Mario J. Saldana

Clinical Presentation and Outcome of Patients with HIV Infection and Tuberculosis Caused by Multiple-Drug-resistant Bacilli

OBJECTIVE To determine the clinical manifestations of patients with human immunodeficiency virus (HIV) infection and tuberculosis caused by multiple-drug-resistant bacilli compared with those with single-drug-resistant or susceptible bacilli. DESIGN Descriptive, case-control, and cohort studies. SETTING A large urban teaching hospital. PATIENTS Sixty-two patients with tuberculosis caused by multiple-drug-resistant bacilli (cases) and 55 patients with tuberculosis caused by single-drug-resistant or susceptible bacilli (controls). MEASUREMENTS Characteristics of clinical presentation, radiographs, pathologic abnormalities, antituberculosis treatment, and clinical course. RESULTS Twenty cases (32%) had concomitant pulmonary and extrapulmonary disease at presentation compared with 9 controls (16%; odds ratio, 2.4; 95% CI, 1.0 to 5.9). More cases had alveolar infiltrates (76%; odds ratio, 3.6; CI, 1.2 to 11.4), interstitial infiltrates with a reticular pattern (67%; odds ratio, 7.8; CI, 1.0 to 83.5), and cavitations (18%; odds ratio, 6.6; CI, 0.8 to 315.3) on initial chest radiographs compared with controls (49%, 19%, and 3%, respectively). Pathologic specimens from cases showed extensive necrosis, poor granuloma formation, marked inflammatory changes with a predominance of neutrophils, and abundant acid-fast bacilli. Twenty-five cases received two or more effective antituberculosis drugs for more than 2 months. Only 2 cases had three consecutive negative cultures for Mycobacterium tuberculosis; one patient died within 1 day of the last negative culture, and the other had positive cultures 496 days later. The remaining 23 cases had persistently or intermittently positive cultures despite therapy. The clinical course of these cases suggested overwhelming miliary tuberculosis with involvement of the lungs (77%), pleura (15%), stool (34%), meninges (13%), bone marrow (16%), blood (10%), lymph nodes (10%), and skin (8%). The median survival time was 2.1 months for cases compared with 14.6 months for controls (P = 0.001, log-rank test). CONCLUSIONS Tuberculosis caused by multiple-drug-resistant bacilli in patients with HIV infection is associated with widely disseminated disease, poor treatment response with an inability to eradicate the organism, and substantial mortality.

Wegener's Granulomatosis, Lymphomatoid Granulomatosis, and Benign Lymphocytic Angiitis and Granulomatosis of Lung: Recognition and Treatment

Observations on 35 patients with pulmonary angiitis and granulomatosis show the value of separating pulmonary lesions of this type into three categories. Fifteen patients had Wegeners granulomatosis characterized by necrotizing granulomatous inflammation of lung, frequent upper airway and renal involvement, and responsiveness to cyclophosphamide. Nine had lymphomatoid granulomatosis characterized by necrotic atypical lymphoreticular infiltrates and frequent cutaneous and neurologic involvement, usually fatal despite intensive cytotoxic drug therapy. Eleven had benign lymphocytic angiitis and granulomatosis, in the past included in the above categories and characterized by nodular collections of mature lymphocytes and plasma cells, with predominantly pulmonary involvement and consistent responsiveness to chlorambucil. Wegeners granulomatosis and benign lymphocytic angiitis and granulomatosis were frequently associated with serum immunoglobulin elevations, with intact cell-mediated responses. Clinical and immunologic assessment was useful indistinguishing benign lymphocytic angiitis and granulomatosis from lymphomatoid granulomatosis.

New strategies are needed in diffuse malignant mesothelioma

Background. Medical records of 50 patients with malignant mesothelioma were reviewed to determine the clinical features and factors influencing survival.

Pilomatrix carcinoma with pulmonary metastasis. Report of a case

A 67‐year‐old white man developed a locally recurrent pilomatrix carcinoma of the back. Within a 4‐year period bilateral pulmonary metastases developed. This to the knowledge of the authors is the first reported case of a metastasizing pilomatrix carcinoma in the medical literature.

