Cavitary Lung Disease Research Articles

Cavitary Pulmonary Infarct in Immunocompromised Hosts

Cavitary Pulmonary Infarct in Immunocompromised Hosts

Melioidosis in a Diabetic Sailor

Melioidosis was diagnosed in a diabetic sailor who presented with a history and chest radiograph that suggested tuberculosis. Melioidosis is a tropical disease with protean manifestations: from asymptomatic infection to chronic cavitary lung disease to overwhelming sepsis. The diagnosis is easily made, even in nonendemic areas when duly considered by the clinicians and microbiology laboratory. Ceftazidime has dramatically improved outcomes in hospitalized patients with severe melioidosis.

Rifabutin in the Treatment of Cavitary Lung Disease Due to Mycobacterium gordonae

We have described a case of progressive pulmonary disease caused by M gordonae that failed to show any improvement in disease status after 9 months of intensive therapy with a conventional four-drug regimen. When rifabutin became available and was included in the regimen, the disease was cured. Although considered a saprophyte of the respiratory tract, M gordonae can cause clinically significant disease in rare instances. Initiation of appropriate therapy with rifabutin and other antituberculous agents could prevent the destructive lesions and prolonged morbidity of patients with disease caused by M gordonae.

Cavitary lung disease. How to read the radiographic patterns.

Many disorders and abnormalities are accompanied by cavitary lesions of the lung, including various diseases that may destroy or replace lung tissue. The most common causes of cavitary lung disease are primary and metastatic neoplasms, granulomas, and necrotizing pulmonary infections. These diseases often have radiographic patterns, clinical signs, and symptoms that are characteristic and may suggest a diagnosis.

Cavitary lung disease caused by Mycobacterium avium-intracellulare in AIDS patients

We report here two patients with AIDS who had disseminated infection with Mycobacterium avium-intracellular and who developed radiographic evidence of cavitary lung disease. In both cases the diagnosis was confirmed at post-mortem

Klebsiella Pulmonary Infections: Occurrence at One Medical Center and Review

Klebsiella pneumoniae is the species of aerobic gram-negative bacteria most commonly recognized as a cause of community-acquired pneumonia. The vast majority of articles concerning the epidemiology, frequency, and clinical and radiographic features of community-acquired pneumonias caused by this organism are over 20 years old. Experience with community-acquired pneumonias due to K. pneumoniae at one medical center over the last 20 years is reported and compared with the previously published literature. The recent experience at Parkland Memorial is quite similar to that in the literature. Salient features include the infrequency of K. pneumoniae as a cause of community-acquired pneumonia, the lack of specificity and sensitivity of most clinical and radiographic findings, and the similarity to and potential confusion with anaerobic pneumonitis and cavitary lung disease if only expectorated sputums are utilized for diagnosis in certain population groups such as alcoholics.

The Epidemiologic Patterns of Drug-resistantMycobacterium tuberculosisInfections: A Community-based Study

A community-based study of tuberculosis in Santa Clara County, California was conducted in order to identify community-specific determinants of drug-resistant Mycobacterium tuberculosis infections. From January 1984 through December 1986, 517 verified cases of tuberculosis were reported from the county. Drug susceptibility test results to isoniazid, streptomycin, ethambutol, and rifampin were available for 256 of the 517 cases. The frequency of resistance of M. tuberculosis isolates to one or more drugs was 27% for all cases and 25% for those who had had no previous antituberculosis treatment. Isolates from Asian immigrants had the highest frequencies of resistance (33 to 45%), and the Southeast Asian immigrants had a drug-resistant tuberculosis case rate greater than 30/100,000 population per year. In patients who had cavitary lung disease and who had a previous history of tuberculosis, drug-resistant tuberculosis was 3.5 times as likely to occur than in persons who had neither of these characteristics (p less than 0.001). For such patients, the positive predictive value of isolating resistant M. tuberculosis approached 90%. We believe these community-based findings will guide clinical and public health interventions specifically appropriate for the community.

