CID 1992; 15 (August)
Correspondence
377
the other two did not have any risk factors for infection with the human immunodeficiency virus type I (HIV -I ). The four patients with AIDS had other serious pulmonary infections that were concomitantly present at the time of B. bronchiseptica isolation (two had P. carinii pneumonia, one had cytomegalovirus pneumonia, and one had pneumonia due to Pseudomonas species). Each of the four patients was treated with therapy specific for their pulmonic infectious disease (gentamicin for the Pseudomonas species infection, ganciclovir for the cytomegalovirus infection, and trimethoprim-sulfamethoxazole for the P. carinii infection). None of the four patients were treated with erythromycin. Symptoms ofchronic cough resolved during the course of therapy for all four individuals. (Since Bordetella is susceptible to trimethoprim-sulfamethoxazole [2], the bordetella infection in the two individuals with P. carinii pneumonia may have inadvertently been treated simultaneously.) Of the two patients who did not have risk factors for infection with HIV-I, one had an exacerbation of his chronic asthma and the other had pulmonary tuberculosis when B. bronchiseptica was recovered from respiratory specimens. The first individual's symptom of shortness of breath resolved spontaneously after appropriate therapy for asthma, and the second individual showed clinical improvement after institution of therapy for tuberculosis. Subsequent respiratory specimens were not submitted for bacterial culture from either individual. Severe pulmonary infection with B. bronchiseptica has primarily been reported to occur in immunocompromised patients [512]. Our retrospective experience is noteworthy in that two of our isolates were from individuals who were not obviously immunocompromised. Furthermore, our isolates obtained from four patients with AIDS did not appear to correlate with clinical infection since at least two of the patients recovered spontaneously without specific therapy for bordetella infection. Although we believe that the first patient's nagging persistent cough was attributable to incurable B. bronchiseptica infection, our retrospective experience coupled with a lack ofspecific clinical symptoms, laboratory values, or radiologic features of previously described cases of pulmonary disease due to B. bronchiseptica has
unfortunately demonstrated that the clinical significance of an isolate of B. bronchiseptica cannot always be readily assessed.
Fatal Measles Pneumonia in an Immunocompetent Patient-Case Report
before admission. The patient was treated with lithium carbonate, fluphenazine, and benztropine mesylate, and her condition improved. On hospital day 12, she had an oral temperature of 102"F. She was asymptomatic, and a physical examination was unremarkable. The patient's medications were discontinued, but she remained febrile. Two days later, exudative pharyngitis was noted, and therapy with oral penicillin V, 500 mg every 6 hours, was started. On the following day, an acneform facial rash developed, and administration of penicillin V was discontinued. A chest roentgenogram obtained later that day revealed diffuse bilateral reticulonodular infiltrates (figure I), and the patient was transferred to the medical center. The patient's oral temperature on admission was 103.4°F, and her respirations were 22/min. Lung fields were clear to auscultation. The leukocyte count was 5,600/mm 3, with an automated differential cell count of 95%granulocytes, 1%mononuclear cells, and 4%lymphocytes. An analysis ofarterial blood gas performed while the patient was breathing room air revealed a
Correspondence: Dr. Edward K. Chapnick, Division of Infectious Diseases, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, New York 11219. Clinical Infectious Diseases 1992;15:377-9 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0028$02.00
Divisions ofInfectiousDiseases and Pulmonary Medicine, Departmentsof Medicine and Laboratory Medicine, University of California, San Francisco. and San Francisco GeneralHospital, San Francisco, California
