Episodes Of Bacterial Pneumonia Research Articles

RECURRENT LUNG INFECTIONS IN A HETEROZYGOUS CARRIER OF NOVEL NSMCE3 MUTATION.

<h3>Introduction</h3> Several biallelic missense mutations in NSMCE3 lead to chromosome breakage syndrome (LICS), which presents with early-onset lung disease, pneumonia, B- and T- cell dysfunction and resultant death in early childhood. The protein product of NSMCE3 helps bridge and stabilize the SMC5/6 complex, which plays a crucial role in DNA double-strand break repair and is thought to help suppress viral infections. <h3>Case Description</h3> A 5-year-old male with atopic dermatitis and reactive airway disease presented for evaluation of recurrent sinopulmonary infections. In one year, he had three episodes of acute otitis media and five viral upper respiratory infections, complicated by multiple bacterial pneumonias. Initial immunologic workup showed low CD8+ T-cells that subsequently normalized. He also had marginally-low IgM, but showed intact humoral response to HiB vaccine and Pneumovax. Three years later, he experienced two more episodes of bacterial pneumonia, one requiring two rounds of antibiotics for clinical improvement. Genetic testing (Invitae Primary Immunodeficiency Panel) showed a heterozygous variant of uncertain significance, a deletion-insertion mutation of the NSMCE3 gene (nucleotides 41 and 42 are deleted and two cytosines inserted, which changes glutamine to proline at the 14th amino acid position in the protein product). <h3>Discussion</h3> In most cases, heterozygous carriers can compensate for a defective allele. Our patient has a missense mutation in one NSMCE3 allele, which may affect the protein product's conformation. Since this protein functions in DNA repair and known mutations have been associated with pneumonia and viral infections, we hypothesize that his reduced level of normal protein may underlie his recurrent pneumonias.

Plasma C3d levels as a diagnostic marker for complete complement factor I deficiency

Plasma C3d levels as a diagnostic marker for complete complement factor I deficiency

HIV Tat Protein Induces the TGF‐β Signaling Pathway and Suppresses the CFTR Biogenesis and Activity by microRNA‐Regulated Gene‐Silencing Mechanism

The advent of combination antiretroviral therapy (cART) has led to a dramatic decline in morbidity and mortality from HIV/AIDS. HIV infected subjects are still six times more likely to contract pneumonia compared to non‐infected age matched controls. Mortality, following an episode of bacterial pneumonia was also four times higher in HIV infected subjects compared to non‐infected controls. Thus, pneumonia can also contribute to HIV progression. Understanding the pathophysiological mechanisms that lead to microbial colonization of the airways in HIV infected patients is therefore important to public health. HIV Tat and CS can suppress CFTR function, which is a critical determinant of ASL depth and this can lead to depressed MCC and consequent microbial colonization. Our study showed that HIV‐infected cells in the airway namely alveolar macrophages, other immune cells or bronchial epithelial cells can serve as reservoirs and a source of HIV proteins like Tat which upregulates TGF‐beta mRNA in primary human bronchial epithelial cells with a corresponding decrease in CFTR mRNA. Chromatin immunoprecipitation with RNA Polymerase II demonstrated that transcription from the CFTR promoter is unaffected and blocking the miRNA processing pathway with Aurin Tricarboxylic acid (ATA) restore CFTR inhibition caused by TGF‐ beta. Our data showed that HIV infection suppress CFTR mRNA and function and blocking TGF‐beta signaling rescues this. Together this posits a strong role for (TGF‐beta induced) miRNA in Tat mediated CFTR gene silencing.Support or Funding InformationFlight Attendant Medical Research Institute (FAMRI)HypothesisFigure 1HIV Tat suppresses CFTR via common TGF‐beta signalingFigure 2

