[Aerosol pulmonary scintigraphy. A new test in the diagnostic strategy of pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome]

In eleven patients with AIDS and suspected Pneumocystis carinii pneumonia we measured the pulmonary clearance and half-life of aerosolized 99m Tc-DTPA (diethylenetriamine pentaacetate). We correlated the half-life with gallium scans and bronchoalveolar lavages. In all nine patients with Pneumocystis, this half-life was shorter than normal value, documenting a significant increase of lung epithelial permeability (p less than 0.001). Six of these 9 patients had abnormal gallium scans. However, in two patients with normal chest X-rays, PaO2 and gallium scans, only the reduced half-life of 99mTc-DTPA evidenced acute lung disease. After treatment, the results of the DTPA half-life correlated with the presence or absence of Pneumocystis. This method is, therefore, a sensitive initial diagnostic test in patients with suspected Pneumocystis pneumonia. A short half-life should prompt bronchoalveolar lavage even when PaO2 and/or chest X-rays and gallium scans are normal.

Legionnaires' disease after bone marrow transplantation

Four patients developed legionnaires' disease after bone marrow transplantation. Two cases occurred early after transplant and were considered as part of a hospital epidemic due to contamination of water supply. The other two cases were considered to be sporadic because they occurred 3-4 weeks after hospital discharge. The outcome was good in two patients. In the third patient, recurrent disease was probably due to acquired resistance to macrolides, and complete cure was achieved after treatment with pefloxacin and rifampicin. The fourth patient died of overwhelming infection despite early treatment with erythromycin and pefloxacin. During the same period we treated 14 patients with pefloxacin for prevention of bacterial infection, of whom none developed Legionella pneumophila infection, while three of the patients reported here were in a group of 11 patients who received only oral non-absorbable antibiotics for gut decontamination. The fourth patient in this report was receiving no antibiotics. Thus pefloxacin seems to be effective as prophylaxis against L. pneumophila infection. When the hospital water supply was heated to 60 degrees C and chlorinated, the nosocomial cases in the hospital completely disappeared.

AIDS virus-specific cytotoxic T lymphocytes in lung disorders

Human immunodeficiency virus (HIV) is implicated in the development of AIDS (acquired immune deficiency syndrome). HIV infection leads to the generation of HIV-specific thymus-derived (T) lymphocytes in humans and apes. We describe an experimental system permitting the quantitative and systematic analysis of HIV-specific cytotoxic T lymphocytes (CTL). Functional, HIV-specific CTL are obtained by broncho-alveolar lavage (BAL) from the lungs of seropositive patients with lymphocytic alveolitis. These alveolar CTL: (1) recognize and kill HIV-infected alveolar macrophages in vitro under autologous, but not heterologous, conditions; (2) correspond to standard CTL as they express the CD3 and CD8 surface markers, but not the CD4 marker; and (3) are restricted by class I HLA transplantation antigens in their cytotoxic activities. We propose the hypothesis that interactions between HIV-specific CTL and infected macrophages induce major inflammatory reactions in seropositive patients.

Technetium-99m DTPA aerosol and gallium scanning in acquired immune deficiency syndrome

In 11 non-smoking AIDS patients suspected of pneumocystis carinii pneumonia (PCP), the results of Tc-99m DTPA aerosol clearances, gallium scans, and arterial blood gases were compared with those of bronchoalveolar lavage (BAL). Nine patients had PCP. All had increased clearances five times higher than the normal (5.6 +/- 2.3% X min-1 vs 1.1 +/- 0.34% X min-1, N = 10, P less than 0.001), suggesting an increased alveolar permeability. Gallium scans were abnormal in six patients but normal or slightly abnormal in the three others. Four of these nine patients had normal chest x-rays. In two of these the gallium scan was abnormal, but in the two others, only the increased Tc-99m DTPA clearances showed evidence of lung disease. Two patients had normal BAL, with normal clearances and gallium scans. Four out of the nine patients with PCP were studied after treatment. Three recovered and had normal clearance and gallium scans. One still had PCP with increased clearance but normal gallium scan. Gallium scanning and Tc-99m DTPA clearance are useful for detecting lung disease in AIDS patients with suspected PCP and for prompting BAL when chest x-rays and PaO2 levels are normal. Due to its high sensitivity, a normal Tc-99m DTPA clearance could avoid BAL.

