A.S. Rebuck

CORTICOSTEROIDS AS ADJUNCTIVE THERAPY IN TREATMENT OF PNEUMOCYSTIS CARINII PNEUMONIA IN PATIENTS WITH ACQUIRED IMMUNODEFICIENCY SYNDROME

10 patients with the acquired immunodeficiency syndrome whose respiratory failure due to Pneumocystis carinii pneumonia (PCP) was deteriorating rapidly had 7 days of intravenous methylprednisolone added to their antibiotic regimen. 8 similar patients were treated with antibiotic therapy alone. 9 of the 10 methylprednisolone-treated patients survived their episode of PCP, compared with 2 of the 8 conventionally treated patients. Clinical improvement was evident within 2 days of the start of steroid therapy, and in none of the 10 patients did clinical deterioration or recurrence of PCP occur on cessation of steroid therapy. In 1 steroid-treated patient disseminated herpes zoster developed 2 days after discontinuation of methylprednisolone. Methylprednisolone seems to be a useful adjunctive therapeutic agent for patients with AIDS in whom Pneumocystis carinii is the sole respiratory pathogen.

PREDNISONE AND METHYLPREDNISOLONE DISPOSITION IN THE LUNG

To compare the penetrability of methylprednisolone into lung tissue with that of prednisone, blood and bronchoalveolar lavage (BAL) fluid levels of methylprednisolone and prednisone were measured in 17 patients with a variety of lung diseases. To correct for variations in the quantity of lung fluid obtained by BAL, steroid levels were expressed in relation to creatinine concentrations. The level of methylprednisolone penetration in the pulmonary parenchyma, expressed by the slope of the relation between blood and BAL fluid, was 0.5 (r = 0.8; p less than 0.03). By contrast, despite serum levels of between 59 and 219 ng/ml, prednisone could not be detected in the BAL fluid in 3 patients; the overall correlation between blood and BAL fluid for all patients was r = 0.5 (slope = 0.3; p less than 0.1). Thus methylprednisolone is better able than prednisone to penetrate lung acini.

NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE IN PNEUMOCYSTIS CARINH PNEUMONIA

10 cm H2O of nasal continuous positive airway pressure (CPAP) was applied in nine subjects with Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome, all of whom had presented with bilateral pulmonary infiltrates and hypoxaemia. The procedure was tolerated well by eight patients and none of the nine had complications. 20 minutes of nasal CPAP without supplemental oxygen increased mean PaO2 from 55.9 to 68.4 mm Hg and decreased the calculated alveolar-arterial oxygen gradient from 48.3 to 34.3 mm Hg. In one patient who was breathing oxygen at 4 litres per minute, PaO2 increased by 35 mm Hg. Nasal CPAP could be a useful method for augmenting oxygenation in P carinii pneumonia.