Superiority of Enviomycin or Streptomycin over Ethambutol in Initial Treatment of Lung Disease Caused by Mycobacterium avium Complex

The rate of sputum conversion (continuously negative cultures for six months or more) was compared among four regimens given to 83 patients with moderately advanced, cavitary lung disease caused by Mycobacterium avium complex untreated previously. The regimens of rifampin + isoniazid + enviomycin and rifampin + isoniazid + streptomycin appeared to be superior to the regimen of rifampin + isoniazid + ethambutol. No statistically significant difference was observed between the regimens rifampin + isoniazid + enviomycin and rifampin + isoniazid + streptomycin.

Pneumocystis carinii Pneumonia Presenting as Cavitary Lung Disease

Pneumocystis carinii Pneumonia Presenting as Cavitary Lung Disease

Comparison of Antituberculosis Drug Regimens for Lung Disease Caused by Mycobacterium avium Complex

A total of 123 patients with moderately advanced, cavitary lung disease caused by Mycobacterium avium complex untreated previously received different regimens of antituberculosis agents. The rate of sputum conversion (continuously negative cultures for six months or more) was compared among the regimens. It was shown that the regimens of rifampin + isoniazid + streptomycin and rifampin + isoniazid + enviomycin were superior to the regimens of streptomycin + isoniazid + p-aminosalicylate, isoniazid alone or isoniazid + p-aminosalicylate. This finding demonstrated that the regimens including rifampin, isoniazid and streptomycin or enviomycin were really effective in the initial treatment of lung disease caused by M avium complex.

Evidence for Destruction of Lung Tissues During Pneumocystis carinii Infection

Five cases of Pneumocystis carinii infection with evidence of lung tissue destruction that occurred in patients with the acquired immunodeficiency syndrome were reviewed. None of the patients had a history of cigarette smoking, but all five had either cavitarylike lesions in the lungs or had pneumothorax at the time of presentation to the hospital. All patients had P carinii identified in specimens obtained either from bronchial washings or from open-lung biopsy. In four of the five patients, no other pathogens were involved in the lungs, while the fifth patient had concomitant cytomegalovirus infection. Findings on chest roentgenograms included large thin-walled cavitarylike lesions, multiple cavitary lesions, or pneumothorax. These presentations of the infection have not been previously described, and the mechanisms for lung tissue damage are as yet unknown. Cavitary lung disease found on chest roentgenograms in patients should not exclude the diagnosis of P carinii pneumonia, and patients with the acquired immunodeficiency syndrome presenting with pneumothorax should have the possibility of P carinii infection included in the differential diagnosis.

Evidence for destruction of lung tissues during Pneumocystis carinii infection

• Five cases of<i>Pneumocystis carinii</i>infection with evidence of lung tissue destruction that occurred in patients with the acquired immunodeficiency syndrome were reviewed. None of the patients had a history of cigarette smoking, but all five had either cavitarylike lesions in the lungs or had pneumothorax at the time of presentation to the hospital. All patients had<i>P carinii</i>identified in specimens obtained either from bronchial washings or from open-lung biopsy. In four of the five patients, no other pathogens were involved in the lungs, while the fifth patient had concomitant cytomegalovirus infection. Findings on chest roentgenograms included large thin-walled cavitarylike lesions, multiple cavitary lesions, or pneumothorax. These presentations of the infection have not been previously described, and the mechanisms for lung tissue damage are as yet unknown. Cavitary lung disease found on chest roentgenograms in patients should not exclude the diagnosis of<i>P carinii</i>pneumonia, and patients with the acquired immunodeficiency syndrome presenting with pneumothorax should have the possibility of<i>P carinii</i>infection included in the differential diagnosis. (<i>Arch Intern Med</i>1987;147:746-749)

Pulmonary cavitation following pulmonary infarction.

