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Disseminated cryptococcosis with cutaneous lesions.

A case of disseminated cryptococcosis in an HIV-negative patient presenting with cutaneous lesions is described for the first time in Egypt. The patient, a 16-year-old male, presented with cough, expectoration, loss of weight, and cutaneous lesions, mainly on the face and trunk. The lesions consisted of vegetating crusted plaques discharging purulent to sanguinous fluid and flattened, shiny, erythematous to brownish plaques. Anorexia, headache and personality changes soon followed. Histopathological examination of lesions was highly suggestive of a deep mycosis, particularly cryptococcosis. The fulminant disease advanced with central nervous system involvement. The progression was not arrested when systemic antifungal therapy was administered late in the disease course. Pathological examination of lungs, liver, pancreas and spleen revealed disseminated infection with no evidence of other underlying pathology. Disseminated cryptococcosis is a morbid infection, rare in an area where heightened awareness and raised index of suspicion will surely allow earlier diagnosis, management and better prognosis.

Adolescent↗

Mediators of hypersensitivity in the sputum of young, symptomatic cigarette smokers.

We have measured the concentrations of mediators of hypersensitivity in the sputum of twenty-five young, symptomatic cigarette smokers who regularly expectorated and twenty-three matched non-smokers with a respiratory infection. The measurements included sputum and blood eosinophils, IgE, IgG, IgA and IgM and also sputum histamine. We found a significant increase of sputum histamine, and a higher sputum/serum ratio of IgE in smokers when compared to non-smokers. These findings support the view that the bronchial inflammatory response in smokers, as in chronic bronchitis, involves the participation of mediators of hypersensitivity.

Adult↗

Experience with allergic bronchopulmonary aspergillosis: some unusual features.

The clinical and immunologic features of ten patients with allergic bronchopulmonary aspergillosis (ABPA), observed over periods varying from 12 months to 10 years, are reported. Acute attacks of ABPA were characterized by several, or all of: increased cough and sputum, haemoptysis, pleuritic pain, expectoration of sputum plugs, and increasing airways obstruction. Peripheral blood eosinophilia and acutely elevated serum IgE levels were seen in all patients during acute attacks, sputum eosinophilia and recovery of Aspergillus in sputum was less common. However, blood eosinophilia was not present in all attacks of ABPA and sputum eosinophilia varied similarly from one attack to another. Six patients with previously documented multiple precipitin lines have had no demonstrable precipitins to Aspergillus on several occasions between attacks, three of these patients have also been negative during attacks. Five of the six patients have again developed positive precipitin lines. The total number of episodes in these ten patients was fifty two, three patients have had more than nine acute attacks of ABPA. There is no seasonal variation in this group of patients. Since diagnosis, only three patients have had an attack-free interval longer than 12 months. Two patients are steroid-dependent because of severe asthma, and nine have symptoms of bronchiectasis.

Adult↗

Sputum eosinophilia after asthmatic responses induced by isocyanates in sensitized subjects.

To assess the nature and the time-course of the cellular component of airway inflammation induced by isocyanates, we examined nine subjects with occupational asthma induced by toluene- or methylene diphenyl-diisocyanate (TDI, MDI) and four control subjects never exposed to isocyanates. Sputum was induced by inhalation of ultrasonically nebulized hypertonic saline (3-4% NaCl) before and 8, 24, 48 h after inhalation challenge with TDI or MDI. Expectorated samples were incubated with dithiothreitol, washed and cytocentrifuged. Differential cell counts were obtained on slides stained with May-Grünwald-Giemsa. Metachromatic cells (mast cells and basophils) were counted on slides stained with toluidine blue at pH 0.1. One occupational asthmatic exhibited a dual reaction to TDI, two exhibited a single early asthmatic reaction to MDI, six exhibited a late asthmatic reaction to TDI (n = 5) or MDI (n = 1), whereas no reactions were observed in control subjects after TDI challenge. In sensitized subjects eosinophils increased from a median value (interquartile range) of 5 (15)% before challenge to 29 (29)% (P = 0.014) and to 30 (31)% (P = 0.031) 8 and 24 h after TDI/MDI challenges, respectively. Sputum eosinophilia was observed both in early and late reactors and declined to near to baseline values 48 hr after challenge. Percentages of eosinophils in control subjects did not exceed 7% during the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Physical and psychosocial consequences of total laryngectomy.

