We report four cases of malignant pleuropericardial effusions in patients with chronic phase myelomonocytic leukemia (CMML). Based on current literature, this event is rare and very poorly understood. Our cases shed light on three important clinical characteristics: (1) patients with CMML develop effusions during uncontrolled leukocytosis; (2) these effusions are very responsive to conventional chemotherapy; and (3) effusions may develop without clinical forms of disease in other sites of extramedullary hematopoiesis.

Airway constriction during a breath hold could not be examined previously using standard methods. We used high-resolution computed tomography (HRCT) in vivo to assess the temporal changes in airway area and the effects of a deep inspiration with and without vagal suppression. Five dogs were anesthetized, intubated, and their lungs ventilated with 100 percent oxygen. Fifteen HRCT slices were obtained at functional residual capacity (FRC) either immediately after stopping ventilation at end expiration after either a tidal volume breath or three deep inspirations. Subsequently the dogs were given atropine, 0.2 mg/kg, and the scans were repeated. The cross-sectional areas of 33 airways ranging in size from 1.6 to 9.7 mm in diameter were measured. Airways were separated in three groups based on size: small (< 3 mm in diameter); medium (3 to 6-mm in diameter); and large (> 6 mm in diameter). The small, medium, and large airways showed a spontaneous constriction over time to 49 +/- 8 percent, 83 +/- 4 percent, and 82 +/- 4 percent of initial airway size, respectively (p < 0.01), (p < 0.0001). The deep inspiration caused an initial dilation only in the smallest airways to 133.3 +/- 4 percent. The subsequent constrictions were even greater than after the tidal volume breath averaging 67 +/- 15 percent, 61 +/- 6 percent, and 60 +/- 9 percent of initial airway area in the small, medium, and large airways, respectively (p = 0.001). Atropine caused an average increase in baseline airway area of 115 +/- 5 percent and 121 +/- 6 percent after a tidal volume breath and deep inspiration, respectively, compared with the preatropine controls, with no difference between the three groups. Atropine also completely abolished the spontaneous airway constriction observed after either a tidal volume breath or a deep inspiration in all three groups equally. In conclusion, using direct airway imaging in vivo, we found that airways spontaneously constrict during a prolonged expiratory pause, and a deep inspiration significantly augments this airway constriction. These responses are mediated via vagal afferent pathways, likely arising from progressively decreasing slow-adapting receptor activity.

To evaluate the sensitivity of acid-fast sputum smears in the diagnosis of pulmonary Mycobacterium tuberculosis (MTB).

We reviewed our experience with 115 patients with pleural effusion in whom bronchogenic carcinoma was suspected who underwent fiberoptic bronchoscopy (FOB) to identify those for whom the procedure was useful. In 6 of 12 patients with hemoptysis, 8 of 12 with a mass or infiltrate, and 8 of 18 with atelectasis with negative fluid cytology and 3 of 7 with cytology positive, FOB was useful in diagnosis. Sixty-six patients had an isolated cytology-negative effusion. Seven of 18 with massive effusion had FOB detecting cancer. Fiberoptic bronchoscopy usually was nondiagnostic in lesser-sized effusions (47 of 48). Using outcome for those with nondiagnostic FOB, we established operating characteristics for the procedure. We conclude that FOB is useful in diagnosing bronchogenic carcinoma in such patients when there is hemoptysis, accompanying lung mass or infiltrate, atelectasis, the effusion is massive, or in cytology-positive effusions without obvious primary tumor. Due to the low prevalence of bronchogenic carcinoma in patients with effusions of lesser size, we suggest that in this group FOB not be routinely performed.

Eosinophilic pulmonary infiltration is an uncommon presentation from cocaine abuse. We present a patient with migratory pulmonary infiltrates and eosinophilia consistent with Löffler's syndrome. Our review uncovered two other similar patients. The importance of early recognition is stressed in our report. Either abstinence from cocaine usage and/or steroids result in resolution of this illness.

Human immunodeficiency virus infection changes the clinical presentation of tuberculosis infection with atypical radiographs and more common extra-pulmonary involvement. We retrospectively studied pleural tuberculosis in HIV-positive patients over a 5-year period. We identified 70 patients with pleural tuberculosis by positive Mycobacterium tuberculosis cultures of pleural fluid and/or pleural tissue, including 43 HIV-positive and 27 HIV-negative patients. The HIV-positive patients were significantly younger (mean age, 38 +/- 1 years in HIV-positive vs 52 +/- 3 years in HIV-negative patients, p < 0.05). There were more intravenous drug abusers in the HIV-positive group (74 vs 30 percent, p < 0.01). The HIV-positive group had significantly fewer positive tuberculin skin tests (41 percent vs 76 percent, p < 0.03). Both groups had similar pleural fluid cellularity and pleural biopsy histologic conditions, but the HIV-positive patients demonstrated significantly more acid-fast bacteria identifiable in pleural tissue (69 percent vs 21 percent, p < 0.01), and a higher incidence of positive M tuberculosis cultures of sputum (53 percent vs 23 percent, p = 0.02). Pleural tuberculosis in HIV-positive patients presented more often as a manifestation of a greater burden of microorganisms and impaired host response.

