A computed tomography scan assessment of regional lung volume in acute lung injury. The CT Scan ARDS Study Group

The lobar and cephalocaudal distribution of aerated and nonaerated lung and of PEEP-induced alveolar recruitment is unknown in acute lung injury (ALI). Dimensions of the lungs and volumes of aerated and nonaerated parts of each pulmonary lobe were measured using a computerized tomographic quantitative analysis and compared between 21 patients with ALI and 10 healthy volunteers. Distribution of PEEP-induced alveolar recruitment along the anteroposterior and cephalocaudal axis and influence of the resting volume of nonaerated lower lobes were also assessed. Anteroposterior and transverse dimensions of the lungs of the patients were similar to those of healthy volunteers, whereas cephalocaudal dimensions were reduced by more than 15%. Total lung volume (aerated plus nonaerated lung) was reduced by 27%. Volumes of upper and lower lobes were 99 and 48% of normal values. In addition to an anteroposterior gradient in the distribution of aerated and nonaerated areas, a cephalocaudal gradient was also observed. Nonaerated areas were predominantly found in juxtadiaphragmatic regions. PEEP-induced alveolar recruitment was more pronounced in nondependent than in dependent regions and in cephalad than in caudal regions. A significant correlation between resting volume of nonaerated lower lobes and regional PEEP-induced alveolar recruitment was observed. In ALI, loss of lung volume involves predominantly lower lobes. The thorax shortens along its cephalocaudal axis. PEEP-induced alveolar recruitment predominates in nondependent and cephalad lung regions and is inversely correlated with the resting volume of nonaerated lung.

A lung computed tomographic assessment of positive end-expiratory pressure-induced lung overdistension

The aim of this study was to assess positive end-expiratory pressure (PEEP)-induced lung overdistension and alveolar recruitment in six patients with acute lung injury (ALI) using a computed tomographic (CT) scan method. Lung overdistension was first determined in six healthy volunteers in whom CT sections were obtained at FRC and at TLC with a positive airway pressure of 30 cm H2O. In patients, lung volumes were quantified by the analysis of the frequency distribution of CT numbers on the entire lung at zero end-expiratory pressure (ZEEP) and PEEP. In healthy volunteers at FRC, the distribution of the density histograms was monophasic with a peak at -791 +/- 12 Hounsfield units (HU). The lowest CT number observed was -912 HU. At TLC, lung volume increased by 79 +/- 35% and the peak CT number decreased to -886 +/- 26 HU. More than 70% of the increase in lung volume was located below -900 HU, suggesting that this value can be considered as the threshold separating normal aeration from overdistension. In patients with ALI, at ZEEP the distribution of density histograms was either monophasic (n = 3) or biphasic (n = 3). The mean CT number was -319 +/- 34 HU. At PEEP 13 +/- 3 cm H2O, lung volume increased by 47 +/- 19% whereas mean CT number decreased to -538 +/- 171 HU. PEEP induced a mean alveolar recruitment of 320 +/- 160 ml and a mean lung overdistension of 238 +/- 320 ml. In conclusion, overdistended lung parenchyma of healthy volunteers is characterized by a CT number below -900 HU. This threshold can be used in patients with ALI for differentiating PEEP-induced alveolar recruitment from lung overdistension.

Nonspecific interstitial pneumonia. Individualization of a clinicopathologic entity in a series of 12 patients

Nonspecific interstitial pneumonia/fibrosis (NSIP) has recently been individualized within the group of idiopathic interstitial pneumonias mainly based on a pathologic pattern of temporally uniform lesions distinct from usual, desquamative, and acute interstitial pneumonia. We studied 12 consecutive patients with NSIP at lung biopsy done as a diagnostic procedure for idiopathic interstitial lung disease. The patients were six males and six females, aged 52.5 +/- 11.8 yr. In 8 of 12 cases the pathologic lesions consisted of both cellular interstitial inflammation and fibrosis, whereas only cellular inflammation was present in three cases, and fibrosis in one. Dyspnea, cough, inspiratory crackles, and squeaks were the most common symptoms and signs. Six cases were cryptogenic. An associated disorder or a presumed cause was present in the other six patients, including underlying connective tissue disease (n = 3), organic dust exposure (n = 2), and prior acute lung injury (n = 1). Lung function tests found a restrictive ventilatory defect (11/12), impairment of TLCO (11/11), and hypoxemia at rest (7/12). Chest X-ray showed infiltrative opacities in all cases. Computed tomography of the chest in 11 cases mainly showed ground glass opacities (9/11), patchy areas of alveolar consolidation (6/ 11), and thickening of interlobular septas (5/11). All patients were treated with corticosteroids, and seven with immunosuppressive agents. All patients were alive at last follow-up, 50 +/- 40 mo after diagnosis. Ten patients (83%) were clinically improved or stabilized. Thus, despite its heterogeneity, NSIP deserves to be individualized as an original clinicopathologic entity and should be clearly distinguished from usual interstitial pneumonia, especially because of a better prognosis.