Cavitation following bland pulmonary infarction is not commonly considered in the differential diagnosis of cavitary lung disease. In a 4-year period we have found 10 cases of cavitating pulmonary infarction (CPI) by reviewing serial chest radiographs from autopsies with pulmonary infarction and in all cases with positive ventilation-perfusion lung scans. We have compared these cases to 31 previously reported cases in the English literature that met our criteria for CPI. In our 10 patients, there were 12 radiographic cavities; 5 in the upper lobes, 5 in the lower lobes and 2 in the middle lobe. This distribution was consistent with a relative upper-lobe predominance in the literature review. In nine patients the cavitation appeared rapidly (mean, 5 days) and was associated with fever, purulent sputum, and leukocytosis. Sputum cultures were obtained in eight patients, revealing Pseudomonas aeruginosa and Escherichia coli in three each and Proteus species in two. In four patients, pulmonary infarction was not considered and the diagnosis was made at autopsy, a situation also common in previously reported cases. We have seen a high incidence of CPI in a retrospective review of patients with pulmonary infarction, and we believe that it is important to consider this diagnosis when evaluating cavitary lesions.

The Many Faces of Pulmonary Aspergillosis

The recognition of aspergillus in all its clinical disguises remains a challenge to clinicians in all fields of medicine. Fortunately, aspergillus has low pathogenicity for humans and requires very heavy inoculum of spores (aspergillary pneumonitis) in order to infect those whose pulmonary defense mechanisms, inherent structure, and physiology are intact. Patients with problems from aspergillus may be seen in either inpatient or outpatient clinical practice. The patient with fibrotic or cavitary lung disease finds himself at risk to be colonized and develop an aspergilloma (fungus ball). Conservative therapy (that is, antibiotics, pulmonary hygiene) or simple observation is often all that is required. With significant hemoptysis, surgical removal could be definitive treatment; but these patients often have such compromised pulmonary function that alternative therapies like infusion of antifungal agents locally are tempting. Part of the problem of the patient with asthma or COPD may actually be secondary to hypersensitivity to aspergillus (ABPA), which exacerbates bronchospasm and adds "pulmonary infiltrates" to the underlying disease. The recognition of this entity and then the judicious use of corticosteroids to control the symptoms will stabilize the clinical course of the disease. The immunocompromised patient may be relatively free of pulmonary disease.; but aspergillus, waiting until cytotoxic agents, corticosteroids, granulocytopenia, broad-spectrum antibiotics, and previous pneumonias destroy the local lung defense mechanisms, will then attack with a vengeance. The resultant invasive pulmonary aspergillosis requires treatment with amphotericin B, along with its own inherent toxicity.

Utility of Pneumonotomy in the Treatment of Cavitary Lung Disease

Three patients were judged to be prohibitive operative risks despite the need for urgent drainage of cavitary pulmonary lesions. Cavernostomy was performed in each case, with a satisfactory long-term outcome in two patients. The third patient recovered from his pulmonary insult, but died much later, secondary to an unrelated illness. One patient had a purulent lung abscess due to aspiration, one had atypical tuberculosis resistant to all antibiotics, and the third patient experienced massive hemoptysis from a tuberculous cavity. Two-stage procedures were utilized in the first two patients, while urgent operation in the third patient was facilitated by adhesions from a previous thoracotomy and pleural infection. Care must be taken to minimize endobronchial and pleural contamination by meticulous attention to detail during the performance of percutaneous tube drainage. There are relatively few indications for percutaneous drainage of cavitary pulmonary lesions in this antibiotic era. However, certain clinical situations should prompt consideration for a pneumonotomy. These include a severely septic or debilitated patient who is unresponsive to medical management, the presence of resistant pathogens in a compromised host, and the presence of severe adhesive pleuritis which may prohibit an expeditious thoracotomy and resection for massive hemoptysis.

Differentiation of tuberculous from nontuberculous cavitary lung disease.

Tuberculous and nontuberculous cavitary lung disease is often initially misdiagnosed, delaying therapy. To identify findings which might help avoid such delays, we performed a retrospective review of all patients admitted to two community hospitals over a 6-year period for infectious cavitary disease of the upper lobe or apical segment of the lower lobe. 10 patients with tuberculosis and 16 with nontuberculous infections were identified. Delays in initiating therapy were common to both. Most signs and symptoms were nonspecific. The mean duration of symptoms was greater in tuberculosis (72 days) compared to nontuberculous infections (18 days). Putrid sputum was found only in nontuberculous infections (11/16). Roentgenographic features of fibronodular infiltration and atelectasis occurred only in tuberculosis. Air fluid levels were seen only in nontuberculous disease (10/16). Leukocytosis with immature neutrophils was found only in patients with nontuberculous cavities. We conclude that the previously described clinical, laboratory, and roentgenographic features may be useful in correctly diagnosing infectious cavitary lung disease.