First lung transplant recipient of Indian armed forces

In 2010, a 22-year-old female presented with progressive breathlessness and multiple joint pain in bilateral knee and wrist joints. She was diagnosed with rheumatoid arthritis (RA) based on the clinical as well as serological criteria, and her breathlessness was attributable to RA-associated interstitial lung disease. Despite being on immunosuppressants, her lung involvement continued to progress as she got dependent on oxygen at home for 2011 and required domiciliary noninvasive ventilatory support for 2017. The prognosis was grave as the disease continued to affect her lungs relentlessly despite all possible medical therapies. Our experience with lung transplants in service hospitals was nonexistent as it was not a common practice to refer patients for lung transplant because of inadequate data of its success in our country and the mammoth cost involved. However, in view of the emerging reports of successful lung transplantation and the risk benefit ratio favoring the patient, she was referred to a lung transplant center. The patient chose to have the lung transplantation at a hospital in Chennai. On May 22, 2018, the patient underwent a successful bilateral lung transplant. She is being managed with triple immunosuppression and antimicrobial prophylaxis at her home. Over the past 1½ year, the patient has developed one episode of bacterial pneumonia which was successfully managed with antibiotics. The patient continues regular visit at our hospital as she is able to work independently of any ventilatory support. We intend to narrate the experience of first-lung transplant recipient among our clientele.

Risk of bacterial pneumonia and pneumococcal infection in youths with celiac disease — A population-based study

ObjectiveAssess the risk of hospitalizations for bacterial pneumonia or pneumococcal infections, in a cohort of young individuals with celiac disease (CD) compared to matched references. Study designThe cohort consists of 213,635 individuals, born in 1989–2012 and resident in Friuli-Venezia Giulia (Italy). Through pathology reports, hospital discharge records or co-payment exemptions, we identified 1294 CD patients and 6470 reference individuals matched by gender and birth year. We considered hospital admissions for first episodes of bacterial pneumonia and pneumococcal infections. Hazard ratios (HRs) for episodes after CD diagnosis were calculated with Cox regression and odds ratios (OR) for the ones before CD diagnosis with conditional logistic regression. Further analyses were performed on unvaccinated follow-up periods. Results14 CD patients (in 9450 person-years) and 42 references (in 48,335 person-years) experienced a first episode of bacterial pneumonia, with an increased risk among CD patients (HR 1.82; 95%CI 0.98–3.35). Risks of bacterial pneumonia were significantly increased before CD diagnosis and especially the year before CD diagnosis (OR 6.00, 95%CI 1.83–19.66). Risks of pneumococcal infections showed a non-significant increase in CD patients. ConclusionsCD children and youth showed an increased risk of bacterial pneumonia, especially in proximity to CD diagnosis. Anti-pneumococcal vaccination should be recommended to all young CD patients.

Rituximab for remission induction in elderly patients with ANCA-associated vasculitis

ObjectivesAdvancing age is a risk factor for treatment-related side effects and mortality in AAV patients treated with cyclophosphamide (CYC) and glucocorticoids (GC) for remission induction. The efficacy and safety of rituximab (RTX) in elderly AAV patients has not been well described. MethodsWe performed a single center retrospective review of 31 consecutive AAV patients aged 60 or more at the time of RTX use for remission induction. All patients received RTX with GC for remission induction. Four patients received concomitant CYC for a mean duration of 52 days. We evaluated clinical and laboratory variables at diagnosis, rates of complete remission defined as Birmingham Vasculitis Activity Score/Wegener’s Granulomatosis (BVAS/WG) = 0 and patient survival, renal survival, infections requiring hospitalization, and vasculitis relapse 24 months following RTX use. ResultsOf the 31 patients, 77% were Caucasian, 68% female, mean age was 71 ± 6 years, 58% were MPO ANCA positive, and 42% had relapsing disease. The mean BVAS/WG score entry was 4.4 ± 1.5, 71% had glomerulonephritis (GN) and 10% had alveolar hemorrhage. The mean baseline e-GFR was 40 ± 28ml/min/1.73m2. Thirty patients achieved remission with a mean time to remission of 57 ± 27 days. The single patient with refractory vasculitis responded to CYC. The mean prednisone dose at 6 months was 5.6 ± 4mg. Remission maintenance therapy was started within 12 months of RTX induction in 6 patients (4 with RTX, 1 with azathioprine, and 1 with mycophenolate mofetil). One patient suffered a limited relapse 10 months post RTX use. Among the 22 patients with GN at baseline, 1 developed ESRD. One-year patient survival among 25 patients with at least 1 year of follow-up was 100%. There were no episodes of infusion reaction or leukopenia. There were 3 episodes of bacterial pneumonia, 1 episode of candida pneumonia, and 1 episode of disseminated cutaneous zoster. ConclusionsThis study demonstrates that rituximab is effective for remission induction in elderly patients with AAV. Furthermore, we observed a high incidence of infectious complications. Our experience was limited by its retrospective design, and further studies are needed to evaluate the efficacy and safety of RTX in elderly AAV patients.

