Robert S. Holzman

An outbreak of community-acquired Pneumocystis carinii pneumonia. Initial manifestation of cellular immune dysfunction.

Eleven cases of community-acquired Pneumocystis carinii pneumonia occurred between 1979 and 1981 and prompted clinical and immunologic evaluation of the patients. Young men who were drug abusers (seven patients), homosexuals (six), or both (two) presented with pneumonia. Immunologic testing revealed that absolute lymphocyte counts, T-cell counts, and lymphocyte proliferation were depressed, and that humoral immunity was intact. Of the 11 patients, one was found to have Kaposis sarcoma, and another had angioimmunoblastic lymphadenopathy. Eight patients died. In the remaining three, no diagnosis of an immunosuppressive disease was established, despite persistence of immune defects. These cases of pneumocystosis suggest the importance of cell-mediated immune function in the defense against P. carinii. The occurrence of this infection among drug abusers and homosexuals indicates that these groups may be at high risk for this infection.

Cryptococcal Disease in Patients with the Acquired Immunodeficiency Syndrome: Diagnostic Features and Outcome of Treatment

Between 1 January 1981 and 1 December 1984, 34 of 396 patients with the acquired immunodeficiency syndrome (AIDS) developed cryptococcal infections. Twenty-six cases are reviewed. Twenty-two patients had brain or meningeal disease; the others had pulmonary disease (2 patients), pericarditis (1 patient), and antigenemia (1 patient). During treatment, 3 patients died of cryptococcosis and 3 died of other causes. Fifteen patients were followed for more than 6 weeks after treatment. Of 8 patients who received no additional amphotericin B, 4 had relapses and died of cryptococcosis within 6 months, 3 died of other causes, and 1 survived. Of 7 patients who received maintenance therapy with amphotericin B, none had relapses, 3 died of other causes, and 4 survived. Our data suggest that maintenance therapy with amphotericin may be needed to prevent relapse in patients with AIDS.

Pyogenic Liver Abscess: Recent Trends in Etiology and Mortality

BACKGROUND Pyogenic liver abscess, a potentially life-threatening disease, has undergone significant changes in epidemiology, management, and mortality over the past several decades. METHODS We reviewed the data for patients admitted to Bellevue Hospital and New York University Downtown Hospital (New York, New York) over a 10-year period. RESULTS Of 79 cases reviewed, 43% occurred in patients with underlying biliary disease. The most common symptoms were fever, chills, and right upper quadrant pain or tenderness. The most common laboratory abnormalities were an elevated white blood cell count (in 68% of cases), temperature >or=38.1 degrees C (90%), a low albumin level (70.2%), and an elevated alkaline phosphatase level (67%). Seventy percent of the abscesses were in the right lobe, and 77% were solitary. Klebsiella pneumoniae was identified in 41% of cases in which a pathogen was recovered. Eighteen (50%) of 36 Asian patients had K. pneumoniae isolated, in contrast to 6 (27.3%) of 22 non-Asian patients (not statistically significant). Fifty-six percent of cases involved treatment with percutaneous drainage. Although prior reports noted mortality of 11%-31%, we observed only 2 deaths (mortality, 2.5%). CONCLUSIONS The data suggest that K. pneumoniae has become the predominant etiology of pyogenic liver abscess and that mortality from this disease has decreased substantially.

A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. AIDS Clinical Trials Group Protocol 021.

BACKGROUND Pneumocystis carinii pneumonia (PCP) continues to be the most common index diagnosis in the acquired immunodeficiency syndrome (AIDS), but it is not clear which of several available agents is the most effective in preventing a recurrence of PCP. METHODS We conducted a comparative, open-label trial in 310 adults with AIDS who had recently recovered from an initial episode of PCP and had no treatment-limiting toxic effects of trimethoprim-sulfamethoxazole or pentamidine. All the patients were treated with zidovudine and were randomly assigned to receive either 800 mg of sulfamethoxazole and 160 mg of trimethoprim once daily or 300 mg of aerosolized pentamidine administered every four weeks by jet nebulizer. The participants were followed for a median of 17.4 months. RESULTS In the trimethoprim-sulfamethoxazole group (n = 154) there were 14 recurrences of PCP, as compared with 36 recurrences (including 1 extrapulmonary recurrence) in the aerosolized-pentamidine group (n = 156). The estimated recurrence rates at 18 months were 11.4 percent with trimethoprim-sulfamethoxazole and 27.6 percent with pentamidine (P < 0.001). The risk of a recurrence (adjusted for initial CD4 cell count) was 3.25 times higher in the pentamidine group (P < 0.001, 95 percent confidence interval, 1.72 to 6.16). There were no significant differences between the groups in survival or in hematologic or hepatic toxicity. Crossovers from trimethoprim-sulfamethoxazole to aerosolized pentamidine were more common than the reverse (27 vs. 4 percent), partly because of the study protocols for the management of leukopenia. There were 19 serious bacterial infections in the trimethoprim-sulfamethoxazole group and 38 in the pentamidine group. The time to a first bacterial infection was significantly greater for those assigned to trimethoprim-sulfamethoxazole (P = 0.017). CONCLUSIONS In patients with AIDS who are receiving zidovudine, trimethoprim-sulfamethoxazole is more effective than aerosolized pentamidine in conventional doses for the prevention of recurrent pneumocystis infection.