Recent advances in radiology of the interstitial lung disease

Idiopathic interstitial pneumonias are currently classified into four categories of disease: usual, desquamative, and acute interstitial pneumonia, and nonspecific interstitial pneumonia and fibrosis. Usual interstitial pneumonia appears on high-resolution CT (HRCT) as patchy subpleural areas of ground-glass opacity, irregular lines, and honeycombing. Desquamative interstitial pneumonia presents as patchy subpleural areas of ground-glass opacity in middle and lower lung zones. Acute interstitial pneumonia presents as extensive bilateral airspace consolidation and patchy or diffuse bilateral areas of ground-glass opacity. Nonspecific interstitial pneumonia and fibrosis appears as patchy or diffuse areas of ground-glass opacity with associated areas of consolidation and irregular lines. In a subset of patients with diffuse lung disease (especially in those with chronic interstitial lung disease), accurate diagnosis can be made with HRCT findings only, without surgical biopsy. However, HRCT provides a lower level of confidence in the diagnosis of acute or subacute interstitial lung disease such as infection, diffuse alveolar damage, drug reaction, or hemorrhage. Additional expiratory HRCT scans and scans with patients prone help to narrow the differential diagnosis among various diseases and help diagnose or exclude subtle disease in the posterior part of the lung, respectively. HRCT provides a reproducible method for evaluating the global extent of disease. It also discriminates between fibrotic and reversible inflammatory diseases.

Chest radiography as a predictor of outcome in posttransplantation lymphoproliferative disorder in lung allograft recipients

OBJECTIVE

The radiologic findings of posttransplantation lymphoproliferative disorder in lung transplant recipients have received little attention compared with the findings for recipients of other solid organ transplants. We describe the intrathoracic findings and explore whether the radiographic presentation can predict outcome.

MATERIALS AND METHODS

Twenty-six patients (mean age, 32 years; range, 2-63 years; 18 female, eight male) with histologically proven lymphoproliferative disorder were identified from 518 lung transplantation patients, a 5.0% frequency. Chest radiographs, obtained within 1 week of diagnosis, were compared with baseline posttransplantation radiographs for all 26 patients and with chest CT scans for 20 patients.

RESULTS

The interval between transplantation and diagnosis ranged from 6 weeks to 7 years (mean, 16 months; median, 6 months). The thorax was involved in 18 (69%) of 26 patients. A new chest radiographic abnormality was present in all 18 patients and provided the first indication of disease in 14 (78%) of 18 patients. The most common finding was a solitary pulmonary nodule, seen in nine (50%) of 18 patients. Other findings included multiple nodules, multifocal alveolar infiltrates, and hilar and mediastinal adenopathy. CT scans detected additional nodules and lymph nodes but did not show occult disease in any case that appeared normal on radiography. Eight (89%) of nine patients with solitary pulmonary nodules at presentation were alive 1 year after diagnosis, compared with six (35%) of 17 patients with other presentations (p < .01).

CONCLUSION

Thoracic manifestations are present in most lung transplant recipients with lymphoproliferative disorder. Patients with solitary nodules have a better outcome in the first year after diagnosis than do patients with other presentations.

Radiographic aspects of Pneumocystis carinii pneumonia in the miniature Dachshund

The thoracic radiographic changes of Pneumocystis carinii in 7 miniature Dachshunds were reviewed. The dogs were 7-12 months old and presented with polypnea, exercise intolerance and clinical signs suggestive of immune-incompetence. P. carinii pneumonia was diagnosed in all the dogs using transtracheal aspirate cytology and confirmed at postmortem in 3 dogs that died. Radiographically, diffuse pulmonary changes were present and varied from a mild interstitial and bronchial pattern to an alveolar pattern. Radiographic evidence of cor pulmonale was present in 1 dog. The most severe radiographic changes were seen in 2 of the dogs that died.

