Prolonged toxicity following massive ingestion of sustained-release theophylline preparation

Massive ingestion of sustained-release theophylline preparations in three patients was treated with gastric lavage and repeated dosages of orally-administered activated charcoal. Therapy was initiated promptly; however, two patients had their highest theophylline levels documented six to 12 hours after ingestion, and theophylline levels on arrival at the hospital were significantly lower than the maximal level documented. All three patients had prolonged elevations of the level, with markedly delayed half-lives of the drug. Overdosages due to sustained release preparations may lead to prolonged toxicity and require aggressive and continuous therapy.

Failure of ketoconazole in an immunosuppressed patient with pulmonary blastomycosis

A renal transplant recipient presented with pulmonary blastomycosis. Because of recent data suggesting a role for ketoconazole in the treatment of blastomycosis and concern for preserving her functioning renal transplant, she was started on therapy with ketoconazole, 400 mg daily. After four months of continuous therapy, she developed skin and laryngeal involvement requiring emergency tracheostomy; subsequent therapy with amphotericin B resulted in resolution of her disease. This is an example of life-threatening progression of blastomycosis in an immunosuppressed patient during ketoconazole therapy.

Lung sound analysis for continuous evaluation of airflow obstruction in asthma

We developed a system for monitoring airflow obstruction noninvasively, based on the principle that the proportion of the breath cycle occupied by wheezing (Tw/Ttot) in any one subject corresponds to the severity of airways obstruction. Lung sounds were recorded continuously from the chest wall. Fifty 250 ms sound segments were randomly chosen from five-minute periods and analyzed for the presence or absence of wheezes. The proportion with wheezes was used as an estimate of Tw/Ttot (Est Tw/Ttot). For 12 wheezy patients, there was a good correlation between the Est Tw/Ttot and the forced expiratory volume in one second (r = 0.893, p less than 0.001). The system was used to evaluate nocturnal asthma. Five subjects were studied over eight nights. It was found that there was more wheezing from 4:00 to 4:30 AM than from midnight to 12:30 AM (p less than 0.05). This technique may prove useful in continuous, noninvasive monitoring of wheezy patients.

Systemic immune response of patients with active pulmonary sarcoidosis

Twenty-two patients with active pulmonary sarcoidosis had the subpopulations of the lymphocytes in the bronchoalveolar lavage (BAL) fluid measured. All 12 with hypergammaglobulinaemia had a T4/T8 ratio of greater than 2.0 and five of 10 without hypergammaglobulinaemia had a ratio less than 2.0 (chi 2 = 5.18, P less than 0.025). When an increased number of T4 lymphocytes was present in the BAL fluid, there was a significant decrease in the absolute number of T4 lymphocytes in the peripheral blood (chi 2 = 6.84, P less than 0.01). The number of T4 lymphocytes in the BAL fluid correlated with the subsequent response to daily steroid therapy for 2 months, as assessed by improvement in vital capacity (r = 0.89, P less than 0.01).

Effect of changing instilled volume for bronchoalveolar lavage in patients with interstitial lung disease

Patients with and without interstitial lung disease (ILD) underwent bronchoalveolar lavage (BAL) with 4 boluses of 60 ml of normal saline. Fluid was withdrawn after each bolus, and the results after the first and second bolus were pooled and compared with the results after the third and fourth bolus. In the control group (n = 9), there was a significantly higher percentage of lymphocytes and neutrophils after the first half than after the second half (first half: lymphocytes, 8 +/- 1.9%, mean +/- SEM; neutrophils, 2 +/- 1.2%. Second half: lymphocytes, 5 +/- 1.2% (p less than 0.01); neutrophils, 0.3 +/- 0.12% (p less than 0.05). In the ILD group (n = 8), there was a rise in the number of lymphocytes from 15 +/- 4.9% to 20 +/- 3.9% (p less than 0.05) and the number of neutrophils from 8 +/- 4.8% to 10 +/- 5.6%. The ILD group had more cells aspirated after the second half than after the first half of the BAL, whereas the control group did not. Abnormalities in the cell population of the BAL fluid were more striking when the larger volume was used.

Decreased phosphatidylcholine in the lung fluid of patients with sarcoidosis

Surfactant decreases the immune response of lymphocytes. Pulmonary sarcoidosis is a disease characterized by an increased number and activity of lymphocytes in the lung. We measured the lipids and lymphocytes retrieved from the lung by bronchoalveolar lavage. Thirteen patients with active pulmonary sarcoidosis had a significantly higher percentage of lymphocytes (18 +/- 21%, mean +/- standard error of the mean) than 10 control subjects (4 +/- 1.9%, p less than 0.01). Using an external marker, we found the absolute amount of disaturated phosphatidylcholine to be higher in the control group (174 +/- 17.4 micrograms/ml lung fluid) than in the sarcoid group (91 +/- 1.9 micrograms/ml of lung fluid, p less than 0.002).