Mycobacterium avium-intracellulare: A Cause of Disseminated Life-Threatening Infection in Homosexuals and Drug Abusers

Five men developed disseminated infection with Mycobacterium avium-intracellulare. These patients all lived in the New York City area and presented with their illnesses between January 1981 and September 1981; four were homosexual and one was an intravenous drug abuser. Four patients died. All five patients had defects in the cell-mediated immune response. The infections were characterized histopathologically by poor or absent granulomatous tissue reaction. Clinical isolates of M. avium-intracellulare from all five patients agglutinated commonly used antimycobacterial drugs. The spectrum of opportunistic infections among populations of homosexuals and drug abusers should be expanded to include disseminated disease due to M. avium-intracellulare.

Sevoflurane Depresses Myocardial Contractility Less than Halothane during Induction of Anesthesia in Children

Background Cardiovascular stability is an important prerequisite for any new volatile anesthetic. We compared echocardiographically derived indices of myocardial contractility during inhalation induction with sevoflurane and halothane in children. Methods Twenty children were randomized to receive either halothane or sevoflurane for inhalation induction of anesthesia. No preoperative medications were given. Myocardial contractility was evaluated at baseline and at sevoflurane and halothane end-tidal concentrations of 1.0 minimum alveolar concentration (MAC) and 1.5 MAC. Results There were no differences between groups in patient age, sex, physical status, weight, or height. Equilibration times and MAC multiples of sevoflurane and halothane were comparable. Vital signs remained stable throughout the study. Left ventricular end-systolic meridional wall stress increased with halothane but remained unchanged with sevoflurane. Systemic vascular resistance decreased from baseline to 1 MAC and 1.5 MAC with sevoflurane. Halothane depressed contractility as assessed by the stress-velocity index and stress-shortening index, whereas contractility remained within normal limits with sevoflurane. Total minute stress and normalized total mechanical energy expenditure, measures of myocardial oxygen consumption, did not change with either agent. Conclusions Myocardial contractility was decreased less during inhalation induction of anesthesia with sevoflurane compared with halothane in children. Although the induction of anesthesia with sevoflurane or halothane was equally well tolerated, the preservation of myocardial contractility with sevoflurane makes it an attractive alternative for inducing anesthesia in children.

Anaesthesia for patients with mediastinal masses

Anaesthesia for patients with mediastinal masses may be associated with significant respiratory and cardiovascular complications. In this review, we discuss the anatomical and pathological considerations in these adult and paediatric patients and the three types of intra-thoracic compromise that may be found: compression of the tracheobroncheal tree, compression of the pulmonary artery and heart and the superior vena caval syndrome. Patient evaluation by symptom history, computerized tomography and flow-volume loops is emphasized. Preoperative thoracic radiation therapy in severely symptomatic patients is associated with a decrease in postoperative respiratory complications and an improvement in risk. During radiation therapy a small window can be created to spare some tissue for adequate histological diagnosis. Anaesthetic management techniques for these patients are discussed. Life-threatening complications can occur at any point during anaesthesia for patients with mediastinal masses. Anaesthetists should have a high degree of awareness of the underlying anatomy, pathophysiology and anaesthetic alternatives when caring for these patients.RésuméLes enfants et les adultes qui ont une masse médiastinale sont à risque de complications respiratoires ou cardio-vasculaires tors de l’anesthésie. Nous en décrivons l’anatomo-pathologie et les trois types de problèmes intrathoraciques associés: compression trachéo-bronchique, compression du coeur et de l’artère pulmonaire et enfin, syndrome de la veine cave supérieure. Nous insistons sur l’évaluation par l’histoire, la tomodensitométrie et la courbe débit-volume. On peut diminuer le risque de complications respiratoires par une radiothérapie pré-opératoire chez les patients très symptomatiques tout en épargnant une fenêtre qui servira au diagnostic histologique. Nous décrivons aussi les techniques anesthésiques appropriées. Des complications graves peuvent survenir à n’importe quel moment de l’anesthésie chez ces patients. Dans ces cas la, l’anesthésiste doit être bien au fait de l’anatomie et de la pathophysiologie de la lésion et des alternatives qui s’offrent à lui.