Scintigraphical evaluation of alveolar clearance in horses

This study proposed a standardized method for measuring alveolar epithelium membrane permeability in the horse. The normal rate of clearance (%.min-1) from lung into blood of nebulized 99mTc-DTPA has been established for healthy horses (Group A) compared with values obtained with horses suffering from chronic obstructive pulmonary disease (COPD; Group B). The 99mTc-DTPA clearance was measured in the caudoventral (R1) and in the half caudal (R2) parts of the left lung during different time intervals. The two regions aimed to define the influence of the airways on measured clearance (R2 contained proportionally more conducting airways than R1). It was concluded that a comparison of groups of subjects may be performed in R2 and on data collected during a 20 min period. The normal clearance rate in R2 was 1.80 +/- 0.46%.min-1 (T1/2R2 = 40.99 +/- 12.45 min) in Group A. In Group B, a significantly faster 99mTc-DTPA transfer rate was found (4.17 +/- 0.83%.min-1 or T1/2R2 = 17.17 +/- 3.38min). Bronchoalveolar lavage (BAL) suggested that the increased permeability measured in Group B could be the result of lung inflammatory responses. Our results have demonstrated the ability of the 99mTc-DTPA clearance test to detect alveolar epithelial damage in horses. Furthermore, we were able to show that a regional analysis of the alveolar-capillary barrier integrity may be performed satisfactorily in the equine patient.

Improved delivery of inhaled steroids to the large and small airways

The reformulation of asthma medications with non-ozone depleting propellants such as hydrofluoroalkane-134a (HFA) has provided the opportunity to apply new knowledge and inhaler technology to improve significantly the delivery of aerosol drugs to the respiratory tract. Beclomethasone dipropionate (BDP), the most commonly prescribed inhaled corticosteroid for asthma therapy, is effective therapy; however currently available chlorofluorocarbon (CFC)-BDP metered dose inhalers typically deliver no more than 10% of the inhaled drug to the lungs with the remainder deposited in the oropharynx. Compared with an average particle size of 3.5-4.0 microns for CFC-BDP, the new HFA-BDP formulation has an average particle size of 1.1 microns and a respirable fraction of approximately 60%. The lung deposition of 99mTc-radiolabelled HFA-BDP has been investigated in healthy volunteers and patients with asthma. Results showed that the HFA-BDP formulation reverses the pattern of distribution seen with CFC-BDP products, delivering most of the dose of inhaled steroid directly to the lungs rather than to the oropharynx and gut where it may lead to unwanted side-effects. As such, HFA-BDP is likely to achieve equivalent efficacy to existing CFC-BDP formulations with lower doses and with reduced potential for local adverse effects.

[Recurrent false infundibulo-pulmonary aneurysm after complete correction of Fallot tetralogy]

Infundibulo-pulmonary aneurysm is a rare complication of complete correction of Tetralogy of Fallot and its recurrence has not been previously reported. A girl with Tetralogy of Fallot with two small pulmonary branches underwent complete correction at 3 years of age with widening of the infundibulum, the pulmonary annulus and artery with a pediculated pericordial path. Five years later, the left parasternal systolic murmur increased in intensity due to an infundibulo-pulmonary aneurysm and severe stenosis of the bifurcation of the pulmonary artery confirmed by echocardiography and catheterisation. The child was reoperated with resection of the aneurysm and widening of the pulmonary tract and its two branches with a Dacron patch. Three years later, the aneurysm and pulmonary stenoses recurred and required percutaneous angioplasty and stenting. The inadequacy of the result led to a further surgical procedure.

A longitudinal study of pulmonary involvement in primary Sjögren's syndrome: relationship between alveolitis and subsequent lung changes on high-resolution computed tomography

Eighteen non-smoking women suffering from primary Sjögren's syndrome (pSS) with previously documented alveolitis were re-examined, clinically and by pulmonary function tests (PFT), bronchoalveolar lavage (BAL), chest X-ray and high-resolution computed tomography (HRCT) after a 2 yr follow-up period. Longitudinal evaluation revealed unchanged PFT. The final BAL study showed a normal differential count in six of 14 patients with initial lymphocyte alveolitis, and a persistent alveolar lymphocytosis in the remaining eight patients, associated with an increased percentage of neutrophils in one of them. In four patients with initial mixed alveolitis, the BAL cell profile was unchanged 2 yr later. Five of 18 patients (28%) had abnormal HRCT, represented by isolated septal/subpleural lines in three patients, ground-glass opacities with irregular pleural margins in one patient, and ground-glass opacities associated with septal/subpleural lines in another. All these patients had abnormal BAL results with an increased proportion of both neutrophils and lymphocytes. The presence of alveolar neutrophils was associated with a significantly (P=0.005) greater mean rate of reduction of carbon monoxide diffusing capacity (DLCO) -- more than four times the normal rate of loss of DLCO. Chest X-ray, repeated at the end of the 2 yr follow-up period, showed parenchymal abnormalities in only one patient who had evidence of fibrosis on HRCT. This study provides evidence that lung involvement is not an uncommon extraglandular manifestation of pSS and that a BAL neutrophilia may play an important role in the pathogenesis of pulmonary disease in this autoimmune disorder.

