Concurrent Pulmonary Infection Research Articles

Pneumonia caused by Enterococcus faecalis and tropical candida in a maintenance hemodialysis patient concomitant with COVID-19: A case report and literature review [RETRACTED

Rationale: Maintenance hemodialysis (MHD) represents a crucial form of renal replacement therapy for patients suffering from end-stage renal disease. These MHD individuals are especially susceptible to pulmonary infections due to compromised immune defenses. High throughout metagenomic sequencing technologies allow for the precise identification of pathogens at the genetic level, leading to personalized treatment plans that improve patient outcomes. This case represents the first reported instance of a mixed pulmonary infection with Enterococcus faecium and Candida tropicalis in a MHD man concomitant with coronavirus disease 2019 (COVID-19), which responded well to anti-infection treatment. The objective of this article is to enhance comprehension of concurrent pulmonary infections in individuals undergoing MHD and to enhance the capability for prompt detection and differential diagnosis. Patient concerns: A MHD man who developed COVID-19 and subsequently experienced recurring chills, high fever, coughing, expectoration, and difficulty breathing after a week. Laboratory analyses indicated elevated markers of inflammation, while a computed tomography scan detected inflammation in both of the patient’s lungs. Diagnosis: Chronic kidney disease stage V, pneumonia, and COVID-19. Interventions: Following initial treatment with a wide range of antibiotics guided by blood and sputum cultures, there was no improvement in the patient’s health. Further examination of the bronchoalveolar lavage fluid through metagenomic next-generation sequencing revealed the exact pathogens responsible for the infection. Outcomes: We lead to a tailored antimicrobial treatment plan that significantly alleviated the patient’s pulmonary inflammation and overall symptoms. The patient’s body temperature reverted back to its normal range, with an absence of any notable coughing or sputum generation. Additionally, there was a marked decrease in inflammatory markers. Furthermore, a chest computed tomography scan exhibited enhanced absorption of pulmonary lesions in comparison to previous scans. Lessons: The greater risk and mortality of pneumonia in MHD patients have not received adequate attention. Such uncommon cases require heightened awareness among clinicians to prevent delays in diagnosis and treatment.

Analysis of risk factors for pulmonary infection in acute ischemic stroke patients following intravenous thrombolysis with alteplase.

To identify the risk factors for pulmonary infection in acute ischemic stroke patients treated with intravenous thrombolysis using alteplase. A retrospective analysis was conducted on 110 acute ischemic stroke patients who received intravenous alteplase thrombolysis between January 2019 and November 2022. The patients were categorized into a pulmonary infection group (40 cases) and a non-infection group (70 cases). Multivariate logistic regression analysis identified the following independent risk factors for pulmonary infection: age, National Institutes of Health Stroke Scale (NIHSS) score at admission, underlying lung disease, hypertension, mechanical ventilation, aspiration, confusion, and elevated C-reactive protein (CRP) levels (all P<0.05). The sensitivity and specificity of CRP ifor predicting pulmonary infection were 88.57% and 75.00%, respectively. The NIHSS score demonstrated a sensitivity of 87.14% and a specificity of 70.00%. Further stratification of patients into a good prognosis group (75 cases) and a poor prognosis group (35 cases) revealed that high NIHSS scores at admission, increased fibrinogen (FIB) levels, a thrombolysis window exceeding 3 hours, and concurrent pulmonary infection were independent risk factors for poor prognosis. The area under the ROC curve for NIHSS in predicting prognosis was 0.890, and for FIB, it was 0.854 (P<0.001). The sensitivity and specificity of NIHSS for predicting poor prognosis were 89.33% and 82.86%, respectively, while for FIB, they were 84.00% and 82.86%. These findings indicate that factors such as age, NIHSS score, underlying lung disease, hypertension, and elevated CRP levels significantly contribute to the risk of pulmonary infection in acute ischemic stroke patients. Clinicians should closely monitor these values to manage the risk of pulmonary infection effectively.

Diffuse alveolar hemorrhage after hematopoietic cell transplantation- response to treatments and risk factors for mortality.

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.

