Five patients are reported who have pleural effusion and pyogenic vertebral osteomyelitis. In four of the five patients, the presenting problem was a large pleural effusion, and three of these four patients had an exudative effusion. Initial evaluation and investigations in these patients were directed toward the pleuropulmonary disease, delaying the diagnosis of osteomyelitis, and in two patients, this delay resulted in neurologic complications. In the fifth patient, the pleural effusion was initially small; however, during the course of a workup for osteomyelitis, the effusion increased rapidly. Two out of the five patients had empyema, and the other three patients had a large pleural effusion associated with and apparently caused by vertebral osteomyelitis. Vertebral osteomyelitis should be considered in the differential diagnosis of pleural effusion of uncertain cause especially if there is associated back pain.

This article reports a case of acute community-acquired pneumonia due to Aspergillus fumigatus in a healthy patient and reviews 11 previously reported cases occurring in presumably immunocompetent hosts. The diagnosis was delayed for all patients; mortality was 100%. Clues that might suggest Aspergillus as a pathogen in community-acquired pneumonia include a chest radiograph revealing diffuse infiltrates or new cavitation; lack of bacterial or viral cause; a preceding influenza A infection; and respiratory secretion cultures positive for Aspergillus. When these clues are present, the physician should consider an early biopsy of lung tissue. Increased recognition and more timely diagnosis in future cases will improve the outcome of this rare but fatal infection.

To examine the impact of the timing of tracheotomy on the duration of mechanical ventilation, the secondary changes to the trachea, and the clinical course of critically ill patients in the ICU.

The National Asthma Education and Prevention Program recently published updated guidelines that stress the importance of peak flow monitoring for patients with moderate-to-severe persistent asthma. In this specific patient population, a peak flowmeter provides a simple, quantitative, objective measurement of large airway function. The purpose of this article is to describe indications for peak flow monitoring in asthmatic patients, review technical requirements for peak flowmeters as described by the National Heart, Lung, and Blood Institute, and evaluate the literature on commercially available peak flow devices to aid the health professional in selecting an appropriate meter for the patient with moderate-to-severe persistent asthma.

The relatively new Mycobacterium tuberculosis direct test (MTDT) enzymatically amplifies M tuberculosis complex 16s ribosomal RNA. The sensitivity of the test ranges from 75 to 100%, with specificity of 95 to 100%, positive predictive value between 78% and 100%, and negative predictive value between 95% and 100%. Similar test characteristics have been documented in nonrespiratory specimens and in specimens that ultimately grow nontuberculous mycobacterium (NTM). This test allows for rapid identification of M tuberculosis in the smear-positive patient and may greatly improve sensitivity over acid-fast bacilli smear alone. A negative test result with a positive smear suggests infection with NTM or Mycobacterium avium complex. We present a case that illustrates the value of MTDT for analysis of tissue specimens in immunocompromised patients with suspected mycobacterial disease and review the rapidly developing literature about this test. We propose an algorithm using MTDT, acid-fast smear, and mycobacterial culture for the diagnosis and treatment of the immunocompromised patient with suspected mycobacterial infection.

Identify and critically review the peer-reviewed, English-language studies of the effects of medical antireflux therapy in asthmatics with gastroesophageal reflux (GER).

Measurement of pH of the stomach wall (gastric intramural pH) by the tonometric method has been utilized both experimentally and clinically as an indicator of the capability of the stomach to extract and utilize oxygen. As such, it serves as a metabolic marker of acute perfusion failure (circulatory shock). More recently, researchers have found that increases in the PCO2 accounted for the decline in pH; this was documented in tissues other than the stomach wall, including the esophageal and sublingual mucosa. In this review, tissue PCO2 is identified as a universal indicator of impaired perfusion and contrasted with conventional hemodynamic and metabolic markers of perfusion failure.

Aspergillosis is an infrequent but commonly fatal infection among HIV-infected individuals. We review 342 cases of pulmonary Aspergillus infection that have been reported among HIV-infected patients, with a focus on invasive disease. Invasive pulmonary aspergillosis usually occurs among patients with <50 CD4 cells/mm3. Major predisposing conditions include neutropenia and steroid treatment. Fever, cough, and dyspnea are each present in >60% of the cases. BAL is often suggestive, but biopsy specimens are necessary for definite diagnosis. Amphotericin B is the mainstay of treatment and mortality is > 80%. Avoiding neutropenia and judicious use of steroids may be helpful in prevention. Aggressive diagnostic approach, early initiation of treatment, adequate dosing of antifungals, and close follow-up may improve the currently dismal prognosis.

Tropical pulmonary eosinophilia (TPE) usually affects people living in the tropics, especially those in Southeast Asia, India, and certain parts of China and Africa. However, owing to the rising frequency of world-wide travel and the migration between continents, this disease is increasingly seen in the West, where the diagnosis can be easily missed since it is rarely encountered and can mimic many other conditions. Cases of TPE have typically been reported to masquerade as acute or refractory bronchial asthma. TPE results from a hypersensitivity reaction to lymphatic filarial parasites found in endemic regions. There is evidence that it is more likely to occur in nonimmune individuals, ie, visitors to endemic regions, than in individuals of endemic populations who have developed immunity to filarial infections. Clinical features include paroxysmal cough, wheezing and dyspnea, and systemic manifestations such as fever and weight loss. A history of residence in a filarial endemic region and a finding of peripheral eosinophilia >3,000/mm3 should initiate a consideration of this disease. Other criteria for the diagnosis of TPE include absence of microfilariae in the blood, high titers of antifilarial antibodies, raised serum total IgE >1,000 U/mL, and a favorable response to the antifilarial, diethylcarbamazine, which is the recommended treatment. This disease, if left untreated or treated late, may lead to long-term sequelae of pulmonary fibrosis or chronic bronchitis with chronic respiratory failure. Herein lies the importance of early diagnosis and treatment of TPE.