The incidence and severity of respiratory symptoms after total laryngectomy and their influence on daily living were studied in 59 laryngectomized patients. Daily sputum production was the principal complaint of these patients (98%), followed by coughing (64%) and the need for frequent forced expectoration (more than 5 times a day) in order to clear the airway (57%). Frequent stoma cleaning (more than 5 times a day) was required by 37% of the patients. Significant correlation was found between respiratory symptoms, voice rehabilitation and several aspects of daily living, including fatigue, sleep problems, social contacts and psychological distress. These findings indicate that respiratory symptoms after total laryngectomy are both frequent and troublesome. The development of effective methods for minimizing and/or preventing such respiratory problems would contribute significantly to improving the quality of life of laryngectomized patients.

Aged↗

The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy.

The influence of a heat and moisture exchanger (HME) on the respiratory symptoms after total laryngectomy was studied in 42 patients. A significant reduction was found in the mean daily frequency of sputum production, forced expectoration in order to clean the airway and stoma cleaning after use of the HME for 6 weeks. Symptoms of fatigue and malaise decreased significantly, while social contact improved. Patients using oesophageal speech or an electrolarynx benefited more than patients using a voice prosthesis. The findings indicate that respiratory problems after total laryngectomy can be reduced significantly with the use of a device with heat and moisture exchanging properties. In turn, reduction of respiratory symptoms results in an improved quality of life.

Adolescent↗

Rheological and transport properties of airway secretions in cystic fibrosis--relationships with the degree of infection and severity of the disease.

It has recently been suggested that in cystic fibrosis (CF), there is no rheological abnormality of airway secretions other than that associated with purulence, and that the apparent inhibition in the mucociliary transport rate might be partly due to a ciliary inhibitor present in these secretions. In order to ascertain this assumption, expectorated airway secretions were collected without salivary contamination in twenty-four CF patients and the rheological properties were measured. Using a photometric method, the effects of CF sputum samples were analysed on the ciliary beat frequency (Fm) of the frog palate, and we measured their mucociliary transport rate (TR). In all but one CF sputum, TR and Fm were lower than that of the control frog mucus (median TR: 18.7 and 11.6 mm min-1; median Fm: 12.3 and 11.3 Hz, respectively). In the eighteen patients in whom the rheological properties were outside the range for optimal mucociliary transport, the clinical Shwachman score was significantly (P less than 0.05) lower (median score: 66.2 points) than in the six patients with optimal rheologic properties (median score: 73 points). In the eleven CF patients with superinfection, the apparent viscosity (eta o) was significantly higher (P less than 0.01; median eta o: 24.4 Pa. s) and TR, expressed as a percentage of the reference value, was significantly lower (P less than 0.05; median Tr: 54.5%) in comparison with the values obtained for the thirteen non-superinfected CF patients (median eta o: 15 Pa. s and median TR: 66% respectively). The CF patients with markedly hyperviscous sputum (eta o higher than 30 Pa. s) exhibited a low Shwachman score.

Adolescent↗

Evidence for the pathogenic role of Rhodococcus species in pulmonary diseases.

Three hundred expectorated sputa from patients suffering from chest disorders were examined microscopically and cultured on various media. Among other micro-organisms isolated there were four strains of Rhodococcus aurantiacus (Gordona aurantiaca), one each of Rh. erythropolis, Rh. pellegrino, Rh. rubropertinctus and Rh. rhodnii. Suspensions in 5% hog gastric mucin were virulent for immuno-suppressed white mice and the pathology of their lungs was compatible with those produced in experimental nocardial and rhodococcus infections. The in-vitro antibiogram was similar to that of Nocardia asteroides. Two of the patients from whom Rh. aurantiacus and Rh. pellegrino were isolated responded bacteriologically and clinically to treatment with co-trimoxazole. The frequency with which these rhodococci were isolated and the clinical conditions of the patients strongly indicated a pathogenic role for some Rhodococcus species. It is suggested that rhodococci should be sought in chronic pulmonary infections, particularly in those who are immuno-compromised or debilitated, and their aetiologic role determined.

Actinomycetales Infections↗

Dispersion of a fluorescein dye-ampicillin mixture after intratracheal administration in calves.

The pulmonary and systemic dispersion of a dye mixture after intratracheal (i.t.) administration was characterized in young dairy calves. Five calves were given i.t. injections of a fluorescein and ampicillin mixture, and were then killed at 2, 5 or 15 min after treatment. The respiratory system, nasal pharynx area, nose, liver, kidney, stomach and esophagus were removed and examined. Sections were taken from lung areas for histopathological examinations and all tissues were photographed, using floodlight and ultraviolet light. There was uniform low-grade fluorescence throughout the lung, but the greatest fluorescence followed an anterior ventral dispersion. The dye was readily absorbed from the lung into the bloodstream, causing fluorescence in the liver, bile, kidney and urine. Coughing of the calves during the injection caused some of the mixture to be expectorated and swallowed, resulting in fluorescence in the esophagus, stomach contents, and nasal pharanges, turbinates and nostrils.