Unilateral epididymal tuberculosis with scrotal fistula: a case report

Tuberculosis (TB) affects millions of people globally every year. Although TB is predominantly a lung infection, it can affect almost any organ system in the body. Therefore, the presentation can be highly variable. Extrapulmonary TB accounts for up to 25% of all reported TB cases, and lymphoreticular and genitourinary systems are the most frequently affected. However, male genital TB infection is a rare phenomenon. A clear majority of patients with male genital TB have a concurrent pulmonary infection. We report a male patient presenting with features suggestive of usual epididymo-orchitis who later developed a frank abscess perforation through a scrotal fistula despite repeated antibiotic courses. He was later diagnosed to have epididymal TB without lung involvement. Clinicians need to be vigilant of tuberculous infection when the accepted treatment of bacterial infections invokes poor responses, especially in areas with TB endemicity.

A RARE CASE OF TRIPLE PNEUMONIA: TB, COCCIDIOIDOMYCOSIS, AND COVID-19

TYPE: Late Breaking Case Report TOPIC: Chest Infections INTRODUCTION: This is a case of concurrent pulmonary infections with mycobacterial tuberculosis, coccidioidomycosis, and SARS-COV-2 in an otherwise immunocompetent host. CASE PRESENTATION: A 62-year-old male with no known medical history presented with three weeks history of worsening non-productive cough, dyspnea and pleuritic chest pain with associated small volume hemoptysis, twelve-pound weight loss, intermittent fevers and night sweats. The patient’s vital signs were normal except for a temperature of 38.2C. Physical exam showed a well-nourished man with no abnormal findings. Initial labs were significant for pancytopenia, a positive COVID PCR nasopharyngeal swab, and negative HIV. Chest x-ray showed bilateral opacities and a subsequent computed tomography angiogram of chest showed bilateral multiple thick-walled cavitating lung lesions in the upper lobes and bilateral scattered ground glass opacities suggestive of COVID pneumonia. Further work-up resulted in induced sputum showing acid fast bacilli which speciated Mycobacterium tuberculosis 3 weeks later. Serology revealed positive IgM antibodies to Coccidioides by quantitative immunodiffusion and negative IgG by complement fixation. Cocci-Direct PCR was negative twice. Fungal culture from induced sputum grew Paecilomyces formosus. DISCUSSION: The patient likely had both these conditions and more recently acquired SARS-COV-2. There is no literature regarding a triple infection but, an excellent case series was done by Cadena et al that looked at 44 cases of PTB/Coccidioidomycosis co-infection. They found a significantly higher mortality rate compared to monoinfection. Such a coinfection in a patient with severe COVID-19 could become potentially devastating. CONCLUSIONS: Treatment was initiated with rifampin, isoniazid, pyrazinamide, ethambutol, and fluconazole. He was discharged in good health. DISCLOSURE: Nothing to declare. KEYWORD: Coccidioidomycosis

Establishment of a Risk Prediction Model for Pulmonary Infection in Patients with Advanced Cancer.

Objective Based on clinical data, the risk prediction model of pulmonary infection in patients with advanced cancer was established to predict the risk of pulmonary infection in patients with advanced cancer, and intervention measures were given in advance. Methods The clinical data of 2755 patients were divided into infection group and control group according to whether they were complicated with lung infection. 1609 patients' data from January 2016 to December 2018 served as the training set, and 1166 patients' data from January 2019 to December 2020 served as the testing set. Demographics, whether the primary cancer was lung cancer, lung metastasis, the pathological classification of lung cancer patients, the number of metastases, history of surgery, history of chemotherapy, history of radiotherapy, history of central venous catheterization, history of hypertension, diabetes, and whether with myelosuppression were recorded. The presence of concurrent pulmonary infection was recorded and defined as the primary outcome variable. Stepwise forward algorithms were applied to informative predictors based on Akaike's information criterion. Multivariable logistic regression analysis was used to develop the nomogram. An independent testing dataset was used to validate the nomogram. Receiver-operating characteristic curves and the Hosmer-Lemeshow test were used to assess model performance. Results The sample included 2755 patients with advanced cancer. An independently validated dataset included 1166 patients with advanced cancer. In the training dataset, gender, age, lung cancer as primary cancer, the pathological classification of lung cancer patients, history of chemotherapy, history of radiation therapy, history of surgery, the number of metastases, presence of central venous catheterization, and myelosuppression were identified as predictors and assembled into the nomogram. The area under curve demonstrated adequate discrimination in the validation dataset (0.77; 95% confidence interval, 0.74 to 0.79). The nomogram was well calibrated, with a Hosmer-Lemeshow χ2 statistic of 12.4 (P = 0.26) in the testing dataset. Conclusions The present study has proposed an effective nomogram with potential application in facilitating the individualized prediction of risk of pulmonary infection in patients with advanced cancer.

