Concurrent Pneumocystis carinii and cytomegalovirus pneumonia after autologous peripheral blood stem cell transplantation

A 46-year-old woman developed concurrent CMV and Pneumocystis carinii pneumonia (PCP) 140 days after autologous peripheral blood stem cell transplantation (APBSCT) for AML. She was seropositive for CMV before undergoing APBSCT and had required prednisone for immune thrombocytopenia and allergic dermatitis for 9 weeks prior to the onset of pneumonia. She had also been receiving PCP prophylaxis with pentamidine aerosol every month for 3 months before developing symptoms. The pneumonia was complicated by severe hypoxia, requiring ventilator support and pneumothorax requiring chest tube thoracostomy. She recovered following treatment with trimethoprim-sulfamethoxazole (TMP-SMX), prednisone, gancyclovir and intravenous immunoglobulin. Although the overall incidence of severe CMV disease is low after APBSCT, preventive measures such as surveillance culture and secondary prophylaxis with gancyclovir may be warranted in patients whose cellular immune response is further compromised by corticosteroid use or other factors.

Acute respiratory failure and pulmonary fibrosis secondary to administration of mycophenolate mofetil

BACKGROUND

We report the first documented case of pulmonary toxicity to mycophenolate mofetil in this article.

METHODS

A 51-year-old woman experienced systemic reactions beginning 10 days after cadaveric renal transplantation.

RESULTS

Recurrent respiratory failure and documented progressive pulmonary fibrosis ensued. Cultures were negative and other agents were discontinued. It was not until the mycophenolate was stopped did the patient improve.

CONCLUSIONS

Mycophenolate mofetil can cause acute respiratory failure simulating opportunistic infection or pulmonary edema. If not recognized, this may lead to the rapid development of severe pulmonary fibrosis, some of which may not be reversible.

Directional atherectomy treatment for hemodialysis access: early results

The Simpson atherectomy device was used to treat 12 intragraft stenoses, six complete subclavian vein occlusions, and 14 venous outflow stenoses in 24 patients undergoing hemodialysis. Patients were followed up clinically and by means of venography at approximately 1, 3, 6, 9, and 12 months after treatment. Twenty-eight atherectomy specimens were examined histologically. Twenty-six (81%) of 32 lesions were treated with initial technical success. Including technical failures, seven (58%) of 12 intragraft stenoses are angiographically patent at a mean of 5.0 months and five (50%) of 10 are clinically patent at 6 months. Three (50%) of six subclavian veins are angiographically patent at a mean of 5.6 months, and four (67%) of six are clinically patent at 6 months. Three (21%) of 14 venous outflow stenoses are angiographically patent at a mean of 5.0 months and five (38%) of 13 are clinically patent at 6 months. Histologic examination showed neointimal fibromuscular hyperplasia in 26 of 28 lesions. When 30% or less angiographic residual stenosis is used as the criterion for initial technical success, directional atherectomy appears to be effective therapy for intragraft stenoses and, with balloon angioplasty, for some catheter insertion-related subclavian occlusions. Directional atherectomy appears to have a recurrence rate for venous outflow stenoses similar to that for balloon angioplasty when the same criterion is used.

Morphology of the uvula in obstructive sleep apnea

Alterations in pharyngeal structure and function are considered fundamental in the pathogenesis of obstructive sleep apnea (OSA). However, little is known about morphologic features of the pharynx in patients with OSA. We therefore studied the tissue composition of the uvula (midsagittal section) in patients with OSA, using a quantitative, morphometric point-counting technique. Uvula tissue was obtained by uvulopalatopharyngoplasty (UPPP) in 33 patients (mean number of apneas per hour of sleep = 32.7 +/- 5.2) and by autopsy in 22 normal subjects not known to have OSA. All statistical comparisons were controlled for differences caused by age and body mass index. Patients with OSA had a significantly greater percentage of muscle in the uvula (18.1 +/- 1.9% versus 9.3 +/- 2.1%, p = 0.02) than did normal subjects. A significant difference in fat content was also found (9.5 +/- 1.4% in patients versus 4.0 +/- 1.0% in normal subjects, p less than 0.02). These differences between patients with OSA and control subjects could not be accounted for by anthropometric or sex differences. The percentage of uvula fat tissue was significantly related to the frequency of apneas and hypopneas in sleep (r = 0.43, p less than 0.01). Uvula morphology in 6 nonapneic snorers undergoing UPPP was similar to that of patients with OSA. We conclude that the uvula in patients with OSA contains more muscle and fat than the uvula in control subjects, possibly contributing to pharyngeal narrowing in OSA.

Early postoperative function of suppressed parathyroid glands with microscopic hyperplasia

Calcium-parathyroid hormone (Ca-PTH) relationships were studied perioperatively in 35 patients with primary hyperparathyroidism. Twenty-nine patients had solitary adenomas that caused preoperative hypercalcemia; those patients whose remaining glands were subjected to biopsy were classified as having either microscopic evidence of suppression in those glands (15 patients) or no evidence of suppression (less than or equal to 30% stromal fat on biopsy cross sections, 11 patients). Before surgery, all patients showed the expected positive slopes for Ca-PTH linear regression curves. After surgery, all patients with adenomas showed an immediate and sustained shift of the Ca-PTH regression to the right; this shift achieved statistical significance only in those patients whose remaining glands showed microscopic evidence of suppression (greater than 30% fat, p less than 0.05). Moreover, the slope of the Ca-PTH regression curve for these patients assumed a negative value 1 month after surgery. All patients with adenomas were eucalcemic after surgery, regardless of the cellularity of the remaining in situ glands. We conclude that the absence of microscopic suppression in grossly suppressed parathyroid glands at the time of adenoma resection for hyperparathyroidism does not affect postoperative results. However, the presence of microscopic hyperplasia in macroscopically normal or suppressed glands may represent a persistent alteration in biologic function, evidenced by failure of these glands to achieve negative calcium regulation.

Evaluation of the Micro-ID, the API 20E and the Rapid 20E for same-day identification of Enterobacteriaceae

In a comparative study of three methods for same-day identification, the Rapid 20E identified 91.8% of 328 clinically isolated Enterobacteriaceae correctly to species level, 0.3% to genus level, 4.0% as part of a spectrum of identifications, and 4.0% incorrectly. Corresponding data for Micro-ID were 86.6%, 3.7%, 5.8%, 4.0%, and for same-day API 20E values were 72.6%, 7.3%, 13.4%, and 6.7%. Both Rapid 20E and Micro-ID provide accurate identification within four hours; same-day five-hour API 20E was less satisfactory.