Extensive T8-positive lymphocytic visceral infiltration in a homosexual man

Lymphocytic visceral infiltration has recently been noted in association with lymphadenopathy-associated virus infection. A homosexual man, who had clinical and immunologic features of the acquired immune deficiency syndrome (AIDS)-related complex, is described. The patient presented not only with peripheral blood lymphocytosis but also with extensive lymphocytic infiltration involving lungs, lymph nodes, nerves, muscles, and esophagus. Lymphocyte subset immunostaining analysis showed that the lymphocytes were T8-positive. Thirty months after the clinical onset of the disease, no evidence of progression to AIDS was seen. Moreover, clinical improvement was observed, even though the patient did not receive long-term treatment. The clinical history of this patient suggests that lung T8-positive lymphocytic infiltration is associated with an increased risk of infectious episodes such as pneumonia and bronchitis.

Acquired immunodeficiency syndrome after travelling in Africa: an epidemiological study in seventeen Caucasian patients

Seventeen Caucasian patients with acquired immunodeficiency syndrome (AIDS) contracted after long stays in Africa are reported. Central Africa was concerned in all cases. Men are particularly exposed to AIDS whatever their occupation. This study suggests that the risk of contracting AIDS in Africa is high; the transmission of the virus was related to sexual contact, particularly with prostitutes, in Africa in most of the cases. It suggests also that Caucasians who travel in Africa spread the virus throughout the world by means of their heterosexual relations.

[Radiologic aspects of acute invasive pulmonary aspergillosis in 18 immunodepressed patients]

A retrospective study of 18 immunodepressed patients with acute invasive pulmonary aspergillosis enabled the radiologic picture of this increasingly frequent opportunist affection to be described, and different manifestations of the disease as a function of underlying conditions to be determined. Two groups could be distinguished: the first of patients with malignant blood diseases (n = 10) when the "aplasia" factor was dominant; the second of patients without blood diseases (n = 8) when the immunodepression was usually induced by a recent increase in corticoid therapy. Neutropenia was not a finding in any of these patients. The most frequent radiologic finding was single or multiple round excavating foci, these corresponding to zones of bronchopneumonia containing aspergillus filaments with central tissue necrosis forming the "target" lesion. The aplasia was distinguished by the multiplicity of lesions and their excavation following aplasia in the shape of a crescent due to sequestrum formation. Prognosis was related to severity of subjacent lesions. In the 2nd group, lesions could be single and nodular; prognosis was improved by the possibility of reducing immunodepression factors.

[AIDS and associated syndromes: clinical manifestations]

Numerous clinical and immunological manifestations are commonly observed in AIDS patients. Among these, Kaposi's sarcoma and major opportunistic infections appear today as clinical "markers" of the disease. Other signs and symptoms such as fever, diarrhea, lymphadenopathy and immunological abnormalities are currently recognized as "associated" disorders. One of the main problems faced by clinicians is to evaluate the significance of these "associated" abnormalities, especially when they occur in at risk populations. Much work is still needed to clarify whether they actually imply an individual predisposition to contract the disease, a minor form or some early stage of AIDS.

[Treatment of an asthmatic crisis by acupuncture. Probable role in the onset of pneumothorax with development to status asthmaticus]

The onset of pneumothorax during acupuncture treatment has been reported since 1973. Usually unilateral, it occurs in patients free from any bronchopulmonary disease, and its consequences are therefore relatively benign. However, rare cases of bilateral pneumothorax have been reported since 1978, as well as a pneumothorax developing in asthmatic patients, with often dramatic consequences. A 15-year-old girl with a severe attack of asthma was treated by implantation of needles, and this coincided with the onset of a pneumothorax, and a subsequent state of status asthmaticus. A fatal outcome was only just avoided. The question is raised as to the technical quality of the implantations practised, as well as the validity and dangers of acupuncture in asthmatics, particularly during the acute attack.

[The amiodarone lung]

During the past 3 years, 51 cases of pulmonary lesions associated with the use of amiodarone, an effective anti-arrhythmic and anti-angina drug, have been reported in 17 publications. Durations of treatment, daily doses and total dosage were extremely varied. Clinical symptoms as well as radiological findings, respiratory function studies and laboratory data suggested hypersensitivity pneumonia. However, the histopathological substrate remains ill-defined, and while some data suggest a toxic effect, others are in favour of an immune reaction ending in diffuse pulmonary fibrosis. Five of the 11 deaths reported seem to be directly related to the drug. It would appear that long-term treatment with amiodarone requires regular periodical examination of the respiratory system.