Ampicillin↗

Health seeking behaviour for child illness in rural Guatemala.

Considerable efforts were made in Guatemala to cover rural areas with health centres, and health programmes have been launched to treat and prevent the most important childhood diseases. Despite this, the utilization rate of public health services has reportedly been low throughout the past two decades. How, and how effectively, do mothers resolve the health problems of their children? To gain better insight into health care behaviour, we conducted a health services utilization survey in two highland communities in the department of Sacatepequez in 1992-1993. We asked 324 mothers in two villages whether, and where, they had sought help the last time their children under 5 years of age had suffered from diarrhoea, fever, cough symptoms or worms. Mothers relied on home care in 63-83% of reported episodes and the use of health services-Western or traditional-was consistently low. Although Western health care was easily accessible, it was used in only 8-15% of cases. The only identifiable significant independent determinants of utilization were occupational status of the mother (RR = 1.5 if employed) and overall level of socioeconomic development of the community (RR = 1.7). Inquiry into treatments used revealed that except for worms, which were frequently treated with herbs (31%) or external remedies (20%) alone, modern pharmaceuticals predominated. Antibiotics were the remedy of choice against diarrhoea (63%), antipyretics in case of fever (83%) and cough syrups with expectorants or antitussives against cough (65%). One hundred and twenty-one of the children born after 1975 died; in only 64 cases (53%) was a Western health service consulted between onset of disease and death. No relation was found between attendance and socioeconomic characteristics of the parents, but a positive linear association between duration of the fatal illness episode and age of the child could be identified. Independent sources report a drop in infant mortality of 53 and 35% respectively in the two communities between 1977 and 1991. Our findings seem to indicate that this reduction was achieved despite under-utilization of Western health services.

Adult↗

A contrast technique to improve sampling in cavitating lung lesions.

Twelve patients with cavitating lung lesions of uncertain aetiology, who had percutaneous aspiration combined with the instillation of radiographic contrast media, are presented. A diagnosis was made in 11 of the 12 patients (92%). A positive culture was obtained in all patients already receiving treatment for lung abscesses. Cultures of lavage fluid were positive in 89% of infected cavities. The instillation of radiographic contrast media into the lung cavity assists biopsy of the cavity wall, can be used to lavage the cavity, and may facilitate expectoration of sputum.

Adult↗

Physiological studies of gastro-oesophageal reflux and airway protective responses in the young animal and human infant.

1. The mechanisms that underlie the Sudden Infant Death Syndrome (SIDS) must explain its two unique features; age at death and death during apparent sleep. 2. The occurrence of gastro-oesophageal reflux (GOR) during active sleep in infants presenting with apparent life threatening episodes (ALTE) and their similar age distribution to SIDS infants, suggested that reflux could be a cause of asphyxia. 3. Sleep related GOR was found to be a physiological and not a pathological event in normal, healthy term infants. 4. In healthy term infants, those infants that were formula-fed (who have a higher incidence of SIDS) had significantly longer oesophageal clearance times for acid reflux and significantly more active sleep compared with breast fed infants. 5. In very preterm infants (who are at increased risk for SIDS), both the frequency and duration of reflux during active sleep was significantly less at term equivalent age compared with healthy term infants, suggesting additional factors must operate to promote an ALTE. 6. One mechanism which may explain the pathogenesis of GOR could be that the reflux reaches the level of the pharynx and this, in turn, stimulates laryngeal receptors to produce apnoea. 7. Simulated reflux to the level of the pharynx in the sleeping piglet evoked airway protective responses, namely swallow, arousal and occasionally expectoration, but neither apnoea nor oxygen desaturation. 8. In the same piglets treated with pentobarbitone sodium, swallowing was impaired and arousal depressed. Simulated reflux to the pharynx produced significant apnoea and oxygen desaturation and death in two of five piglets.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

The world's longest surviving paediatric practices: some themes of Aboriginal medical ethnobotany in Australia.