Predictive Values of sTREM-1, PCT and CRP for Multiple Trauma-Induced Acute Respiratory Distress Syndrome Complicated with Pulmonary Infection.

The aim is to investigate the predictive values of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), procalcitonin (PCT) and C-reactive protein (CRP) for multiple trauma-induced acute respiratory distress syndrome (ARDS) complicated with pulmonary infection. One hundred and twelve patients with multiple trauma-induced ARDS admitted from April 2019 to April 2021 were selected and divided into infection group (n = 49) and non-infection group (n = 63). Their general data and laboratory test indicators were compared. Multivariate logistic regression analysis was utilized to identify the influencing factors for concurrent pulmonary infection. Pearson's analysis was employed to analyze the correlations of sTREM-1, PCT, and CRP with other influencing factors. The predictive values of sTREM-1, PCT, and CRP for pulmonary infection in ARDS patients were evaluated using receiver operating characteristic (ROC) curves. Based on the cutoff values, the patients were assigned to low-, medium-, and high-risk groups. Survival curves were plotted by Kaplan-Meier method to compare the 28-day survival. The infection group had significantly higher injury severity score (ISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, sTREM-1, PCT, CRP, and macrophage inflammatory protein (MIP)-1α, longer tracheal intubation time and intensive care unit (ICU) stay time, and lower oxygenation index than those of the non-infection group (p < 0.05). Multivariate logistic regression analysis revealed that increased ISS, APACHE II score, as well as elevated blood concentrations of sTREM-1, PCT, CRP and MIP-1α were risk factors for concurrent pulmonary infection (p < 0.05). sTREM-1, PCT, and CRP were positively correlated with ISS, APACHE II score, and MIP-1α (p < 0.05). The areas under ROC curves of sTREM-1, PCT, CRP, and their combination were 0.795, 0.784, 0.756, and 0.860, respectively (p < 0.001), indicating high predictive values. The survival rate of the high-risk group (46.43%) was significantly lower than those of the low-risk group (89.58%) and medium-risk group (75.00%) (p < 0.05). sTREM-1, PCT, and CRP are highly expressed in serum of patients with multiple trauma-induced ARDS complicated with pulmonary infection. The combined detection of three markers is of high predictive value.

Clinical features of tuberculous lymphadenitis in a low-incidence country

BackgroundTuberculous lymphadenitis (TBLA) is the most common extrapulmonary manifestation of tuberculosis (TB) in Denmark. However, the clinical features of patients with TBLA have never been systematically studied in this setting. MethodsPatients treated for TBLA in Central Region Denmark from 2007 to 2016 were identified using the national TB surveillance register and The Danish Hospital Patient Registry. Data of clinical characteristics and treatment were extracted from hospital records. ResultsEighty-three TBLA patients were identified. The median age was 32 years (IQR 23–42); 71 (85.5%) were migrants; 58 (69.9%) presented with cervical lymphadenopathy; and 45 (54.2%) had one or more systemic TB symptom such as fever, chills, night sweats, fatigue, and weight loss. Sixty-five patients had no comorbidities (78.3%). HIV co-infection was seen in five (7.2%) of the 69 who were tested for HIV. Abscesses and/or draining sinuses were noted in 13 (15.7%) patients and 15 (18.1%) had concurrent pulmonary infection. The median time from first hospital contact to treatment initiation was 42 days (IQR 16–82) and admitted patients were hospitalised for a median of 7 days (IQR 3–13.5). For 24 patients (28.9%), lymph node material was not sent for mycobacterial culture and 52 (62.7%) had microbiologically confirmed TB. Treatment outcome was successful for 70 patients (84.3%). ConclusionIn Denmark, TBLA is mainly seen among young and previously healthy migrants presenting with cervical lymphadenopathy and sparse systemic symptoms. The diagnosis is often considerably delayed and not microbiologically verified, implying diagnostic difficulties. Treatment outcome needs to be improved.

PULMONARY COINFECTION BY Pneumocystis jiroveci, Cryptococcus neoformans AND CYTOMEGALOVIRUS IN HIV PATIENT WITHOUT ANTIRETROVIRAL TREATMENT

Pulmonary diseases are among the main causes of morbidity and mortality in HIV patients. Here, we present the fatal case of a 30 year-old AIDS patient, who did not undergo antiretroviral treatment, presenting pulmonary coinfection by Pneumocystis jiroveci, Cryptococcus neoformans and Cytomegalovirus diagnosed in the postmortem histological examination. Concurrent pulmonary infection by these three agents is not common and, to date, apparently had not been reported in the literature.

