SUCCESSFUL TREATMENT OF PNEUMOCYSTIS CARINII PNEUMONITIS IN A PATIENT WITH CONGENITAL HYPOGAMMAGLOBULINEMIA

Pentamidine isethionate. A review of its antiprotozoal activity, pharmacokinetic properties and therapeutic use in Pneumocystis carinii pneumonia

Pentamidine isethionate, an aromatic diamidine, is an antiprotozoal agent proven to decrease mortality from Pneumocystis carinii pneumonia in debilitated infants and immunodeficient adults and children. Like the combination antimicrobial agent co-trimoxazole, pentamidine has been shown in retrospective studies to resolve episodes of pneumonia in approximately 41 to 87% of patients, including those with the acquired immunodeficiency syndrome (AIDS), when used alone or as sequential therapy. Although about 45% of all patients given pentamidine experience side effects--which may include nephrotoxicity, hypotension, hypoglycaemia or local reactions--in patients with AIDS the incidence of side effects is less with pentamidine than with co-trimoxazole. Thus, despite its profile of potentially severe side effects, pentamidine isethionate is a proven antimicrobial agent with a distinct place in the treatment of Pneumocystis carinii pneumonia in the growing population of AIDS patients.

The deoxyuridine suppression test

The deoxyuridine suppression (dU) test, first described in 1964, has gained an important place both in the diagnosis of megaloblastic anemias and in the study of vitamin B12 folate interrelationships in the pathogenesis of megaloblastic anemia. The test measures the integrity of the de novo synthetic pathway of DNA synthesis, in which vitamin B12 and folate play an essential role. The exact mechanism of the test is still largely unknown. However, it is probably the most sensitive and specific functional test for the establishment of vitamin B12 and/or folate deficiency. As such, it is an important diagnostic tool in the investigation of patients suspected of suffering from deficiency of either or both of these vitamins. The test may also have applications towards the study of other factors required for the de novo synthesis of DNA.

Pneumocystis carinii pneumonia. Diagnosis by lung biopsy

Pneumocystis carinii pneumonia was suspected in 52 patients who underwent lung biopsy for diagnosis of diffuse pulmonary infiltrates. All but five of the procedures were limited thoracotomies. There were no instances of significant postoperative hemorrage or of pneumothorax compromising ventilation. The diagnosis of P. carinii pneumonia was made rapidly from imprints of the lung stained by the Gram-Weigert method in the 18 patients who had P. carinii pneumonia. Over-all, the rate of recovery from Pneumocystis pneumonia after treatment with pentamidine isethionate was 41 percent. However, among patients with no other pulmonary lesion (group A), the survival rate was 58 per cent; none of the patients with coexisting pulmonary disease (group B) recovered. The pulmonary infiltrates in the other 32 patients represented a variety of processes, of which 5 were fungal infections and 5 were due to lymphoma. Fifteen patients had an organizing interstitial and intraalveolar pneumonia of undertermined origin.

Direct fluorescent-antibody method for the diagnosis of Pneumocystis carinii pneumonitis from sputa or tracheal aspirates from humans

A direct fluorescent antibody (DFA) method was applied to sputum or tracheal aspirate from 68 patients with clinical or radiological evidence suggesting Pneumocystis carinii pneumonitis, and to 50 control patients. P. carinii was detected by DFA in specimens from 33 of the 69 clinical cases and 3 of the 50 controls. Specimens of lung from 11 of 33 DFA-positive cases were examined histologically, and 9 were positive. Four of 35 DFA-negative cases were examined histologically, and all were negative. Sputa or tracheal aspirates from 6 patients who were positive by both DFA and histological examination were examined also by methenamine silver staining; none could be diagnosed conclusively by this method. The results indicate that the DFA method is a sensitive and dependable procedure for the laboratory diagnosis of P. carinii pneumonitis in man.

Immunoglobulin levels in infantile pneumocystosis

Two hundred and twelve determinations of IgA, IgG, and IgM were performed in 50 infants during an epidemic of interstitial plasma cell pneumonia. Criteria for diagnosis are discussed. The immunoglobulin levels in pneumocystic, non-pneumocystic, and normal American infants are compared. An analysis of the findings in individual cases reveals a time-related immunoglobulin response, which helps to elucidate the pathogenicity of the disease.

Infections in recipients of liver homografts

Seventeen patients received liver homografts between 1963 and May, 1968. The eight treated before July, 1967, died within 34 days; seven had progressive infections with gram-negative bacilli, Candida albicans and cytomegalovirus. The infections were similar to but more fulminating than those after renal homotransplantation.

In nine later cases, there was more discriminating donor selection, improved immunosuppression, and better organ preservation. In the first five of these nine patients, all infants, lobar hepatic gangrene apparently secondary to delayed right hepatic arterial thrombosis developed. Two died within a few days, two and three and a half months after transplantation. The three who did not die immediately subsequently had multiple bacteremias, fungemias and cytomegalovirus pulmonary infections. One of these children is alive twelve months after transplantation; the others died after four and a half and six months. In contrast, the last four patients, in whom septic liver infarctions were avoided, have been free of serious infections for two to five and a half months.

Transplant lung--a new syndrome

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Pneumocystis carinii pneumonia and reticuloses

Three cases of Pneumocystis carinii pneumonia occurring in the course of diseases of the lymphoreticular system are described. One case was diagnosed in life and unsuccessfully treated with pentamidine isethionate. Incidence of the pneumonia is associated with a depressed immune response and may be more frequent than is usually realized in patients with reticuloses who are receiving corticosteroid and cytotoxic drugs.

The parasitic diseases of childhood with emphasis on the newer diagnostic methods

The ubiquitousness of certain protozoan and helminth parasites and the increasing geographic mobility of individuals point up the need for an awareness of the role of parasitic infections in pediatric prac tice.

This paper (a) surveys the advances in diagnosis and clinical understanding of those parasitic diseases of children which are the most common in Northern tem perate climates—amebiasis, giardiasis, pin worm infestation, visceral larva migrans, toxoplasmosis, pneumocystosis—and (b) surveys the usefulness, specificity, and limitations of the newer serologic tests in the diagnosis and management of these diseases. Therapy is not stressed.

Because of the recent recognition of the significance of Pneumocystis carinii infection, this is considered in somewhat greater detail than its rarity might other wise warrant.

Thymic alymphoplasia

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