Bronchoscopy Before Start of Antibiotic Therapy

A presumptive etiologic diagnosis, valuable for the management of the patients, was obtained in all of the six patients examined before the start of antibiotic therapy (Table 4). The PB culture was positive in four of the patients, whereas in one patient (No. 21), S pneumoniae was found only in cultures from bron­chial secretion. In the last patient (No. 24), a bronchial tumor was found, but no infectious agent.

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Demographic Data The mean age of the 24 patients, 13 women and 11 men, undergoing bronchoscopy was 53 years (SD ± 16). Ten were smokers and one was a known alcoholic. Eight patients had a known pre-existing medical condition, and two of these were immunocom­promised.

Patient Compliance and Complications

Consent was given by all patients to whom FOВ was suggested because of therapy failure. Six of eight patients who were asked to participate in the study before antibiotic therapy was started agreed to bron­choscopy. No complications were seen during or after bronchoscopy in any of the 24 patients.

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Contraindications to Bronchoscopy

Absolute contraindications were bleeding abnormalities, severe cardiac disease, acute asthma, and allergy to local anesthetics. High age (>=70 years) and severe hypoxia (PaOz<8kPa) were relative contraindications. Bronchoscopy Procedure Before the bronchoscopy, the patient fasted for at least three hours. Prothrombin value and blood platelets were measured and a blood-gas analysis was performed. The only premedication given was atropine, 0.5 mg intramuscularly, one half hour before the bronchoscopy. During the bronchoscopy, the patient was observed with continuous electrocardiogram, and if necessary, received extra oxygen through a nasal catheter.

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Patients with CAP treated in the Department for Infectious Diseases at Danderyd Hospital were included in the study.

Pilot study: to test the planned bronchoscopy procedure, seven CAP patients received bronchoscopy between October 1985 and December 1986.

Main study: during a ten-month period in 1987, all adult (>=18 years) patients (HIV patients excluded for technical reasons) hos¬pitalized with clinical signs of a community-acquired lower respiratory tract infection and a pulmonary x-ray film showing new infiltrates, or infiltrates resolving after treatment, were included in a study of the etiology and prognosis of CAP.

Repeated samples were obtained from blood and sputum for bacteriologic culture. Sputum was cultured quantitatively after washing and deeming its purulehce. Sputum and urine specimens were also examined for the presence of pneumococcal capsular polysaccharide antigen by coagglutination (Capsular-CoA). Serolog¬ical tests with paired sera were performed for Mycoplasma pneumoniae, Chlamydia psittaci, Legionella species, and respiratory viruses.

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Community-acquired pneumonia remains one of the most common causes of morbidity and hos­pitalization, especially among elderly people.

Although Streptococcus pneumoniae is still the most common causative agent among adults who are hos­pitalized because of CAP, there are a number of less common pathogens for which treatment with penicil­lin is not adequate. Therefore, the precise identifi­cation of the agent(s) causing the pneumonia is most important. Yet this identification is often difficult. The definitive diagnosis by means of a positive blood or pleural culture is achieved too infrequently and rou­tine sputum is often unobtainable or nondiagnostic.

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We were quite interested in the six cases of spontaneous pneumothoraces reported by Martinez et al. We have not experi­enced any episodes of spontaneous pneumothorax in our AIDS patients in either of our two secondary prophylaxis aerosolized pentamidine studies.

From June 1, 1988 to December 31, 1988, there have been 55 patients involved in our double-blind randomized, placebo-con­trolled trial comparing treatment with pentamidine vs placebo for secondary prophylaxis of Pneumocystis carinii pneumonia (PCP). Since the study is still in progress, we do not know the exact number of individuals on pentamidine therapy. However, after eight months of prophylactic treatment, no spontaneous pneumothorax has been detected. These patients were clinically assessed on a monthly basis, had complete pulmonary function tests on a bi-monthly basis, and had chest radiographs (CXR) at baseline and at six months.

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We read with interest the article regarding right heart thrombus by Crowell et al (Chest 88; 94:1236-39). In the discussion, the presence of a central venous catheter is not mentioned as a cause of right heart thrombus, although in the literature the incidence is up to 29 percent. In the following case report, we would like to illustrate that a hemodialysis catheter can be the cause of right heart thrombus, intractable sepsis and pulmonary embolism.

A 68-year-old female dialysis patient was admitted to the hospital because of chronic low back pain. In 1983 hemodialysis was started because of end-stage renal disease due to diabetes mellitus and a left nephrectomy (infected nephrolithiasis). Diabetic macroangiop- athy resulted in amputation of the right leg in 1987.

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