Pneumocystis Pneumonia in Patients with Autoimmune Diseases: A Retrospective Study Focused on Clinical Characteristics and Prognostic Factors Related to Death.

BackgroundWith the increasing use of immunosuppressive agents, the number of opportunistic infections has risen in patients with autoimmune diseases. Pneumocystis pneumonia (PCP) is one of these opportunistic infections that have a high mortality rate. However, only a few studies have described PCP in these patients, and these studies are limited in scope. We conducted this retrospective study to describe the clinical characteristics and factors associated with outcomes of PCP in patients with autoimmune diseases.MethodsA retrospective study was performed in laboratory diagnosed PCP patients with autoimmune diseases in an academic hospital over a 10-year period. Patients with human immunodeficiency virus (HIV) infection were not included. Clinical characteristics were collected and the factors related to death were analysed.ResultsA total of 69 patients with PCP during the study period were included. Common clinical features included fever (81%), cough (56%), and dyspnea (35%). Ground glass opacity (81%) and reticulation (52%) were the most common radiological findings. Concurrent pulmonary infections including bacterium, aspergillus and cytomegalovirus were found in 34% of the patients. The overall in-hospital mortality rate was 32%. High mortality was associated with lower PaO2/FiO2 ratios and albumin levels. The lymphocyte count, CD4+ T cell count, previous usage of immunosuppressive agents, the duration and dose of glucocorticoids did not affect the outcome.ConclusionsThe mortality rate in PCP patients with autoimmune diseases is high. Low PaO2/FiO2 ratios and albumin levels are independent prognostic factors of mortality.

The impact of concomitant pulmonary infection on immune dysregulation in Pneumocystis jirovecii pneumonia.

BackgroundConcurrent infection may be found in Pneumocystis jirovecii pneumonia (PJP) of non-acquired immunodeficiency syndrome (AIDS) patients, however, its impact on immune dysregulation of PJP in non-AIDS patients remains unknown.MethodsWe measured pro-inflammatory cytokines including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-8, IL-17, monocyte chemoattractant protein-1 (MCP-1) and anti-inflammatory cytokines including IL-10 and transforming growth factor (TGF)-β1 and IL-1 receptor antagonist (IL-1RA) and inflammatory markers including high mobility group box 1, Krebs von den Lungen-6, receptor for advanced glycation end product, advanced glycation end product, surfactant protein D in bronchoalveolar lavage fluid (BALF) and blood in 47 pure PcP and 18 mixed PJP and other pulmonary infections (mixed PJP) in non-AIDS immunocompromised patients and explored their clinical relevance. The burden of Pneumocystis jirovecii in the lung was determined by counting number of clusters of Pneumocystis jirovecii per slide and the concentration of β-D-glucan in BALF. PJP severity was determined by arterial oxygen tension/fraction of inspired oxygen concentration ratio, the need of mechanical ventilation and death.ResultsCompared with pure PJP group, mixed PJP group had significantly higher BALF levels of IL-1β, TNF-α and IL-8 and significantly higher blood levels of IL-8. The BALF ratios of TNF-α/IL-10, IL-8/IL-10, IL-1β/IL-10, TNF-α/TGF-β1, IL-8/TGF-β1, IL-1β/TGF-β1 and IL-1β/IL-1RA were significantly higher in mixed than in pure PJP patients. There was no significant difference in clinical features and outcome between pure and mixed PJP groups, including inflammatory biomarkers and the fungal burden. In pure PJP patients, significantly higher BALF levels of IL-8 and the ratios of IL-8/IL-10, IL-1β/TGF-β1, MCP-1/TGF-β1, MCP-1/IL1RA and IL-8/TGF-β1 were found in the patients requiring mechanical ventilation and in non-survivors.ConclusionsIn summary, concurrent pulmonary infection might enhance immune dysregulation of PJP in non-AIDS immunocompromised patients, but did not affect the outcome as evidenced by morbidity and mortality. Because of limited number of cases studied, further studies with larger populations are needed to verify these issues.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2466-14-182) contains supplementary material, which is available to authorized users.