Incidence, Timing, and Determinants of Bacterial Pneumonia Among HIV-Infected Patients

The aim of the study was to evaluate incidence and determinants of bacterial pneumonia (BP) after starting combination antiretroviral therapy (cART) in the Italian Cohort of Antiretroviral-Naive Patients. Patients free from BP at cART initiation enrolled between 1996 and 2011 were analyzed. Kaplan-Meier curves were calculated to estimate the time to the first episode of BP; uni- and multivariable Cox proportional hazard models, with time-updated covariates, were applied to identify the risk factors of the first episode of BP. Four thousand nine hundred forty-two patients were followed for a median of 63.7 months (interquartile range: 23.6, 106.7); 73% were men, median age 36 years (interquartile range: 32, 42), 35% hepatitis C virus antibody positive, 28% smokers, 15% with an AIDS diagnosis (not BP) before cART, 46% with nadir CD4⁺ T-cell count ≤200 cells per microliter. During 27,569 person years, 137 patients developed 156 BPs, for a crude incidence of 5.66 [95% confidence interval (CI): 4.81 to 6.62] per 1000 person years. The probabilities of first BP at 3, 5, 10, and 14 years from cART initiation were 2.0% ± 0.22%, 2.9% ± 0.28%, 4.3% ± 0.42%, and 5.7% ± 0.75%, respectively. The occurrence of a first BP was associated with low nadir CD4⁺ [hazard ratios (HR) (per 100 cells/μL higher) = 0.86, 95% CI: 0.79 to 0.94], low current CD4 [HR (per 100 cells/μL higher) = 0.88, 95% CI: 0.84 to 0.92], high CD8⁺ [HR (per 100 cells/μL higher) = 1.02, 95% CI: 1.01 to 1.03], low hemoglobin [HR (per g/dL higher) = 0.74, 95% CI: 0.71 to 0.78], and unfavorable virological outcome [HR (HIV-RNA >50 vs <50 copies/mL) = 1.29, 95% CI: 1.04 to 1.60] in addition to older age, male gender, non-Italian nationality, smoking, and longer time to cART initiation. BP is an infrequent clinical event in the cART era and is associated with traditional risk factors, viroimmunological failure to cART, and low hemoglobin.

Goldenhar syndrome: a cause of secondary immunodeficiency?

Goldenhar syndrome (GS) results from an aberrant development of the 1st and 2nd branchial arches. There is a wide range of clinical manifestations, the most common being microtia, hemifacial microsomia, epibulbar dermoids and vertebral malformations. We present two cases of GS and secondary immunodeficiency due to anatomical defects characteristic of this disorder. Case 1 (3-year-old female) averaged 6 episodes of sinusitis and otitis media per year. Case 2 (7-year-old female) also had recurrent otitis media, an episode of bacterial pneumonia, and 2 episodes of bacterial meningitis. Their immune evaluation included a complete blood count with differential, serum immunoglobulin levels and specific antibody concentrations, lymphocyte phenotyping, and mitogen and antigen responses, the results of which were all within normal ranges. Both children demonstrated major structural abnormalities of the inner and middle ear structures, retention of fluid in mastoid air cells, and chronic sinusitis by computed tomography. These two cases illustrate how a genetically-associated deviation of the middle ear cleft can cause recurrent infections and chronic inflammation of the middle ear and adjacent sinuses, even meninges, leading to a greatly reduced quality of life for the child and parents.