Epidemiological features of Legionnaires' disease in the Paris area

Although the first French case of Legionnaires' disease (LD) was diagnosed in 1979 and the first six serogroups of L. pneumophila and L. longbeachae serogroup 2 were demonstrated in environmental samples from the Paris area, the incidence of the disease has not yet been evaluated in France. Prevalence of antibodies, as detected by an immunofluorescent assay, in the Paris population of our study ranged from 0.9 to 2.2%. LD was demonstrated in 155 (4.4%) of 3502 patients investigated mainly by serology. In a prospective study in a respiratory intensive care unit 20 (7.8%) cases of pneumonia out of 257 were caused by L. pneumophila. 171 of the 175 cases of LD diagnosed in Paris during 33 months were caused by L. pneumophila serogroup 1. Risk factors and epidemiological features of patients are similar to those described in other countries.

[Acquired immunodeficiency syndrome in 4 homosexuals]

Two young homosexual men apparently without any obvious cause of immunosuppression suddenly developed a series of opportunistic infections. Two others presented with prolonged fever and multiple lymph node enlargement of obscure origin. Immunological investigations in these 4 patients showed skin anergy and inversion of helper/suppressor lymphocyte ratio. Proliferative responses to mitogenic agents, soluble antigens and allogenic cells were altered only in the 2 patients with opportunistic infections. Humoral immunity seemed to be preserved in all cases. These 4 patients had previously suffered from many sexually-transmitted infections, had spent some time in the United States and had signs of past or present cytomegalovirus infection. As in the U.S.A., where this "acquired immunodeficiency syndrome" suddenly developed during the past 2 years, one may suspect, among several hypotheses, that it is caused by a transmissible agent now present in France.

[Emergency treatment of severe hemoptysis by embolization of systemic arteries]

Over a 6-year period 23 patients with massive haemoptysis were treated at the Hôpital Tenon, Paris. Eighteen of these, usually considered "non-surgical" cases, underwent emergency embolization of the bronchial artery (B.A.E.). The immediate outcome was favourable in 14 patients; 4 died of early recurrence. B.A.E. therefore appears to be a valuable treatment of massive haemoptysis in "non-surgical" patients or in patients awaiting transfer to a thoracic surgery unit. However, because of the failure rate, B.A.E. cannot compete with thoracic surgery in its classical indications, and its effectiveness and safety should be compared with those of balloon catheter endobronchial tamponade in "non-surgical" patients.

[Pulmonary infections caused by Pneumocystis carinii]

The following topics are discussed: 1. Pneumocystis carnii: appearance, antigenic structure, pathogenicity...; 2. Human pneumocytosis: clinical, diagnostic, prognostic and therapeutic aspects; 3. Pneumocystis carnii and the pneumocystoses: coexistence, theoretical and practical consequences, difficulties in interpretation of bronchiolo-alveolar lavage.

[Behcet's disease associated with pulmonary lesions: a case report]

A 24-year-old man presented clinically confirmed Behcet's disease. He developed thoracic pain accompanied by hemoptyses as a result of thromboses and aneurysm formation in the pulmonary artery. The presence of these aneurysms was suggested by perihilar images on standard radiography, and confirmed by pulmonary arteriography findings and results of histological examination of the operative specimen. Radiological and anatomical evidence of the presence of bronchial endarteritis lesions was also obtained.

A hypereosinophilic syndrome with retinal arteritis and tuberculosis

A 35-year-old man was initially seen with a decrease in visual acuity, renal insufficiency, and elevation of the eosinophil count in the blood. The ocular syndrome was caused by extensive arterial occlusions of the retina. The subsequent apparition of cardiac, pulmonary, and neurologic signs fulfilled the criteria for the diagnosis of hypereosinophilic syndrome (HES). Most symptoms, including ocular, were temporarily but notably improved by hydroxyurea. The patient died after two years. An autopsy showed an endomyocardial fibrosis and disclosed destruction of the left kidney by an active tuberculosis. A pathogenic relationship between the infectious disease and the HES is envisaged.