A Minimally Invasive Technique for Occluding Large Muscular Ventricular Septal Defects in Infants

Objective: This study investigated the feasibility, timing and indications for closure of large muscular ventricular septal defects (VSDs) in infants without use of a cardiopulmonary bypass. Methods: A total of 9 infants with large muscular VSDs ranging in size from 7 to 15 mm were treated by minimally invasive closure without cardiopulmonary bypass between April 2010 and February 2013. Results: All surgeries were successful without resulting in uncontrolled systemic infection, a pulmonary hypertensive crisis or a severely low cardiac output, and with an apparently shorter operation time and postoperative tracheal cannula. Conclusions: VSD closure without cardiopulmonary bypass can improve the efficacy and prognosis of infants with large muscular VSDs and concurrent pulmonary infections or respiratory failure.

Answer to September 2013 Photo Quiz

Answer: Concurrent pulmonary infection with both Pneumocystis jirovecii and Histoplasma capsulatum var. capsulatum. The figure in the photo quiz shows a macrophage containing a cluster of Pneumocystis jirovecii trophic forms and one spore of Histoplasma capsulatum. Small trophic forms are about 1.5 to 2 μm in size, with acidophilic nuclei that are clearly identified on the figure, contrary to cytoplasmic shapes that are irregular. The distinctive oval spore, about 2 to 3 μm in size, containing an uncolored vacuole which reduces fungal cytoplasm to a tiny arc, makes it possible to diagnose putative histoplasmosis. This macrophage was the only one that contained both a spore of H. capsulatum and P. jirovecii trophic forms. Two other macrophages containing one spore of H. capsulatum in the absence of P. jirovecii were detected on one slide, indicating the presence of a low fungal burden in the lungs. Cultures of skin biopsy specimens were positive after only 10 days, revealing H. capsulatum, whereas bronchoalveolar lavage (BAL) specimen culture, stored at room temperature, was positive 8 weeks after BAL retrieval, consistent with disseminated histoplasmosis of pulmonary origin. Treatment with liposomal amphotericin B (3 mg/kg/day) followed by itraconazole (200 mg/day) as a secondary prophylaxis provided clinical improvement and absence of relapse until at least January 2005, the month of the patient's departure to another French city. This observation emphasizes the risk of overlooking histoplasmosis in cases of low fungal burden. This low burden, combined with slow fungal growth and the absence of a trained microscopist in an area where histoplasmosis is not endemic, was the cause of a delayed diagnosis. The absence of specific treatment led to dissemination from the lungs. There is evidence that the infection was due to reactivation of latent spores acquired at least 16 months earlier in Martinique. This overseas French territory is an area where histoplasmosis is endemic, in which (i) the incidences of AIDS and histoplasmosis in human immunodeficiency virus (HIV)-infected patients are 0.4/100,000 patients and 1.7% of patients, respectively (1), and (ii) Pneumocystis pneumonia (PCP) and disseminated histoplasmosis represent AIDS-defining illnesses (1, 2). Nonetheless, in Martinique and other areas of endemicity, occurrence of concurrent histoplasmosis and pneumocystosis in AIDS patients has been cited in about 15 instances (3–6) and has not been histologically described until now. (See page 2809 in this issue [doi:10.1128/JCM.01466-12] for photo quiz case presentation.)

Influenza A Virus Infection Impairs Mycobacteria-Specific T Cell Responses and Mycobacterial Clearance in the Lung during Pulmonary Coinfection

Individuals infected with mycobacteria are likely to experience episodes of concurrent infections with unrelated respiratory pathogens, including the seasonal or pandemic circulating influenza A virus strains. We analyzed the impact of influenza A virus and mycobacterial respiratory coinfection on the development of CD8 T cell responses to each pathogen. Coinfected mice exhibited reduced frequency and numbers of CD8 T cells specific to Mycobacterium bovis bacille Calmette-Guérin (BCG) in the lungs, and the IFN-γ CD8 T cell response to BCG-encoded OVA was decreased in the lungs of coinfected mice, when compared with mice infected with BCG alone. Moreover, after 2 wk of infection, mice coinfected with both pathogens showed a significant increase in the number of mycobacteria present in the lung compared with mice infected with BCG only. Following adoptive transfer into coinfected mice, transgenic CD8 T cells specific for OVA(257-264) failed to proliferate as extensively in the mediastinal lymph nodes as in mice infected only with BCG-OVA. Also noted was a reduction in the proliferation of BCG-specific CD4 transgenic T cells in mice coinfected with influenza compared with mice infected with BCG alone. Furthermore, phenotypic analysis of CD11c(+) dendritic cells from mediastinal lymph nodes of the infected mice showed that coinfection was associated with decreased surface expression of MHC class II and class I. Thus, concurrent pulmonary infection with influenza A virus is associated with decreased MHC expression on dendritic cells, reduced activation of BCG-specific CD4 and CD8 T cells, and impaired clearance of mycobacteria.