A mutation in the human Uncoordinated 119 gene impairs TCR signaling and is associated with CD4 lymphopenia

AbstractIdiopathic CD4 lymphopenia (ICL) is an immunodeficiency disorder of unclear etiology. Here we describe a heterozygous dominant-negative missense mutation (codon 22 GGC→GTC; V22G) of the signaling adaptor protein Uncoordinated 119 (Unc119) in an ICL patient. The patient is a 32-year-old female with < 300 CD4 T cells/μL and with a history of recurrent sinusitis/otitis media, frequent episodes of shingles, a widespread fungal nail infection, fungal dermatitis, oral herpetic lesions, and bronchiolitis obliterans organizing pneumonia after 2 episodes of bacterial pneumonia. The patient's cells have reduced response to TCR stimulation, with impairment in both localization and enzymatic activation of the lymphocyte-specific kinase (Lck) resulting in decreased cell proliferation. Transduction of the mutant Unc119 but not wild-type Unc119 into normal T cells reproduces the signaling and proliferation defects. The mutation disrupts the Unc119-Lck interaction which is normally needed for stimulation of the Lck catalytic activity by TCR. The mutant protein also causes mislocalization of Lck to Rab11+ perinuclear endosomes. The mutation is not present in 2 other patients with ICL, patients with secondary CD4 lymphopenia or 60 healthy subjects. The V22G mutation of Unc119 represents a novel genetic defect in ICL.

A Mutation in the Human Uncoordinated 119 Gene Impairs TCR Signaling and is Associated with CD4 Lymphopenia.

Idiopathic CD4 lymphopenia (ICL) is an immunodeficiency disorder of unclear etiology. Here we describe a heterozygous dominant-negative missense mutation (codon 22 GGC→GTC; V22G) of the signaling adaptor protein Uncoordinated 119 (Unc119) in an ICL patient. The patient is a 32-year-old female with < 300 CD4 T cells/μL and with a history of recurrent sinusitis/otitis media, frequent episodes of shingles, a widespread fungal nail infection, fungal dermatitis, oral herpetic lesions, and bronchiolitis obliterans organizing pneumonia after 2 episodes of bacterial pneumonia. The patient's cells have reduced response to TCR stimulation, with impairment in both localization and enzymatic activation of the lymphocyte-specific kinase (Lck) resulting in decreased cell proliferation. Transduction of the mutant Unc119 but not wild-type Unc119 into normal T cells reproduces the signaling and proliferation defects. The mutation disrupts the Unc119-Lck interaction which is normally needed for stimulation of the Lck catalytic activity by TCR. The mutant protein also causes mislocalization of Lck to Rab11+ perinuclear endosomes. The mutation is not present in 2 other patients with ICL, patients with secondary CD4 lymphopenia or 60 healthy subjects. The V22G mutation of Unc119 represents a novel genetic defect in ICL.