Oxygen delivery in critically ill patients. Relationship to blood lactate and survival

Forty-four critically ill patients with or without adult respiratory distress syndrome (ARDS) were studied in an attempt to define critical levels of oxygen delivery. Blood lactate was used as the indicator of tissue hypoxia independent of cardiac output. Survival was good (55 percent) and blood lactate near normal for those with oxygen delivery more than 8 ml/kg/min. Below this level, survival was poor (14 percent) and blood lactate markedly increased. There were significant nonlinear correlations of lactate with O2 delivery (r = - .735, p less than .001) and cardiac output (r = - .602, p less than .001). Mixed venous oxygen was not a reliable indicator of blood lactate, survival, oxygen delivery, or oxygen consumption.

Bronchoalveolar lavage in acute drug-hypersensitivity pneumonitis probably caused by phenytoin

We have reported a case of acute hypersensitivity pneumonitis, probably caused by phenytoin, in which the results of bronchoalveolar lavage suggested a predominantly lymphocytic type of alveolitis, comparable to the alveolitis of sarcoidosis or chronic hypersensitivity pneumonitis.

Prostaglandins and thromboxanes in the bronchoalveolar lavage fluid: possible immunoregulation in sarcoidosis

Prostaglandins are known to be secreted into body fluids. Arachidonic acid cyclooxygenase metabolites (AACM), including prostaglandin E (PGE), prostacyclin, and thromboxane, were measured in the bronchoalveolar lavage (BAL) fluid in 11 patients with active pulmonary sarcoidosis and 7 healthy volunteers. Using a quantitative technique, we found no difference in the amount of PGE per milliliter lung fluid between the sarcoid group (1,950 +/- 1,507.4 pg/ml lung fluid, mean +/- SD) and the control group (2,112 +/- 932.3 pg/ml lung fluid). In patients with sarcoidosis, there was a positive correlation between the number of lymphocytes in the BAL fluid and the amount of PGE and prostacyclin per milliliters of lung fluid (r = 0.71 and r = 0.81, p less than 0.01), but not thromboxane.

Quantitation of wheezing in acute asthma

Pulmonary sounds were recorded before and after bronchodilator treatment in 20 patients with acute attacks of asthma. Analysis of the sounds showed that improvement in the forced expiratory volume in one second was associated with the following two changes in the sound signal: (1) the proportion of the respiratory cycle occupied by wheeze (Tw/Ttot ratio) was reduced from 86 percent to 31 percent on average; and (2) the sound frequency of the highest pitched wheeze was also reduced, from a mean of 440 Hz to 298 Hz.

A comparative study of aerosolized terbutaline and subcutaneously administered epinephrine in the treatment of acute bronchial asthma

Patients with acute asthmatic attacks were prospectively randomized to receive either aerosolized terbutaline or subcutaneous epinephrine. After treatment there was comparable improvement in pulmonary function in both groups after two, 30 and 60 minutes. There was a significant increase in pulse rate with epinephrine that was not seen with terbutaline.

Comparison of gallium-67 scanning, bronchoalveolar lavage, and serum angiotensin-converting enzyme levels in pulmonary sarcoidosis. Predicting response to therapy

Patients with active pulmonary sarcoidosis underwent bronchoalveolar lavage, gallium scan, and serum angiotensin-converting enzyme (ACE) level determination prior to treatment with corticosteroids. Pulmonary function was tested before and after therapy. Increase in vital capacity after treatment ranged from 40 to 1,030 ml; 12 of the 16 patients studied had an increase of more than 200 ml. There was a close correlation between the percentage uptake of gallium scan and the increase of the vital capacity after therapy (r = 0.95, p less than 0.01). There was no relationship between the percentage of lymphocytes obtained on lavage and the changes in vital capacity with therapy (r = 0.05). There was a positive correlation between the changes in vital capacity and the ratio of T4(+):T8(+)lymphocytes (r = 0.62, p less than 0.05) and number of T4 (+) lymphocytes (r = 0.92, p less than 0.01) in the bronchoalveolar fluid. There was a low correlation between the pretreatment ACE level and the change in vital capacity (r = 0.368, p greater than 0.05).