The risk of zoster after varicella vaccination in children with leukemia

We examined the incidence of zoster in 346 children with underlying acute lymphoblastic leukemia who were immunized with live attenuated varicella vaccine while in remission. We also compared a subset of 84 of these children with a matched group of 84 children with leukemia who had had natural infection with varicella. Of the 346 vaccinated children, 5 (1.45 percent) became infected with zoster after 10,878 months of observation, for an incidence of 0.552 case per 100 person-years. Among the matched pairs of subjects, zoster occurred in 3 (3.6 percent) of the 84 vaccinated subjects during 2936 months of observation--an incidence of 1.23 cases per 100 person-years--and in 11 (13.1 percent) of the subjects with natural infection during 4245 months--an incidence of 3.11 cases of zoster per 100 person-years. Although the incidence of zoster was more than twice as high in the control children as in the vaccinated children (3.11 vs. 1.23 cases per 100 person-years), a Kaplan-Meier product-limit analysis revealed no significant differences in incidence between the two groups. Children from both groups in whom leukemia recurred were more likely to contract zoster than those who did not have a recurrence (7 of 35 vs. 7 of 133, P less than 0.025). Zoster was not a marker for impending relapse. No case of zoster was severe or disseminated. We conclude that the incidence of zoster following immunization with live attenuated varicella vaccine is no greater than that following natural varicella infection.

CT quantitation of tracheal cross-sectional area as a guide to the surgical and anesthetic management of children with anterior mediastinal masses

Pediatric patients presenting with anterior mediastinal masses between January 1980 and November 1988 were reviewed to assess the correlation between tracheal cross-sectional area and anesthetic risks. Forty-two patients had evaluable computed tomography (CT) scans and underwent a surgical procedure. Thirty-four patients had Hodgkins disease, six had non-Hodgkins lymphoma, and two had mediastinal teratoma. Tracheal cross-sectional areas were greater than 75% of expected in 19 cases, greater than 50% to 75% in 16 cases, greater than 25% to 50% in five cases, and less than or equal to 25% in two cases. The presence or extent of symptoms did not correlate well with the degree of tracheal narrowing shown by CT scan except for orthopnea. Local anesthesia was used primarily in patients with significant tracheal narrowing (tracheal size was less than or equal to 56% in 5 of 6 patients). General anesthesia with spontaneous ventilation by mask was performed in four patients with tracheal areas of 33%, 73%, 76%, and 98% of expected. General endotracheal anesthesia was utilized in the remaining 32 patients, only three of whom had tracheal areas of less than 50% of expected (down to 30%, 26%, and 24% of expected) and one received preoperative radiotherapy (26%). None of these 32 patients had symptoms of orthopnea or dyspnea at rest, and only one had dyspnea on exertion. All tolerated anesthesia without difficulty. No patient in this series suffered respiratory or cardiovascular collapse during surgery. Adequate biopsy material was obtained in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Pseudobacteremia Attributed to Contamination of Povidone-Iodine with Pseudomonas cepacia

Pseudomonas cepacia was recovered from the blood cultures of 52 patients in four hospitals in New York over 6 months from April through October 1980. Epidemiologic investigation in one hospital indicated that the positive results of blood culture represented pseudobacteremias and implicated a 10% povidone-iodine solution used as an antiseptic and disinfectant (Pharmadine; Sherwood Pharmaceutical Company, Mahwah, New Jersey) as the source of contamination. Physicians who drew blood cultures positive for P. cepacia were more likely to have left povidone-iodine on the skin before venipuncture (p = 0.026) and were more likely to have applied povidone-iodine to the blood culture bottle tops and to have left it there while inoculating the blood culture media (p = 0.007) than those who drew cultures negative for P. cepacia. Direct inoculation of Pharmadine into brain-heart infusion broth yielded P. cepacia; however, 2 weeks after the first cultures, the same Pharmadine bottles were culture negative. The iodine concentrations of the contaminated Pharmadine solutions were similar to those of 10% povidone-iodine solutions distributed by other manufacturers.