Pulmonary alveolar microlithiasis: high-resolution CT and MR findings

We report the high-resolution CT (HRCT) and MR findings in a case of pulmonary alveolar microlithiasis. HRCT revealed that the black pleural line on a chest radiograph was caused not by subpleural cysts but by a fat-dense layer between ribs and the calcified parenchyma. MRI showed both lower zones with diffusely increased signal intensity on T1-weighted images. We speculated it was caused by the accumulation of small-sized calcific particles.

Pulmonary epithelial permeability and gas exchange: a comparison of inverse ratio ventilation and conventional mechanical ventilation in oleic acid-induced lung injury in rabbits

STUDY OBJECTIVE

(1) To explore the interaction between mechanical ventilation and oleic acid (OA)-induced lung injury on indexes of pulmonary gas exchange and epithelial permeability, and (2) to compare this interaction using two different modes of ventilation: pressure-controlled inverse ratio ventilation (PCIRV) and volume-controlled ventilation with positive end-expiratory pressure (VCV PEEP).

DESIGN

Randomized animal study.

SETTING

Experimental laboratory investigation at Södersjukhuset, Stockholm, Sweden.

ANIMALS

Twenty-four New Zealand white rabbits.

INTERVENTIONS

(1) Ventilation with PCIRV (n=6) or VCV PEEP (n=6) for 6 h at equal end-expiratory alveolar pressure levels of 5 cm H2O followed by induction of lung injury (IV injection of OA 0.15 mL/kg). (2) Induction of lung injury followed by 6 h of ventilation with either PCIRV (n=6) or VCV PEEP (n=6) as described above.

MEASUREMENTS AND RESULTS

Lung mechanics, heart rate, BP, and gas exchange results were equal at baseline. In group A, after 1 h of ventilation, mean airway pressure was 11.9+/-4.4 with PCIRV and 8.3+/-1.0 cm H2O with VCV PEEP (p<0.05). Forty minutes after OA injection, PaO2/fraction of inspired oxygen (FIO2) was 24+/-10 kPa with PCIRV and 44+/-15 kPa with VCV PEEP (p<0.05). Mean airway pressure was higher and peak airway pressure was lower with PCIRV. In group B, after 6 h of ventilation, PaO2/FIO2 was 17+/-5 kPa with PCIRV and 43+/-8 kPa with VCV PEEP (p<0.01). Systemic BP was lower with PCIRV and mean airway pressure was higher. Technetium-99m diethylene triamine penta-acetic acid lung clearance: In group A, curves were monoexponential with both PCIRV (half-life time [T 1/2], 21+/-8 min and VCV PEEP (T 1/2, 126+/-59 min, p<0.005) until injection of OA. In the VCV PEEP-treated animals, a marked increase in clearance rate was observed within 60 s of OA injection (T 1/2, 13+/-9 min, p<0.001). Fifteen minutes after OA injections, T 1/2 had decreased to 38+/-17 min with VCV PEEP. In the animals treated with PCIRV, OA injection did not lead to a significant change in clearance rate, although the elimination pattern was observed to change from single-compartment to multicompartment type. In group B, clearance curves were monoexponential with both ventilatory modes. There was no significant difference in clearance rate between PCIRV (T 1/2, 25+/-9 min) and VCV PEEP (T 1/2, 36+/-16 min, not significant).

CONCLUSIONS

The observation that PaO2 was lower in the PCIRV-treated groups must be interpreted with caution in this animal study with relatively few observations. The finding may reflect differences in the effect of OA injection in the two ventilatory modes. It is also possible that externally applied PEEP is more effective than PCIRV in increasing oxygen tension, either because of a less inhomogenous distribution of ventilation and perfusion or for other reasons. The clearance results imply that PCIRV causes an alteration in lung epithelial or membrane function in comparison to VCV PEEP. This functional difference is most likely caused by the large time-weighted lung volume produced by pressure control in combination with a prolonged inspiration. Induction of high permeability lung injury with OA eliminates the difference between PCIRV and VCV PEEP. It remains to be established whether these findings are relevant with regard to ventilator-associated structural lung injury in man.