Pneumonia in HIV-infected Persons

Bacterial pneumonia is a major cause of morbidity for HIV-infected persons and contributes to excess mortality in this population. To evaluate the frequency and risk factors for occurrence of bacterial pneumonia in the present era of potent antiretroviral therapy. We evaluated data from a randomized trial of episodic antiretroviral therapy. The study, Strategies for Management of Antiretroviral Therapy, enrolled 5,472 participants at 318 sites in 33 countries. Study patients had more than 350 CD4 cells at baseline. Diagnosis of bacterial pneumonia was confirmed by a blinded clinical-events committee. During a mean follow-up of 16 months, 116 participants (2.2%) developed at least one episode of bacterial pneumonia. Patients randomized to receive episodic antiretroviral therapy were significantly more likely to develop pneumonia than patients randomized to receive continuous antiretroviral therapy (hazard ratio, 1.55; 95% confidence interval, 1.07-2.25; P = 0.02). Cigarette smoking was a major risk factor: Current-smokers had more than an 80% higher risk of pneumonia compared with never-smokers (hazard ratio, 1.82; 95% confidence interval, 1.09-3.04; P = 0.02). Participants who were on continuous HIV treatment and were current smokers were three times more likely to develop bacterial pneumonia than nonsmokers. Current smoking status was significant, but a past history of smoking was not. Bacterial pneumonia is a major source of morbidity, even for persons on potent antiretroviral therapy, including those with high CD4 cells. Efforts to reduce this illness should stress the importance of uninterrupted antiretroviral therapy and attainment and/or maintenance of nonsmoking status.

Bacterial Pneumonia, HIV Therapy, and Disease Progression among HIV‐Infected Women in the HIV Epidemiologic Research (HER) Study

To determine the rate and predictors of community-acquired bacterial pneumonia and its effect on human immunodeficiency virus (HIV) disease progression in HIV-infected women, we performed a multiple-site, prospective study of HIV-infected women in 4 cities in the United States. During the period of 1993-2000, we observed 885 HIV-infected and 425 HIV-uninfected women with a history of injection drug use or high-risk sexual behavior. Participants underwent semiannual interviews, and CD4+ lymphocyte count and viral load were assessed in HIV-infected subjects. Data regarding episodes of bacterial pneumonia were ascertained from medical record reviews. The rate of bacterial pneumonia among 885 HIV-infected women was 8.5 cases per 100 person-years, compared with 0.7 cases per 100 person-years in 425 HIV-uninfected women (P < .001). In analyses limited to follow-up after 1 January 1996, highly active antiretroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) use were associated with a decreased risk of bacterial pneumonia. Among women who had used TMP-SMX for 12 months, each month of HAART decreased bacterial pneumonia risk by 8% (adjusted hazard ratio [HR(adj)], 0.92; 95% confidence interval [CI], 0.89-0.95). Increments of 50 CD4+ cells/mm3 decreased the risk (HR(adj), 0.88; 95% CI, 0.84-0.93), and smoking doubled the risk (HR(adj), 2.12; 95% CI, 1.26-3.55). Bacterial pneumonia increased mortality risk (HR(adj), 5.02; 95% CI, 2.12-11.87), with adjustment for CD4+ lymphocyte count and duration of HAART and TMP-SMX use. High rates of bacterial pneumonia persist among HIV-infected women. Although HAART and TMP-SMX treatment decreased the risk, bacterial pneumonia was associated with an accelerated progression to death. Interventions that improve HAART utilization and promote smoking cessation among HIV-infected women are warranted.

Incidence and risk factors of bacterial pneumonia requiring hospitalization in HIV‐infected patients started on a protease inhibitor‐containing regimen

To describe the incidence and risk factors of bacterial pneumonia occurring in patients treated with antiretrovirals. In the ongoing APROCO (Anti-proteases) cohort, 1281 patients at the initiation of a protease inhibitor (PI)-containing antiretroviral regimen were enrolled from 1997-1999. All events requiring hospitalization during follow up are recorded. Of these, bacterial pneumonia was defined as the occurrence of a new pulmonary infiltrate with fever and either evidence of a bacteriological cause (definite cases) or favourable outcome with antimicrobial therapy (presumptive cases). Risk factors of bacterial pneumonia were studied using survival analyses. During a median follow up of 43 months, 29 patients had at least one episode of bacterial pneumonia, giving an incidence of 0.8/100 patient years. The 11 definite cases were attributable to Streptococcus pneumoniae (n=9), Legionella pneumophila (n=1) and Haemophilus influenzae (n=1). In multivariate analysis, bacterial pneumonia was significantly more frequent in older patients, injecting drug users, patients having a CD4 cell count>500 cells/microL at baseline and patients who initiated PI therapy with nonboosted saquinavir. It was significantly less frequent in nonsmokers. The occurrence of bacterial pneumonia was also associated with lower self-reported adherence to antiretroviral therapy and to higher plasma HIV-1 RNA levels during follow-up. Bacterial pneumonia occurs rarely in patients treated with a PI-containing regimen and may be associated with virological failure.