Pulmonary tuberculosis in AIDS patients: transient chest radiographic worsening after initiation of antiretroviral therapy.

Immune function and inflammatory responses often increase in AIDS patients who receive antiretroviral therapy. We evaluated the occurrence and nature of transient worsening on chest radiographs in AIDS patients with tuberculosis after initiation of antiretroviral therapy and compared these findings with chest radiographs of patients undergoing antituberculous therapy alone. A retrospective review of sequential chest radiographs was performed of 87 patients undergoing therapy for pulmonary tuberculosis: AIDS patients receiving antiretroviral therapy (n = 31), HIV-positive patients not receiving antiretroviral therapy (n = 26), and HIV-negative patients (n = 30). Pulmonary consolidations, thoracic lymphadenopathy, and pleural effusions were evaluated for worsening, stability, or improvement. Patients with concurrent pulmonary infections were excluded. Transient worsening on radiography was observed in 14 (45%) of 31 AIDS patients receiving antiretroviral therapy, including seven patients (23%) who showed severe worsening. Of 56 patients in the other two groups, 11 (20%) showed worsening (p = 0.023), two of whom showed severe worsening (p = 0.009). Worsening was first noted between 1 and 5 weeks after initiation of antiretroviral therapy, with improvement occurring between 2 weeks and 3 months later. Four patients with severe worsening converted their tuberculin purified protein derivative responses from anergic to positive after antiretroviral treatment. Transient worsening is frequently seen on chest radiography in AIDS patients with tuberculosis who subsequently undergo antiretroviral therapy. This phenomenon may be related to improved immune function.

Pulmonary Alveolar Proteinosis in an AIDS Patient without Concurrent Pulmonary Infection

Patients with acquired immunodeficiency syndrome (AIDS) are potentially at increased risk for developing secondary pulmonary alveolar proteinosis because of underlying immunosuppression and frequent opportunistic lung infections. This condition. however, has been diagnosed uncommonly in these patients and, with the exception of one previously reported case. only in the presence of concurrent pulmonary infection. The case of a 35-year-old male with AIDS who was found on open lung biopsy to have pulmonary alveolar proteinosis without evidence of associated lung infection is presented.

Early Predictors of In-Hospital Mortality for Pneumocystis carinii Pneumonia in the Acquired Immunodeficiency Syndrome

To the Editor. —In the August 1987 issue of theArchives, Kales et al 1 analyzed clinical and laboratory data in 145 patients with Pneumocystis carinii pneumonia (PCP). They identified the following variables that were associated with increased in-hospital mortality: multiple admissions, leukocytosis, elevated lactic dehydrogenase levels, decreased oxygen pressure (tension) and carbon dioxide (tension), decreased serum albumin levels, and concurrent pulmonary infections. Patients with normal respiratory rates and normal chest examinations had increased survival rates. The authors fail to indicate the drugs that were used to treat the patients. Sulfamethoxazole and trimethoprim and pentamidine are both effective in treating PCP. However, the use of sulfamethoxazole and trimethoprim should be avoided in patients with a history of allergy to its components or patients who require fluid restriction, since intravenous administration requires at least 1200 mL of fluid daily. Sulfamethoxazole and trimethoprim is the drug of choice in patients with preexisting

Disseminated coccidioidomycosis in children

In an effort to define the importance of extrapulmonary coccidioidomycosis in the pediatric age group, we have studied 14 cases and reviewed the literature. The available data suggest that children are as susceptible to dissemination as are adults. Most children with disseminated coccidioidomycosis have evidence, either by history or chest radiographs, of preceding or concurrent pulmonary infection. The most common sites of dissemination are skin, subcutaneous tissue, bone, and meninges. Coccidioides immitis may be detected in tissues or body secretions by microscopic examination or by appropriate culture. Serologic tests are also useful in making the diagnosis and in following the course of the infection. Skin tests are often negative. Infection is progressive in 60% without antifungal therapy. Coccidioidomycosis of bone, skin, or subcutaneous tissue can be managed effectively with combined surgical and antifungal therapy. Meningitis is much more difficult to treat and is fatal in 50% of cases even when treated with amphotericin B.