Mark J. Rosen

Lymphoid Pneumonitis in 50 Adult Patients Infected with the Human Immunodeficiency Virus : Lymphocytic Interstitial Pneumonitis versus Nonspecific Interstitial Pneumonitis

Lymphocytic interstitial pneumonitis (LIP) and nonspecific interstitial pneumonitis (NIP) are pulmonary complications of human immunodeficiency virus (HIV) infection that occur in the absence of a detectable opportunistic infection or neoplasm. We reviewed lung biopsy specimens from 50 adult HIV-infected patients, of whom four had LIP and 46 had NIP. The majority (47 of 50) of specimens from patients with NIP showed mild chronic interstitial pneumonitis (CIP/NIP), with three showing features of diffuse alveolar damage, organizing phase. In contrast to CIP/NIP, the five specimens from four patients with LIP demonstrated more extensive lymphocytic interstitial infiltrates that extended into the alveolar septal interstitium. The majority of the interstitial lymphocytes in both NIP and LIP were of T-cell origin and stained for UCHL-1. The etiologies of NIP and LIP remain unknown. Since the common opportunistic infections were excluded by routine methods, we sought, with special techniques, to investigate whether HIV, Epstein-Barr virus (EBV), or cytomegalovirus (CMV) could be identified in lung biopsy specimens from these patients. By in situ hybridization, we found one LIP specimen with expression of large amounts of HIV RNA primarily within macrophages in germinal centers; in the remaining specimens, occasional cells expressing HIV RNA were found (two LIP and four NIP). Neither CMV nor EBV was found by in situ hybridization in seven specimens; in these same specimens EBV was detected using the polymerase chain reaction in only one case of NIP, similar to results in control specimens. These results, together with the knowledge that lymphocytic pulmonary lesions may be caused by lentiviruses in humans and animals, suggest that HIV plays a significant role in the pathogenesis of both NIP and LIP in adult HIV-infected patients; in contrast, our data do not demonstrate a direct role for either EBV or CMV.

Pulmonary complications of the acquired immunodeficiency syndrome: A clinicopathologic study of 70 cases

The pulmonary complications of 70 patients with the acquired immunodeficiency syndrome (AIDS) are reviewed. Pneumocystis carinii pneumonia (PCP), present in 67 per cent of the patients, was diagnosed by fiberoptic bronchoscopy with transbronchial biopsies in all of the patients except two adults, who required open lung biopsy, and two children, in whom the infection was detected only at autopsy. Other opportunistic infections, such as cytomegalovirus pneumonitis, mycobacterial infections, invasive candidiasis, toxoplasmosis, cryptococcosis, and histoplasmosis, were more difficult to diagnose by fiberoptic bronchoscopy. In only four cases were these conditions detected during life. Neoplasms and lymphoproliferative processes also presented diagnostic problems, and only one case each of Kaposis sarcoma and lymphoid interstitial pneumonitis were detected by fiberoptic bronchoscopy. In four other cases these conditions, as well as two pulmonary lymphomas, diffuse large cell immunoblastic type, were detected only at autopsy. Sixty-eight per cent of the patients in this study died, usually with progressive intractable respiratory failure and pulmonary complications that had not been diagnosed during life, including potentially treatable diseases, such as bacterial pneumonias, PCP, nontuberculous mycobacteria, invasive candidiasis, toxoplasmosis, and invasive aspergillosis. The need for earlier detection of pulmonary complications in patients with AIDS is discussed.

Are Elderly People Less Responsive to Intensive Care

Older patients may be excluded from intensive care units because of the perception that they will benefit less than younger patients. To determine if advanced age is associated with increased mortality independent of severity of illness, we compared older and middle‐aged patients admitted to a medical intensive care unit. We reviewed the charts of 130 patients age 75 years or older and 135 patients age 55 to 65 admitted over a 30‐month period. We controlled for severity of illness using the Acute Physiology Assessment and Chronic Health Evaluation (APACHE II) system without including points for age (APACHE IIM). The groups were similar with regard to gender, whether or not they had a private attending physician, mean APACHE IIM score, and diagnoses, except that older patients had more chronic obstructive pulmonary disease. Hospital stay was slightly longer in the older group (37 vs. 39 days, rank sum, P < .02). Hospital mortality was significantly greater in the older group (39% vs. 51%, Chi‐square P < .05) with a crude relative risk of 1.31 (95% confidence interval [CI]: 1.01, 1.73). However, the relation of age group to mortality differed for patients with different diagnoses. When we used logistic regression to adjust for APACHE IIM, whether the patient had a private attending physician, primary admitting diagnosis, or presence of cancer, older patients did not have a significantly greater risk of dying (adjusted relative risk, 1.05; 95% CI: 0.97, 1.11). When pulmonary artery catheterization was added to the model, it independently predicted mortality (adjusted relative risk, 1.47; 95% CI: 1.05, 2.06). APACHE IIM (calculated without the inclusion of age) was an excellent predictor of mortality. Older age did not predict mortality once severity of illness, admitting diagnosis, and the presence of underlying malignancy were taken into consideration. Further studies should explore the effects of age separately for patients with different diagnoses as well as control for severity of illness.

Outcome of Intensive Care in Patients with the Acquired Immunodeficiency Syndrome

The prognosis of patients who become critically ill due to complications of the acquired immunodeficiency syndrome (AIDS) is generally believed to be poor, but no detailed studies have substantiated this impression. We performed a retrospective analysis of patients with AIDS admitted to the Medical Special Care Unit (MSCU) at Mount Sinai Medical Center in New York over a 42-month period. Of 910 patients admitted to the MSCU, 35 (4% ) had AIDS. An additional patient admitted to the pediatric intensive care unit was included in the analysis. Respiratory failure occurred in 31 patients (86% ) and was the most common problem necessitating admission. Twenty-five of these patients (69% ) had Pneumocystis carinii pneumonia. All 31 patients with respiratory failure required endotracheal intubation and mechanical ventilation, and 27 (87%) died during the same hospitalization. Pneumothorax requiring tube thoracostomy occurred in 6 of 31 patients receiving mechanical ventilatory support. Among the 4 mechanically ventilated survivors, only 2 patients remain alive. Intensive care unit intervention in patients with AIDS and respiratory failure is associated with a poor outcome and probably does not alter the ultimate course in most cases.