Changes in fatty acids in phospholipids of the bronchoalveolar fluid in bacterial pneumonia and in adult respiratory distress syndrome

Fatty acids of the phospholipid fraction of bronchoalveolar lavage fluid from patients with bacterial pneumonia or with the adult respiratory distress syndrome were chromatographed and the patterns compared with those for a control group. In the control group, palmitic acid (16:0) was the predominant fatty acid, accounting for 58.0% (SD 8.25%) of the total fatty acid, a proportion significantly higher (p less than 0.001) than in the distress-syndrome group (42.1%, SD 4.88%) or the acute pneumonia group (32.1%, SD 1.73%). There was a greater proportion of oleic acid (18:1) in the disease groups; thus the ratio of palmitic to oleic acid was useful in distinguishing these three groups. No patient with a palmitic/oleic acid ratio greater than 2.45 had evidence of parenchymal inflammation. Of those with a ratio less than 1.3, 89% had acute bacterial pneumonia.

Changes in fatty acids in phospholipids of the bronchoalveolar fluid in bacterial pneumonia and in adult respiratory distress syndrome

Fatty acids of the phospholipid fraction of bronchoalveolar lavage fluid from patients with bacterial pneumonia or with the adult respiratory distress syndrome were chromatographed and the patterns compared with those for a control group. In the control group, palmitic acid (16:0) was the predominant fatty acid, accounting for 58.0% (SD 8.25%) of the total fatty acid, a proportion significantly higher (p less than 0.001) than in the distress-syndrome group (42.1%, SD 4.88%) or the acute pneumonia group (32.1%, SD 1.73%). There was a greater proportion of oleic acid (18:1) in the disease groups; thus the ratio of palmitic to oleic acid was useful in distinguishing these three groups. No patient with a palmitic/oleic acid ratio greater than 2.45 had evidence of parenchymal inflammation. Of those with a ratio less than 1.3, 89% had acute bacterial pneumonia.

Right and left ventricular function at rest and with exercise in patients with sarcoidosis

Fourteen patients with restrictive pulmonary disease due to sarcoidosis were studied with radionuclide angiocardiography in order to define the incidence and significance of right and left ventricular dysfunction. Right and left ventricular ejection fractions were determined by an equilibrium technique at both rest and exercise. All patients had a normal left ventricular ejection fraction with rest and 12 of 14 had the normal 5 percent or greater rise in ejection fraction with exercise. The right ventricular ejection fraction was abnormal in three patients at rest and only two patients had a 5 percent or greater rise in ejection fraction with exercise. A correlation was found between the right ventricular ejection fraction with exercise and the total lung capacity (r = 0.73, p less than 0.01) and the arterial PO2 during exercise (r = 0.74, p less than 0.01).

Effects of sarcoid and steroids on angiotensin-converting enzyme

Serum angiotensin-converting enzyme (ACE) has been claimed to be a useful guide in the treatment of pulmonary sarcoidosis. We reviewed the clinical course of 36 patients with sarcoidosis who had ACE levels determined on 2 or more occasions during the course of treatment with prednisone for a total of 55 paired observations. There was a clinical deterioration in 13 instances. Of these 13, there was a rise in ACE level in only 7. There was a clinical improvement in 19 instances. Of these 19, only 12 had a fall in ACE level. There was a negative correlation (r = -0.80) between changes in steroid dose and serum ACE level. Of 23 instances where steroids were increased, there was a fall in ACE level. Thus, ACE levels were not useful for following disease activity in patients during a change in medication.

Quantitation of bronchoalveolar lavage with methylene blue

Bronchoalveolar lavage yields a return that is composed of lung liquid and lavage liquid in variable and unknown proportions. Concentrations of chemicals and cells in lung liquid have been presented by previous workers in relative terms, sometimes relating them to the albumin content on the assumption that it is comparatively stable. We report here the use of methylene blue in the introduced fluid as an external marker. This allows the dilution, and thus absolute values, to be calculated. We found the concentrations of albumin in lung fluid to be significantly higher in a group of patients with sarcoidosis (0.50 mg/ml +/- 0.40, mean +/- standard deviation) than in a control group (0.15 mg/ml +/- 0.07; p less than 0.02). Absolute cell counts of lymphocytes in lung fluid lavaged from patients with sarcoidosis were higher than those for control patients (154 lymphocytes/ml +/- 98.9 versus 4 +/- 2.6). There was a correlation between the absolute number of lymphocytes and the albumin concentration per milliliter lung liquid (r = 0.71, p less than 0.001).

Bronchoalveolar lavage in patients with the acquired immune deficiency syndrome (AIDS)

The lymphocytes retrieved by bronchoalveolar lavage (BAL) of three patients with the acquired immune deficiency syndrome were studied to determine the local immune status of these patients. These results were compared to those of patients with pulmonary sarcoidosis, who have similar systemic immune response (anergy, hypergammaglobulinemia). In these AIDS patients, the T4/T8 ratio in the BAL was 0.44 +/- 0.20. In eleven patients with pulmonary sarcoidosis, the bronchoalveolar lavage showed a T4/T8 ratio of 7.51 +/- 2.14. It is possible that patients with AIDS are unable to change the local immune response in the lung and thus are at risk for unusual infections.