The precise roles of fiberoptic bronchoscopy (FOB) and computed tomography (CT) of the chest in the evaluation of patients presenting with hemoptysis have not been clearly defined. On the assumption that both procedures would likely provide unique and complementary information, a prospective study with blinded interpreters using a modified high-resolution CT technique (HRCT) and FOB was designed to evaluate 57 consecutive patients admitted to Bellevue Hospital with hemoptysis. Etiologies included bronchiectasis (25 percent), tuberculosis (16 percent), lung cancer (12 percent), aspergilloma (12 percent), and bronchitis (5 percent): in an additional 5 percent of cases, hemoptysis proved to be due miscellaneous causes, while in 19 percent hemoptysis proved to be cryptogenic. Patients with lung cancer all were at least 50 years old, smoked an average of 78 pack-years, and had less severe hemoptysis but of longer duration. All had conditions diagnosed both by HRCT and FOB. High-resolution CT proved of particular value in diagnosing bronchiectasis and aspergillomas, while FOB was diagnostic of bronchitis and mucosal lesions such as Kaposi's sarcoma. Fiberoptic bronchoscopy localized bleeding in only 51 percent of cases. The high sensitivity of CT in identifying both the intraluminal and extraluminal extent of central lung cancers in conjunction with its value in diagnosing bronchiectasis suggest that CT should be obtained prior to bronchoscopy in all patients presenting with hemoptysis.

Centrally mediated hypoventilation causes respiratory failure without respiratory distress. We present a case of recurrent acoustic neuroma at the cerebellopontine angle causing acute and chronic respiratory failure. Tumor resection eliminated recurrence of respiratory failure.

The purpose of this study was to assess the value of intrapleural urokinase (UK) instillations in enhancing tube drainage of loculated, complex pleural effusions. Tube thoracostomy has variable success in the treatment of complex pleural effusions, with limitations because of viscous fluid, improper tube position or kinking, and, most importantly, loculation. In the past, intrapleural administration of streptokinase has been used to lyse locules. In this study, eight patients with nine loculated pleural processes were treated with intrapleural instillations of UK. Six patients had previously undergone unsuccessful conventional tube drainage. Loculation was suggested by persistent fluid despite an adequate trial of simple drainage, radiographic demonstration of septation, or drainage of a volume of fluid far less than expected by a computed tomography scan. After instillation of a UK solution, the tubes were clamped for 30 to 180 min and then placed back to suction. Five pleural cavities with disease 6 to 18 days old showed complete resolution, and clinical improvement occurred. Three pleural processes showed improvement and one showed no improvement, with disease ranging from 23 days to 3 months. No complications were seen. These results suggest that UK instillations may enhance tube drainage of loculated pleural fluid in the early phase, before fibrosis has developed.

Since first described in 1984, nontraumatic pneumothoraces in patients with AIDS has become more common. When compared with spontaneous pneumothorax in the general population, pneumothoraces in patients with AIDS are often complicated by prolonged air leaks as well as higher recurrence rates. Chemical pleurodesis has an important role in the management of these complications. The most experience with chemical pleurodesis uses tetracycline hydrochloride as the sclerosing agent; however, this agent is no longer available. Doxycycline has been used in pleurodesis of malignant effusions, but its use in managing pneumothoraces is limited. We present five patients who have AIDS with a total of seven pneumothoraces. Each patient experienced a persistent air leak. Six of the pneumothoraces were managed successfully with doxycycline. Although the follow-up period was limited, there were no recurrences noted and the only side effect seen was chest pain in four which was easily controlled with narcotics. Doxycycline sclerotherapy can be used effectively for pleurodesis in the management of nontraumatic pneumothorax in the patient with AIDS.

We recently observed a striking increase in multidrug-resistant tuberculosis (MDR-TB) among patients admitted to the Chest Service at Bellevue Hospital Center in New York. We reviewed the laboratory susceptibility test results of 4,681 tuberculosis (TB) cases over the past 20 years, Combined resistance to isoniazid and rifampin increased from 2.5 percent in 1971 to 16 percent in 1991 with higher rates noted for individual drugs. We reviewed the medical records of 100 patients with drug-resistant TB, finding that these individuals were predominantly less than 40 years of age, minority, male, jobless, undomiciled, with a high percentage of drug abuse and human immunodeficiency virus infection. We conclude that the epidemics of AIDS and TB are complicated by a third epidemic of MDR-TB. This third epidemic requires urgent attention to achieve more rapid diagnosis, to develop new therapeutic regimens, and to address the social and hospital environment ot care for these individuals.

To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS.