Mycobacterial Lung Infections

Abstract

To the Editor: In the article on mycobacterial lung infections by Hadjiliadis, Adlakha, and Prakash, published in the January 1999 issue of Mayo Clinic Proceedings (pages 45 to 51), achalasia often provided the reservoir for lipoid material, particularly for mineral oil. I encountered a patient with mineral oil aspiration and a giant Zenker diverticulum, and another who regurgitated mineral oil and ancient food from a massive epiphrenic diverticulum and had recurrent bezoars that blocked the esophageal lumen. A topic that most medical textbooks do not address and many physicians do not appreciate is the impact of undertreated achalasia and long-standing diverticular retention on medication decisions (including the use of mineral oil1Ungdon DE A risk of mineral oil.N Engt J Med. 1998; 339: 1947-1948Crossref PubMed Google Scholar), Particularly in patients with diverticula, multiple doses of orally administered medications can be retained. Baron2Baron SH Zenker' s divert iculu m as a cause for loss of drug availability: a “new” complication.Am J Gastroenteroi. 1982; 77: 152-153PubMed Google Scholar reported intractable hypothyroidism in a patient with Zenker diverticulum caused by “pooling” and then regurgitation of thyroxine tablets. Dr Stanley Hamilton of Johns Hopkins has a photograph of an epiphrenic diverticulum containing at least 25 ulcerogenic quinidine tablets in various stages of decomposition. Depending on diverticular “whims,” the blood levels of quinidine in this patient could range from 0 to fatal! Because it takes decades for di verticula to achieve such size, they are found most often in elderly patients whose need for multiple pharmaceutical agents compounds the problem. The pH in the diverticula or achalasia pouch is usually similar to that of saliva, and if the patient takes antacids, it is even alkaline. Protective coatings designed for delivery to the small intestine solubilize during prolonged diverticular stasis, a process that releases active agents. “Decoating” then affects drugs inactivated by gastric acids such as pancreatic enzymes and proton pump inhibitors, changes the kinetics of the many sustainedrelease delivery systems, and risks mucosal damage from drugs requiring coatings to prevent gastrointestinal toxicity. Drugs that are toxic to the esophageal wall,3McCord GS Clouse RE Pill-induced esophagcal strictures: clinical features and risk factors for development.Am J Med. 1990; 88: 512-518Abstract Full Text PDF PubMed Scopus (56) Google Scholar such as doxycycline, tetracycline, minocycline, potassium, some nonsteroidal anti-inflammatory drugs, phenytoin, iron, quinidine, and diphosphonate (“Fosamax esophagus”), can also be trapped. Stasis sufficient for bezoar formation or “rotten-food halitosis” predisposes the patient to contact necrosis. One of my patients had food and pills solidly impacted in a Zenker diverticulum and an asymptomatic chronic perforation allowing mediastinal visualization (topical toxicity?). In another patient, just 1 retained doxycycline tablet produced into-the-muscle circumferential debridement. Are such drugs the “X” factor in “idiopathic” diverticular ulcerations, particularly those that hemorrhage or perforate into abutting critical organs? My experience with retained medications has prompted me to recommend, when possible, liquid or chewable products followed by a liquid flush. However, physicians should be aware that, in patients with giant diverticula or undertreated achalasia in whom reliability and rapid availability of medications are essential for therapeutic success, the oral route may be too erraticassociated with unpredictable absorptive delays, “peaks and valleys” in serum levels, and risk of drug predigestion. Mycobacterial Lung Infections: In ResponseMayo Clinic ProceedingsVol. 74Issue 7PreviewI thank Dr Langdon, on behalf of my coauthors, for his interest in our article and his thoughtful comments regarding the complications associated with pharyngoesophageal (Zenker) diverticulum. We agree with him about the possibility of retention oftablets in the diverticulum and resultant complications. If surgical correction is not a therapeutic option in such patients, it is important to educate them about the complications and precautions recommended by Dr Langdon. Full-Text PDF