Pulmonary Mycobacterium avium complex disease without dissemination in HIV-infected patients

Pulmonary disease due to Mycobacterium avium complex (MAC) without evidence of dissemination is uncommon in HIV-infected patients. Five cases were observed over a 2-year period. All patients had AIDS and the median CD4 cell count at the time of presentation was 90 x 10(6)/L. Radiographic patterns included unilobar alveolar infiltrates or diffuse alveolar densities. All patients had a favorable clinical response to antimycobacterial chemotherapy with a median follow-up period of 10 months. MAC should be considered in HIV-infected patients with positive respiratory samples for acid-fast bacilli and pulmonary infiltrates. Patients with such findings in whom presumptive therapy for tuberculosis has failed should receive broad-spectrum antimycobacterial chemotherapy until final identification is available.

[Patent and occult intra-alveolar hemorrhage in leptospirosis]

PURPOSE

Pulmonary involvement (PI) is common in leptospiral infection, usually characterized by hemoptysis and diffuse bilateral infiltrates on chest radiographs. Alveolar haemorrhage (AH) has already been proved by autopsy and some case-reports with fiberoptic bronchoscopy (FB) and bronchoalveolar lavage (BAL). The purpose of this study was 1/to evaluate the incidence of AH in leptospirosis 2/to define the impact of BAL on the early diagnosis of the infection.

PATIENTS AND METHODS

FB with BAL were performed in 23 consecutive patients with leptospirosis (13 patients with patent signs of PI: group 1, 10 patients without: group 2). AH was defined by a percentage of siderophages > or = 20% and/or a Golde score > 100 and/or an haemorrhagic aspect of BAL fluid. Culture tests were performed on specific medium.

RESULTS

We diagnosed AH in all patients of group 1 and in 7 patients of group 2. Filaments were seen in 6 specimens of BAL fluid, initially thought to be leptospires, but culture tests were negative.

CONCLUSION

AH is identified in all cases of leptospirosis with PI. Occult AH often occurs to patients without any respiratory symptom. Physicians should consider leptospiral infection in the differential diagnosis of AH. Culture-tests for leptospirosis in BAL do no help in diagnosing leptospirosis.

Diffuse alveolar damage in a patient treated with gemcitabine

We present a case of diffuse alveolar damage (DAD) that occurred in a male aged 68 yrs treated with gemcitabine, a novel antineoplastic agent, that was given for hepatic relapse of a previously resected non-small cell lung cancer. The patient developed acute respiratory failure after the sixth drug dose, and died 4 days after admission. Autopsy revealed a pattern of DAD. No evidence of infection or other specific aetiologies could be found. To our knowledge, only three cases of pulmonary toxicity resulting from treatment with gemcitabine have been published; two of them were fatal and postmortem examination revealed a pattern consistent with acute respiratory distress syndrome. A careful survey may determine the incidence of pulmonary toxicity of this new drug in the future.

Selection of subtle cases for observer-performance studies: the importance of knowing the true diagnosis

RATIONALE AND OBJECTIVES

To assess the usefulness of classifying degree of difficulty in abnormality detection and to determine the effect of knowing the true diagnosis when selecting subtle images for observer-performance studies.

MATERIALS AND METHODS

A total of 529 posteroanterior chest images that had been used in a multiabnormality, multireader observer-performance study were rated by three observers as to the difficulty of determining the presence or absence of each abnormality when the true diagnosis was known and when it was not known. Changes in image subtlety ratings were evaluated, and actual observer-performance results for the different groups of images grouped according to raters' classifications with and without availability of the true diagnosis were compared.

RESULTS

The majority of negative cases (9,168 of 12,258, 74.8%) were rated as "easy" to determine. Substantial changes were made during the selection of the "subtle" case category when the truth was known compared with when the truth was not provided. These changes caused differences between typical and subtle cases in terms of observer performance. Combined ratings of case subtlety by agreement of multiple classifiers resulted in a well-ordered selection with decreasing observer performance as a function of subtlety ratings.

CONCLUSION

Cases for observer-performance studies that stress the diagnostic system can be successfully selected in the multiple-disease setting by experienced readers and should be selected with the truth known to the raters. The degree of agreement by multiple raters can be used to refine subtlety ratings.