Immunologic findings in HIV infected children with bacterial infections

Bacterial infections are a major cause of illness in HIV-infected children. HIV-infected children with severe dysfunction of cellular and humoral immunity are particularly vulnerable. We conducted a retrospective study to analyse the incidence and spectrum of bacterial infections in HIV-infected children compared to HIV-exposed but not infected controls related to their immunological status. Data collected during 1985 to May 1993 were evaluated considering 333 HIV-infected and 81 controls. During observation time 359 episodes (29% of the visits) of purulent rhinitis were diagnosed in HIV-infected children compared to the controls (53 episodes/8%); p = 0.0001. Comparable results were seen in otitis media. 178 episodes/14% were found in HIV-infected children and 66 episodes/10% in the controls (p = 0.001). 53 episodes/5% of bacterial pneumonia were represented in HIV-infected versus 11 episodes/2% in controls (p = 0.001). The increase of lymphocyte immune defect correlated to an increase of bacterial infections. This alterations were particularly observed in HIV-infected children with bacterial pneumonia. Severe dysfunction of cellular immunity was found in children with recurrent pneumonia compared to children with only one episode of bacterial pneumonia. The proliferate response of peripheral blood lymphocyte to pokeweed mitogen (13,351 cpm versus 3080 cpm); p = 0.009 and Concanavalin A (12,607 cpm versus 2470 cpm); p = 0.01 was significantly reduced in both groups, although the defect was much more pronounced in the group with the recurrent pneumonia. Our observations results showed that bacterial respiratory tract infections occurred significantly more frequently in HIV-infected children compared to an age related control group. Not only the occurrence of opportunity infections but also severe bacterial infections especially recurrent pneumonia are associated with a defect in cell-mediated immunity.

Bacterial Pneumonia in HIV

Bacterial pneumonia, though common in HIV-positive patients, has received far less research attention than PCP. This report from the six-center Pulmonary Complications of HIV Infection Study describes 237 episodes of bacterial pneumonia in a longitudinal cohort of 1130 HIV-positive …

Evaluation of Lung Function during Pulmonary Rejection and Infection in Heart-Lung Transplant Patients

Pulmonary rejection and infection are the most important complications after lung transplantation. To evaluate the diagnostic value of pulmonary function testing for early detection and discrimination of these complications, seven heart-lung recipients were examined. The diagnosis of each complication was confirmed by clinical and laboratory findings including transbronchial biopsies and bronchoalveolar lavage. Eight episodes of rejection, ten episodes of viral infection and six episodes of bacterial pneumonia were analyzed. Pulmonary rejection was associated with a significant fall in the FEV1/IVC% and the FEF50%. In viral infection, the most impressive finding was a reduction in the DCO, whereas no obstructive or restrictive airway dynamics were observed. During bacterial pneumonia, pulmonary function measurement revealed a decrease in IVC without signs of obstructive airway dynamics. Adequate treatment resulted in reconstitution of pretreatment values. Assessment of lung function provides valuable information for the diagnosis of pulmonary complications following HLTx.

