consistent with previous experimental studies showing transport of inhaled spores to mediastinal lymph nodes, where germination and growth lead to local lesions and systemic spread, with resulting edema and cell death, owing to the effects of edema toxin and lethal toxin. The identification of the vascular lesions as a basis for the prominent hemorrhages is a novel observation for human inhalational anthrax.

[A case presenting severe respiratory failure with high antibody titers to Chlamydia pneumoniae]

"HITAZYME C. pneumoniae" is a diagnostic reagent that has been recently developed by adopting an ELISA method for detection of anti-Chlamydia pneumoniae (C. pneumoniae) antibodies. A case presenting bilateral interstitial opacities and severe respiratory failure with high titers of "HITAZYME C. pneumoniae" was described. Sputum, blood, serological, and bronchoalveolar lavage examinations failed to reveal other etiology to explain his severe respiratory illness. Clinicians should be aware that C. pneumoniae may cause severe respiratory failure or ARDS. Further studies are needed to evaluate the role of C. pneumoniae infection in the development of severe pneumonia or ARDS.

Burkholderia cepacia in cystic fibrosis: novel Australian cluster strain without accelerated respiratory deterioration

OBJECTIVE

To determine whether 4 years of colonization with a novel Australian cluster strain (The 'Hunter' strain) of Burkholderia cepacia (B. cepacia) in cystic fibrosis (CF) patients was associated with more rapid decline in nutritional status and pulmonary function than in non-colonized contemporaries from the same CF clinic.

METHODOLOGY

A retrospective review of respiratory function and nutritional data from a single multidisciplinary paediatric CF clinic over 4 years (1993-97).

RESULTS

Paired spirometry data for 1993 and 1997 were available in 47 patients without (n = 31) and with B. cepacia (n = 16) colonization (mean (+/- SD) ages in 1993: 12.1 years +/- 4.0 vs 12.6 years +/- 6.5; P = 0.83). Their percentage predicted forced expiratory volume in 1 s (FEV1) (94.2% +/- 16.7 vs 85.9% +/- 21.2; P = 0.19) were not significantly different. The averaged annual fall in FEV1 over 4 years was also not significantly different (3.8% +/- 3.8 vs 3.6% +/- 3.7; P = 0.82). Weight percentile (Wt%), height percentile (Ht%) and percentage age weight for height (%WFH) were not significantly different between groups in 1993. By 1997, Wt% (36.7% +/- 25.1 vs 22.3% +/- 19.6; P = 0.04) and Ht% (42.5% +/- 29.6 vs 17.6% +/- 19.4; P = 0.002) but not %WFH (102% +/- 10.0 vs 106% +/- 11.2; P > 0.10) were lower in subjects with B. cepacia.

CONCLUSIONS

In adolescent CF patients, colonization with the Hunter strain of B. cepacia was associated with a deterioration in some nutritional parameters but not with an accelerated decline in FEV1 over 4 years. As varying pathogenicity of B. cepacia strains may account for differing rates of pulmonary decline, further assessment of the consequences of colonization with certain strains of B. cepacia in CF is needed.

Chronic obstructive pulmonary disease patients with invasive pulmonary aspergillosis: benefits of intensive care?

OBJECTIVES

Invasive pulmonary aspergillosis (IPA) is increasingly recognized as a cause of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD) treated with corticosteroids. For these patients admission in intensive care unit (ICU) is often required for life-support and mechanical ventilation. Whether this approach improves outcome is unknown.

DESIGN AND SETTING

Retrospective study in a university hospital intensive care unit.

PATIENTS

Between November 1993 and December 1997, 23 COPD patients were admitted in our ICU and received antifungal agents for possible IPA.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The clinical features and the outcome were reviewed. Diagnosis of IPA was classified as confirmed (positive lung tissue biopsy and/or autopsy) or probable (repeated isolation of Aspergillus from the airways with consistent clinical and radiological findings). Among the 23 patients treated for Aspergillus, 16 fulfilling these criteria for IPA were studied. Steroids had been administered at home to all patients but one and were increased during hospitalization in all. Twelve patients suffered a worsening of their bronchospasm precipitating acute respiratory failure. During ICU stay all patients required mechanical ventilation for acute respiratory failure. Although amphotericin B deoxycholate was started when IPA was suspected (0.5-1.5 mg/kg per day), all patients died in septic shock (n = 5) or in multiple-organ failure.

CONCLUSIONS

The poor prognosis of intubated COPD patients with IPA, in spite of antifungal treatment suggests that further studies are required to define the limits and indications for ICU management of these patients.

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome

PURPOSE

Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

SUBJECTS AND METHODS

We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data.

RESULTS

Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients.

CONCLUSIONS

Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.