Contemporary paediatric practices of Australian Aboriginal men and women, in more than 100 Aboriginal Language Groups, comprise a living discipline whose origins predate Western medicine by tens of millennia. The history of paediatrics acknowledges this surviving continuum of the world's oldest child-care practices. Because of the inextricable nexus between Aboriginal men and women and the land in which they live, medical ethnobotany forms a major part of the medical aspects of Aboriginal child care. Traditional tribal healers, called 'Nungungi' in some language groups of Central Australia, are identified as such whilst still young children and are given special education in the healing arts, especially that of medical ethnobotany, by older healers. Distinct from this specialized role, all Aboriginal men and women (and in particular grandmothers) in traditional communities use a sophisticated botanical materia medica in the treatment of sick and injured children. In cultures in transition, medical ethnobotanical practices may persist long after the local use of flora as sources of traditional food, weaponry, totemic identity and religious rites have disappeared. Some selected botanical 'cures' were adopted by early European settlers and a number of such relict uses have become part of mainstream Western life today, particularly as this applies to self-medication. Drugs and medicaments used in the treatment of children are obtained from leaves, bark, roots and flowers, usually as fresh preparations. They are prepared as infusions, decoctions and macerations and may be enjoined with emollients such as emu or kangaroo fat for topical application. Botanical drugs and medicaments are usually prepared fresh for each administration and are rarely stored. Contemporary Australian ethnobotany exploits the medicinal properties of more than 100 genera - using such extracts as antiseptics, analgesics, astringents, antipyretics, sedatives, hypnotics, expectorants and carminatives. Their widespread use, by the world's oldest surviving cultures, reflect perhaps 50 millennia of acute observation and clinical interpretation, trial and error, serendipidity and experimentation. Australian medical ethnobotany generally, and that used specifically for children, is characterized by several features including (i) the multipurpose or 'broad-spectrum' use of many floral species; (ii) a paradigm of the use of botanical material to treat symptoms and symptom-complexes rather than disease-based treatment; (iii) the widespread and universal medical knowledge of botanical remedies by all members of local Aboriginal communities, not only traditional community or tribal healers and (iv) the use of botanical material in the context of preventive medicine. Seventy per cent of the world's population uses traditional herbal remedies in the treatment of sick or injured children. In this context, the detailed and extensive ethnobotanical pharmacopoeia of the Aboriginal Peoples of Australia holds an important place.

Australia↗

Thoracic embolotherapy for life-threatening haemoptysis: a pulmonologist's perspective.

Haemoptysis is the expectoration of blood from the respiratory tract and is life-threatening when blood obstructs the major airway causing asphyxiation. This may occur in the presence or absence of pre-existing compromised pulmonary reserve and medical comorbidities. Life-threatening haemoptysis is a relatively common clinical situation encountered by pulmonologists and thoracic embolotherapy is a key therapeutic option. Although thoracic embolotherapy primarily involves bronchial arterial embolization, it also encompasses embolization of non-bronchial systemic arteries and the pulmonary arterial supply. A pulmonologist's perspective on this topic is presented. Pertinent areas related to this theme, namely surgery and the role of bronchoscopy in life-threatening haemoptysis are discussed briefly.

Bronchi↗

Patterns of care for COPD by Japanese physicians.

OBJECTIVE: COPD treatment guidelines are available worldwide, yet it is not known how widely they are followed. This study evaluated the clinical care of COPD patients in Japan as compared to guideline recommendations. METHODS: A sample of general and specialist physicians was selected from private outpatient clinics and public hospitals in Japan. Physicians were provided two clinical vignettes (COPD and asthma) and asked to make a diagnosis. They were next asked to define diagnostic tests and treatment recommendations specifically for a COPD patient. Responses were compared to recommendations from current COPD guidelines. RESULTS: For the COPD unknown vignette, 6.2% of physicians diagnosed COPD while 54% diagnosed chronic bronchitis or emphysema. For COPD diagnosis, 81.9% of physicians recommended a CXR, 49.1% spirometry, and 17.7% a computed tomography scan. The most frequently recommended medication for a newly diagnosed COPD patient was theophylline (37.2%) followed by expectorants (32.1%) and inhaled anticholinergics (25.9%). Inhaled beta-agonists were recommended by fewer than 20% of all physicians. CONCLUSION: Care for COPD patients by selected Japanese physicians diverges from published practice guidelines. COPD is an infrequently used diagnostic label; diagnostic evaluation is characterized by a high use of computed tomography scans, particularly by specialists; and bronchodilator use was low.

Ambulatory Care Facilities↗

Pseudomonas aeruginosa pyocyanin inactivates lung epithelial vacuolar ATPase-dependent cystic fibrosis transmembrane conductance regulator expression and localization.

