Richard H. Winterbauer

Diffuse Pulmonary Injury Associated with Gold Treatment

Two patients had diffuse, reversible pulmonary injury possibly owing to gold sodium thiomalate treatment: a 32-year-old woman with chronic inflammatory arthritis compatible with seronegative rheumatoid arthritis and a 32-year-old man with shoulder arthralgia. The patients had received 420 mg and 325 mg of gold sodium thiomalate, respectively. Cough and dyspnea began in the seventh and fifth weeks of therapy, respectively. In both patients x-ray study showed bilateral pulmonary infiltrates, with no evidence of pleural disease. The woman had no other manifestations of hypersensitivity to gold. The man had exfoliative dermatitis fever and anemia. Lung biopsies from both patients revealed lymphocytes and plasma cells infiltrating the alveolar septa and interstitial fibrosis. The woman improved slowly during four months after discontinuation of therapy. Pulmonary symptoms recurred after additional gold therapy, and again resolved when gold was discontinued. The man, treated with prednisone, showed prompt remission and remains will without medication.

Langerhans Cells and Serum Precipitating Antibodies against Fungal Antigens in Bronchioloalveolar Cell Carcinoma: Possible Association with Pulmonary Eosinophilic Granuloma

In an ultrastructural study of 37 cases of bronchioloalveolar cell carcinoma (BAC), we identified seven cases (19%) in which Langerhans cells (LC) were closely associated with tumor cells. Serum precipitating antibodies against Aspergillus species and/or thermophilic actinomyces were present in five BAC patients whose tumors contained LC and in six patients whose tumors lacked LC. In a simultaneous study we identified marked atypical bronchiolar and alveolar lining cell hypertrophy and hyperplasma in pulmonary eosinophilic granuloma (PEG). Our data plus current information suggesting that PEG is a form of hypersensitivity pneumonitis support our hypothesis that those cases of BAC in which LC are present may rise in localized or diffuse pulmonary scars caused by PEG.

TREATMENT WITH CORTICOSTEROIDS

Oral corticosteroids remain the cornerstone therapy for sarcoidosis. Critical clinical decisions include selecting the patient who should be treated, dose and duration of therapy, and accurate analysis of the anticipated benefits and potential side effects for the individual patient. The treatment of pulmonary and cardiac sarcoidosis is emphasized and the role of inhaled corticosteroids in the treatment of pulmonary sarcoidosis is reviewed.

Acute severe asthma. How to recognize and respond to a life-threatening attack.

Preview How can the severity of an acute episode of asthma be assessed? What is a reasonable approach to corticosteroid administration in acute severe asthma? For which patients should mechanical ventilation be considered? The answers to these and other questions can be found in this guide to the evaluation and management of potentially fatal exacerbations of asthma.

Chronic Bacterial Pneumonia

Chronic bacterial pneumonias are more common than previously recognized. They often present in the absence of fever and purulent sputum production. Although cough is the most common symptom, constitutional symptoms such as fatigue and weight loss are also frequent. H. influenzae and are the predominant bacterial pathogens in patients both with and without predisposing illness. Sixty-five percent of patients with chronic bacterial pneumonia will have a recognizable predisposing disease. The roentgenographic appearance is variable and nonspecific. Bronchoscopic evaluation is essential. Short courses of therapy have a high incidence of recurrence, despite initial symptomatic improvement. Thus, successful treatment requires prolonged therapy.