A 65-year-old woman presented with recurrent Wegener's granulomatosis following two years of immunosuppressive therapy and three years of complete remission. At her initial presentation, she had a characteristic x-ray picture showing multiple nodules with total resolution of these findings at three months. Five years later, at the time of clinical relapse, her chest x-ray film showed bilateral diffuse infiltrative disease. This change in radiologic presentation upon relapse of Wegener's has not previously been reported. Other unusual features include diffuse infiltrates as the pulmonary presentation and the long interval between cessation of therapy and relapse. We review the radiologic manifestations of Wegener's granulomatosis.

Cor pulmonale is an important consequence of COPD. Although the incidence is not precisely known, it is seen more frequently in patients with hypoxemia, CO2 retention and severely reduced FEV1. When present, it limits peripheral oxygen delivery, increases shortness of breath, and reduces exercise endurance. It is also associated with higher mortality rates independent of other prognostic variables. Numerous factors may contribute to the development of cor pulmonale in patients with COPD, but its primary cause is chronic alveolar hypoxia resulting in pulmonary vasoconstriction, vascular remodeling and pulmonary hypertension. The physical exam, chest radiograph and ECG may be helpful in detecting the presence of cor pulmonale, but because of anatomic changes that occur in the chest, these tests are often insensitive in patients with COPD. Noninvasive diagnostic techniques utilizing Doppler echocardiography and radionuclide angiography allow for detection of RV dysfunction at an earlier stage and in most cases, preclude the need for right heart catheterization. LTO2 is the only therapy shown to improve survival in patients with COPD. However, statistical proof correlating improvements in pulmonary hemodynamics with increased survival is lacking. Bronchodilators, such as the beta 2 agonists and especially theophylline, may have beneficial effects on pulmonary hemodynamics in addition to their effect on respiratory function and are useful in COPD when RV dysfunction is present. Diuretics and phlebotomy are also useful in improving symptoms in appropriate patients. Vasodilators such as calcium channel blockers and ACE-inhibitors may improve pulmonary hemodynamics acutely, but may lower arterial PO2 by worsening ventilation-perfusion matching or blunt the improvement in pulmonary hemodynamics seen with supplemental oxygen. The long-term benefits of these agents have not been proven and their routine use in patients with cor pulmonale due to COPD cannot be recommended.

The objective of our study was to determine the safety of transbronchial biopsy (TBB) in nonhospitalized patients. The design was a prospective study of the consecutive cases from July 1987 until September 1988 in the setting of a university hospital of the third level with 1,800 beds. The patients were a consecutive sample of 169 patients who had 184 procedures of fiberoptic bronchoscopy (FOB) with TBB performed. They suffered from different diseases: lung nodules or masses, diffuse interstitial disease, alveolar condensation, etc. An FOB with TBB was performed in immunocompetent outpatients, who were kept under observation for four hours and then had a chest roentgenogram taken afterwards. We contacted them again after 72 hours to rule out delayed complications. In three cases, more than 100 ml of blood were obtained during the FOB, without significant hemoptysis being recorded in those patients during the observation period; chest pain occurred in 15 patients during the TBB; pneumothorax occurred in two patients (1 percent), one of whom required admission to the hospital, without requiring chest tube drainage. Other complications are reported (bronchospasm, parenchymal hemorrhage, and pneumonia). In conclusion, we consider the TBB to be a technique with a low incidence of complications for outpatients, so therefore we do not believe that admission to the hospital is mandatory for this type of patient, although we do recommend a longer observation period.

The prevalence of radiation-associated cardiac disease is increasing due to prolonged survival following mediastinal irradiation. Side effects of radiation include pericarditis, accelerated coronary artery disease, myocardial fibrosis and valvular injury. We evaluated the cases of three young patients with evidence of significant valvular disease following mediastinal irradiation. One patient underwent the first reported successful aortic and mitral valve replacement for radiation-associated valvular disease (RAVD) as well as concurrent coronary artery revascularization. A review of the literature revealed 35 reported cases of RAVD, with only one successful case of valve replacement that was limited to the aortic valve. Asymptomatic RAVD is diagnosed 11.5 years after mediastinal irradiation compared with 16.5 years for symptomatic patients, emphasizing that long-term follow-up is important for patients receiving mediastinal irradiation. This study defines a continuum of valvular disease following radiation that begins with mild asymptomatic valvular thickening and progresses to severe valvular fibrosis with hemodynamic compromise requiring surgical intervention.

Cardiovascular complications have occurred in clinical trials of interferon. We review herein experience to date of cardiotoxicity with all types of interferons in cancer patients. The most common presentations of cardiotoxicity were cardiac arrhythmia, dilated cardiomyopathy, and symptoms of ischemic heart disease, including myocardial infarction and sudden death. The cardiac effects were not related to the daily dose, cumulative total dose, or period of therapy. Some of the patients in whom interferon has caused cardiovascular sequelae have had a history of coronary heart disease or have previously been given chemotherapy with drugs known to be cardiotoxic. In most of the patients, cardiac toxicity was reversible following the cessation of the drug therapy.

Non-cardiogenic pulmonary edema has not been previously described in calcium channel blocker overdose. We describe a case of non-cardiogenic pulmonary edema occurring during the course of therapy for massive diltiazem overdose in a young patient with anorexia nervosa. Review of the current literature suggests that major and minor pulmonary complications occur with some frequency in the setting of calcium channel blocker overdose although their exact incidence remains unclear.

Endocardial involvement associated with disseminated histoplasmosis has been infrequently documented, especially among patients with prosthetic valves. The therapeutic approach to these patients is also not yet clearly defined. A 54-year-old man with prosthetic valve endocarditis due to histoplasmosis was successfully treated with amphotericin B. A review of the literature suggests that the optimal form of therapy is likely a combination of surgical replacement of the involved valve and high dose amphotericin B. Successful therapy with amphotericin B alone may, however, be achieved if surgery is not a viable option.