Aspergillosis in 25 Renal Transplant Patients: Epidemiology, Clinical Presentation, Diagnosis, and Management

In immunocompromised renal transplant patients, aspergillosis can be a life-threatening opportunistic infection. During an 8-year period, 25 renal transplant recipients at the University of Minnesota Hospitals developed unequivocal invasive aspergillosis that occurred in epidemic-like patterns in immunocompromised patients throughout the hospital. The premortem diagnosis was made in only 14 of the 25 patients. Seventeen patients died, and three of the eight survivors lost their allografts. The prognosis was dependent upon the clinical pattern of illness: three clinical patterns emerged: (1) cavitary lung disease, (2) diffuse pulmonary disease, and (3) central nervous system disease. All patients in the latter two categories died. The best results were with those patients treated with both amphotericin B and excision of cavitary lung lesions. All three patients treated in this manner survived with functioning grafts. Traditionally, sputum cultures have been thought to be unreliable because Aspergillus is a common colonizer of the upper respiratory tract and a contaminant in laboratories. In this study, false positive sputum cultures were common. A positive sputum culture can be helpful, however, all patients with two positive sputum cultures proved to have invasive aspergillosis. In addition, 86% of patients with positive sputum cultures who were clinically ill proved to have invasive infection. Bronchoscopy is a useful technique to follow up a positive sputum culture or investigate negative sputum cultures with typical clinical patterns. Routine bronchoscopy, unfortunately, also yields a high incidence of false positive cultures. Since the use of covered brush bronchoscopy technique, however, no false positive transbronchial cultures have been found. Transbronchial biopsy is a useful adjunct and is proof of the presence of invasive disease when the results are positive. However, false negative results are also found. Overall, the highest diagnostic yield is obtained both with transbronchial lung biopsy and covered brush bronchoscopy culture. All eight patients with both these procedures were correctly identified as having invasive pulmonary aspergillosis.

Cavitary Pulmonary Sarcoidosis

A 25-year-old woman was initially seen with hilar adenopathy and bilateral cavitary lesions. No cause for these roentgenographic abnormalities other than sarcoidosis could be determined. In contrast to what is usually found in acute sarcoidosis, the bronchoalveolar lavage fluid from this patient contained a normal number of lymphocytes and an increased number of multinucleated giant cells. These findings raise the possibility that patients with acute sarcoidosis and cavitation have an atypical form of this disease. Even though cavitation in acute sarcoidosis is rare, this disorder must be considered in making the differential diagnosis of cavitary lung disease.

Progressive lung disease in a malt-worker.

We described a malt-worker whose initial symptoms suggested extrinsic allergic alveolitis. The ensuing cavitating lung disease, Aspergillus fumigatus infection with mycetomata, vigorous immune response, and granulomatous liver disease are unusual features.

Histoplasmosis follow-up

Indianapolis' histoplasmosis outbreak appears to be over, but Indiana University School of Medicine investigators are urging physicians to be alert for long-term sequelae. The 1978-1979 outbreak claimed 15 lives ( JAMA [MEDICAL NEWS] 242:1010, 1979). Before it subsided, 435 histoplasmosis cases were confirmed serologically. The actual total may be much higher, says L. Joseph Wheat, MD, because persons with few or no symptoms were unlikely to see a physician. Wheat is an assistant professor of medicine, Division of Infectious Diseases, at the medical school, which cooperated with local, state, and federal officials in the investigation. He and co-workers are reminding area physicians that possible sequelae of histoplasmosis include fibrous mediastinitis, constrictive pericarditis, chronic obstructive, fibrotic, or cavitary lung disease, presumed ocular histoplasmosis ( JAMA [MEDICAL NEWS] 243:626-627, 1980), and, of course, recurrent histoplasmosis, which may be caused by fluctuations in the infected person's immunity to Histoplasma capsulatum . The source of the Indianapolis