Pseudomonas aeruginosa (PA) is a major pathogen causing morbidity and ultimately mortality in patients afflicted with cystic fibrosis (CF) lung disease. One important virulence factor, pyocyanin (PCN), is a blue, redox-active compound that is secreted in such copious amounts by PA in the CF lungs that it determines the colour of expectorated sputum. In this study, we discovered that physiological concentrations of PCN inactivate the airway epithelial vacuolar ATPase, resulting in reduced expression and trafficking of the cystic fibrosis transmembrane conductance regulator in cultured lung and primary nasal epithelial cells. Our study supports the notion that PCN contributes significantly to the pathogenesis of CF and other bronchiectasis patients infected by PA.

Calcium Channels, L-Type↗

Could saliva stand for plasma in theophylline monitoring in asthmatic children? Still a controversial problem.

Theophylline determination in saliva was proposed several years ago as a convenient and non-invasive alternative to monitoring plasma in children and adults. Published data demonstrated that theophylline saliva concentration linearly correlates plasma concentration. However, the variability found in interindividual serum/saliva ratios and the wide scattering among the data points precluded the clinical use of saliva for theophylline monitoring. The purpose of this study was to compare different standardized methods for obtaining stimulated saliva intending to reduce the variability in plasma/saliva ratios and to determine the most reliable one. A group of 150 ambulatory chronic asthmatic 4.5 to 20.83 (10 +/- 3.7; M +/- SD) year-old patients receiving theophylline 6.85 +/- 1.88 mg/kg every 12 h as slow release preparations for 4 to 100 days was studied. One ml venous blood and salivary specimens were simultaneously collected 5.15 +/- 0.36 h after the morning maintenance dose. In a subgroup of 75 patients, saliva was collected using first a new device called salivette, immediately followed by the collection of an expectorated sample 30 s after citric acid crystals stimulation. In the other patients saliva was collected using citric acid containing salivette. Theophylline concentration was determined using HPLC. For all types of saliva collection, salivary and plasma theophylline concentrations correlated significantly. However whichever method was used, based on the -2 to +2 SD interval, a large range of plasma theophylline was predicted from a single salivary theophylline concentration. Despite a further standardization of the sampling of saliva, saliva theophylline could not accurately predict plasma concentration.

Adult↗

Medication use for pediatric upper respiratory tract infections.

The present study monitored medication prescribing patterns to patients treated for upper respiratory tract infections (URTIs) in the pediatric outpatient department (OPD) at Central Referral Hospital (CRH), Gangtok, Sikkim. A total of 562 URTI prescriptions of children, aged 0-12 years attending pediatric OPD at CRH, Sikkim were collected by a random once-weekly survey between May 2002 and April 2003. Males numbered 284 (50.5%), and females 278 (49.5%). Most of the patients in our study were aged 2-5 years (preschool children) (44.8%). The average number of medications prescribed per encounter was 2.37; 59.2% (789) of medicines were fixed-dose combination (FDC) products and two-thirds of FDCs were respiratory medicines (521). The most commonly prescribed medicines were respiratory medicines (47% of the total medicines prescribed). Others were antimicrobials (30.7%) and analgesic-antipyretics (18.8%). Among respiratory medicines, cough and cold preparations (prescribed in 13 different FDC products in 25 brand names) were prescribed most frequently (62%) followed by nasal preparations (21%) and beta(2) adrenergic agonist inhalers (9.2%). Ninety-eight percent of nasal preparations were isotonic saline drops (129). Antihistaminics (41.8%), non-opioid antitussives (13.5%), alpha agonist oral decongestants (42.3%), expectorants (32.2%), mucolytics (18.7%), paracetamol (14.7%), and beta(2) agonists (17.2%) were common ingredients of respiratory medicine combinations. Antihistamines (2.5%) and beta(2) agonists (9.2%) were used alone. The most commonly prescribed antimicrobial was amoxicillin with clavulanate (28.4%) followed by cefadroxil (20%), cotrimoxazole (9.5%) and amoxicillin alone (9.3%). Average number of antimicrobials prescribed was 0.7 (409/562). The most commonly prescribed analgesic-antipyretic was paracetamol (81.3%) followed by combination of ibuprofen and paracetamol (12.4%) and nimesulide (5.6%). Medication selection was rational in few cases. Various anomalies were observed in various aspects of drug use in children for URTI's. The main aim of the initiative is the need for more rational medicine use in URTIs in children for improvement of clinical effectiveness, cost effectiveness and reduction of potential useless risk of side effects.

Analgesics↗