Radiographic patterns of pulmonary metastasis in 25 cats

Thoracic radiographs of 25 cats with pulmonary metastatic disease and confirmed primary tumors were reviewed retrospectively. Pulmonary patterns of metastasis were divided into three categories, described as well-defined interstitial nodules, ill-defined interstitial nodules or a diffuse pulmonary pattern. The latter consisted of an alveolar pattern with or without ill-defined pulmonary nodules and/or pleural effusion. More cats presented with pulmonary metastatic disease in the category of either ill-defined nodules (n = 10) or a diffuse pattern (n = 7). Within this group, the most commonly represented primary tumor was mammary gland adenocarcinoma.

Sarcoidosis presenting as unilateral alveolar consolidation

Sarcoidosis is a multisystem granulomatous disorder that has variable clinical and radiologic manifestations. We describe a rare case of a 35-year-old black woman who had a nonresolving focal alveolar infiltrate. Her symptoms did not improve with the administration of antibiotics, and a more extensive workup, including fiberoptic bronchoscopy with transbronchial biopsy and a conjunctival biopsy showed noncaseating granulomata. We conclude that sarcoidosis should be included in the differential diagnosis of nonresolving alveolar opacity in populations that have increased incidence.

[Hamman-Rich syndrome in a goldsmith]

We report the case of a 54-year old goldsmith admitted because of dyspnea on exertion, persistent cough, and weakness under the suspicion of exogenous allergic alveolitis. He rapidly developed progressive lung fibrosis with exitus letalis 7 weeks after admission. Radiological examination (chest X-ray and HRCT) first showed ground glass opacties, and later rapid development of severe interstitial pattern with architectural distraction. The findings were similar to idiopathic lung fibrosis; however, the rare Hamman-Rich syndrome was confirmed by progressive course of the disease. Correlations between Hamman-Rich syndrome and idiopathic lung fibrosis are discussed.

Localization of the bronchodilatory effects of isoproterenol and aminophylline in patients with bronchial asthma: an investigation using selective alveolobronchography

The effect of isoproterenol (isoprenaline) and aminophylline on airway calibre in 18 adult patients with bronchial asthma was measured directly using selective alveolobronchography. Isoproterenol caused a significant dilation in the maximal calibre of the central airway from bifurcation numbers 1-5 (P < 0.05) and number 6 (P < 0.01). There was no change in bifurcation number 0 (trachea). Aminophylline caused a significant dilatation in bifurcation numbers 3 and 4 (P < 0.01), with no change in bifurcation numbers 0-2 and 5-6. In the minimal calibre of the central airway, both drugs displayed a significant dilatory effect only at bifurcation number 3 (P < 0.05). These results indicate that the central airway is the main site of the dilatory effects of these drugs. Although their precise mechanisms of action are not known, these results suggest that mechanisms of action of the two drugs are different. Isoproterenol acts on the whole region of the central airway, while the action of aminophylline tends to be limited to bifurcation numbers 3 and 4.

[3 siblings with identical, rare pneumopathy]

Pulmonary alveolar microlithiasis was found in three siblings. Only the youngest of them, a former smoker, developed endstage lung disease. The other two are asymptomatic with normal lung function despite impressive changes on all chest radiographs. The role of smoking in perpetuating microlithiasis and furthering the progression of this disease is discussed.

Leptospirosis: prognostic factors associated with mortality

To determine the prognostic factors for leptospirosis, we conducted a retrospective study of data collected in the emergency department of our hospital between 1989 and 1993. Sixty-eight patients, for whom the diagnosis of leptospirosis was based on pertinent clinical and epidemiological data and positive serology, were included in this study. Fifty-six patients (82%) were discharged from the hospital, and 12 (18%) died. Multivariate logistic regression demonstrated that five factors were independently associated with mortality: dyspnea (odds ratio [OR], 11.7; 95% confidence interval [CI], 2.8-48.5; P < .05), oliguria (OR, 9; CI, 2.1-37.9; P < .05); white blood cell count, >12,900/mm3 (OR, 2.5; CI, 1.8-3.5; P < or = .01), repolarization abnormalities on electrocardiograms (OR, 5.9; CI, 1.4-24.8; P < or = .01), and alveolar infiltrates on chest radiographs (OR, 7.3; CI, 1.7-31.7; P < or = .01). Identification of these factors on admission might provide useful selection criteria for patients who need early transfer to the intensive care unit.