Embolized Crospovidone (poly[ N -vinyl-2-pyrrolidone]) in the Lungs of Intravenous Drug Users

Crospovidone is an insoluble polymer of N-vinyl-2-pyrrolidone that is used as a disintegrant in pharmaceutical tablets. It can potentially embolize to the lung when aqueous tablet suspensions are injected intravenously. In this report, we identified embolized crospovidone in autopsy-derived lung tissue from three adult IV drug users, 1 man and 2 women, whose ages respectively were 27, 38, and 40 years. Suspected crospovidone was compared with pharmaceutical-grade crospovidone by means of histochemical stains, transmission electron microscopy, and infrared spectroscopy. Similar particles were also observed by light microscopy in a 4-mg tablet of hydromorphone, a preparation prescribed to two of the patients. Two patients had sickle cell disease and were taking methadone and/or hydromorphone for pain management; the third was receiving parenteral hyperalimentation after small bowel resection. Crospovidone appeared as deeply basophilic, coral-like particles within pulmonary arteries and in extravascular foreign-body granulomas. Intrapulmonary crospovidone stained similarly to the pure substance, including intense staining with mucicarmine, Congo red, and Masson trichrome. With Movat pentachrome stain, both intravascular and purified crospovidone appeared orange-yellow, whereas most interstitial particles associated with giant cells stained blue-green. Alcian blue failed to stain intravascular or purified crospovidone but strongly decorated some phagocytized particles. Ultrastructurally, both purified powder and tissue deposits of crospovidone appeared as irregular, electron dense, laminated, and finely granular material. Intrapulmonary crospovidone was associated with inflammatory cells and exhibited degenerative changes. By infrared spectroscopy, crospovidone in tissue had the same spectral characteristics as pharmaceutical grade crospovidone and the library reference, polyvinylpyrrolidone (PVP). We conclude that crospovidone contributes to pulmonary vascular injury in some persons who illicitly inject pharmaceutical tablets. It is readily identifiable histologically and distinguishable from other tablet constituents, such as cornstarch, talc, and microcrystalline cellulose. The variable staining with Alcian blue and Movat suggests that crospovidone is altered in vivo by the inflammatory response.

High Amylase Levels in Neoplasm-Related Pleural Effusion

Excerpt Amylase levels elevated in pleural effusions are found in three categories. First, the commonest category is pancreatitis with or without pseudocyst formation or a direct pancreatic-pleural...

Pneumocystis carinii Hepatitis in the Acquired Immunodeficiency Syndrome (AIDS)

Excerpt Pneumocystis cariniiis the opportunistic pathogen most frequently causing pneumonitis in the acquired immunodeficiency syndrome (AIDS). The extrapulmonary or disseminated form of this infec...

Lung cancer in patients with human immunodeficiency virus infection

This retrospective study determined the clinical course of lung cancer in patients with human immunodeficiency virus (HIV) infection. A total of 23 patients with HIV infection archived as lung cancer were studied: 16 were identified from about 1,000 lung cancer patients entered in the tumor registry and medical records of Jackson Memorial Hospital, 7 were identified from about 1,000 HIV-positive patients entered in the Special Immunology registry of Veterans Administration Medical Center, 4 patients did not have pathologic confirmation of lung cancer, and 19 patients, all men, met the criteria for analysis (histopathologic diagnosis of lung cancer and HIV+ by serology). The median age was 47 (range: 36–66). Risk factors for HIV were homosexuality (6 patients), blood transfusion (3), promiscuity (5), intravenous drug abuse (4), and none (3). Six patients had a history of coexistent pulmonary tuberculosis and 5 had Pneumocystis carinii pneumonia. Median survival from diagnosis of lung cancer was 3 months. Advanced stages of both HIV infection and lung cancer may account for the poor survival. All patients were men and noted to be younger than other patients with lung cancer.

Primary sjögren's syndrome with diffuse cerebral vasculitis and lymphocytic interstitial pneumonitis

A 30-year-old black Haitian man with primary Sjögrens syndrome presented with minimal sicca symptoms, negative results of serologic testing, and predominant systemic involvement, including chronic bilateral lymphoplasmocytic pulmonary infiltrates and diffuse central nervous system vasculitis. This case illustrates the recognized fact that a paucity of sicca symptoms can be overshadowed by the predominance of other systemic manifestations, delaying the diagnosis of this disease. The angiographic results in this patient have not been reported before and support the role of vasculitis in the pathogenesis of the central nervous system manifestations in primary Sjögrens syndrome.

Polyarteritis manifesting as calf myositis and fever.

A patient presented with fever of undetermined cause for two months. On physical examination, bilateral calf tenderness was elicited, prompting a diagnostic muscle biopsy for polyarteritis. This limited form of polyarteritis is reviewed in the context of this case and previously reported cases. Polyarteritis limited to muscle seems to have a good prognosis and responds readily to steroids alone.