Detection of Fungi and Other Pathogens in Immunocompromised Patients by Bronchoalveolar Lavage in an Area Endemic for Coccidioidomycosis

Bronchoalveolar lavage (BAL) was performed in 51 adult immunocompromised patients (30 acquired immunodeficiency syndrome [AIDS] and 21 non-AIDS) as part of an extensive diagnostic evaluation for diffuse pulmonary infiltrates. Because multiple episodes occurred in several patients, a total of 60 BALs were performed. A diagnosis of fungal pneumonia was eventually made in 12 patients (24 percent). The organism was identified in BALs from seven of the 12, including five of seven cases of cocciodoidomycosis, one of two cases of aspergillosis, and one of three cases of cryptococcosis. Among the AIDS patients, only one case of coccidioidomycosis was diagnosed, whereas six such diagnoses were made from the 25 BALs performed on the 21 non-AIDS patients. This suggests that coccidioidomycosis is not as frequent an infection in AIDS patients in this endemic area as has been suggested previously. Candida-like organisms were identified in 23 BALs, but in no case were they clinically pathogenic. Their presence correlated with oral candidiasis (p = 0.01). Twenty-seven of 29 episodes related to Pneumocystis carinii were identified by Papanicolaou-stained cytocentrifuged BAL preparations, all but two of which were in AIDS patients. In addition, BALs detected six episodes of bacterial pneumonia and three of five cases of radiation pneumonitis. Overall, the diagnostic sensitivity of BAL was 52 of 60 or 87 percent. While examination of induced sputum for the presence of Pneumocystis may eliminate the need for bronchoscopy in some AIDS patients, BAL remains an excellent diagnostic procedure in the immunocompromised patient without AIDS.

Diagnostic efficacy of a nasotracheal protected specimen brush in patients with suspected bacterial pneumonia.

The diagnostic yield and safety of a novel nasotracheal protected specimen brush (PSB) were evaluated in 15 nonintubated adult patients with suspected bacterial pneumonia. A double-catheter PSB was passed directly through the anesthetized nose and into the trachea without bronchoscopy or fluoroscopy. Endotracheal brushing was performed in less than 10 sec, and the brush was immediately processed for Gram staining and quantitative aerobic and anaerobic cultures. According to clinical follow-up and response to therapy, 11 episodes of bacterial pneumonia and five cases of nonbacterial lung disease were established. The PSB Gram stain confirmed lower respiratory sampling in all cases. The PSB cultures indicated respiratory pathogens in 9/11 (82%) cases of pneumonia, with greater than 10(3) colony-forming units (cfu)/ml in all but two specimens. All patients with pneumonia responded to specific antibiotics. All patients with nonbacterial disorders had PSB cultures of less than 10(3) CFU/ml, and their pulmonary processes improved without antibiotic therapy. The procedure was well tolerated, although two patients had transient bronchospasm or apnea. Experience with the nasotracheal PSB is limited, but the procedure appears to be a reliable and relatively safe alternative diagnostic method in selected patients with suspected bacterial pneumonia. Quantitative cultures are necessary to improve its diagnostic accuracy.

Hypogammaglobulinemia with nodular lymphoid hyperplasia of the intestine. Report of a case with rectosigmoid involvement.

In a review of Mayo Clinic patients with hypogammaglobulinemia and intestinal dysfunction, Hermans et al. (4) defined a new clinical entity. The major features included: (a) unusual susceptibility to respiratory infections, (b) gastrointestinal disorders characterized by cramps, bloating, diarrhea, and occasional steatorrhea, (c) Giardia lamblia in the stools, (d) marked decrease in gamma G immunoglobulin and the absence or virtual absence of gamma A and gamma M immunoglobulins, and (e) diffuse small bowel nodules due to hyperplastic lymphoid follicles within the submucosa. The nodular lesions have been confined to the small bowel or questionably the ascending colon in previous reports (3, 5). The present study is the first reported case of this entity with rectosigmoid involvement. R. S., a 22-year-old white male, was essentially well until otitis media developed at the age of eighteen years. Shortly thereafter, while in the Army, he had five episodes of bacterial pneumonia over a five-month period. Seru...