References I. Amador C, Chiner E, Calpe JL, Ortiz de la Tabla V., Martinez C, Pasquau F. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:771-2. 2. Decker GR, Lavelle JP, Kuman PN, Pierce PF. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:1250-1. 3. Kurzynski TA, Boehm OM, Rott-Petri JA, Schell RF, Allison PE. Antimicrobial susceptibilities of Bordetella species isolated in a multicenter pertussis surveillance project. Antimicrob Agents Chemother 1988; 12:137-40. 4. Goodnow RA. Biology of Bordetella bronchiseptica. Microbiol Rev 1980;44:722-38. 5. Buggy BP, Brosius FC III, Bogin RM, Koller CA, Schaberg DR. Bordetella bronchiseptica pneumonia in a patient with chronic lymphocytic leukemia. South Med J 1987;80: 1187-9. 6. Ghosh HK, Tranter J. Bordetella bronchicanis(bronchiseptica) infection in man: review and a case report. J Clin PathoI1979;32:546-8. 7. Stoll DB, Murphey SA, BallasSK. Bordetella bronchiseptica infection in stage IV Hodgkin's disease. Postgrad Med J 1981;57:723-4. 8. Meis JF. van Griethuisjen AJ. Muytjen JL. Bordetella bronchiseptica bronchitis in an immunosuppressed patient. Eur J Clin Microbiol Infect Dis 1990;9: 366-7. 9. Chauncey JB. Schaberg DR. Interstitial pneumonia caused by Bordetella bronchiseptica in a heart transplant patient. Transplantation 1990;49:817-9. 10. Katzenstein DA. Ciofalo L. Jordan MC Bordetella bronchiseptica bacteremia. West J Med 1984; 140:96-8. II. Papasian CJ, Downs NJ. Talley RL, Romberger OJ, Hodges GR. Bordetella bronchiseptica bronchitis. J Clin MicrobioI1987;25:575-7. 12. Byrd LH, Anarna L, Gutkin M. et al. Bordetella bronchiseptica peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin MicrobioI1981;14:232-3.
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 18, 2015
SIR-There has been a dramatic increase in the incidence of measles in the past 2 years [I]. Pneumonia is a recognized complication and is known to cause fatalities in immunosuppressed patients, but there are only rare reports offatal measles pneumonia in immunocompetent adults [2]. We report such a case. A 32-year-old woman with a history of bipolar affective disorder was admitted to our psychiatric hospital because of mania. She was born in Puerto Rico and moved to New York IS years
Valerie L. Ng, John M. Boggs, Mary K. York, Jeffrey A. Golden, Harry Hollander, and W. Keith Hadley
378
Correspondence
CID 1992: 15 (August)
Figure 1. Chest roentgenogram showing bilateral reticulonodular infiltrates.
pH of7.47. a Pco, of25 mm Hg, and a P0 2 of62 mm Hg. While the patient was breathing 60%O 2 via a face mask. the P0 2 rose to 159 mm Hg. Therapy with intravenous erythromycin. I g every 6 hours. was started. Approximately 12 hours later. the patient's facial rash became confluent and macular. An urticarial rash developed on her upper extremities. The patient remained febrile. with a maximum temperature of I04.6°F. On the following day. she was found to be pulseless and apneic. Efforts at resuscitation were unsuccessful. Cultures of blood and urine obtained at the onset of the patient 's illness were sterile. Throat cultures yielded no growth of group A l3-hemolytic streptococci or measles virus. The titer of IgM antibody to measles virus in serum was ;:.1:80. At autopsy. the only significant pathological findings were in the lungs. Multinucleated giant cells were present. and some of these cells contained intranuclear inclusion bodies (figure 2). In addition, there were occasional polymorphonuclear neutrophils and monocytes. Gram stain and acid-fast stain of lung specimens failed to reveal any organisms. Polymerase chain reaction for human immunodeficiency virus (HIV) antigen in lung tissue was done with use of primers in the gag region as described by Whetsell et al. [3]. No HIV antigen was found. Measles is complicated by pneumonia in 5% of cases [I J. The pneumonia may be due to the virus itself or to bacterial superinfections. Histologically, measles pneumonia is characterized by giant cells [4]. In a pediatric population, pneumonia accounts for 60% of fatalities in patients with measles, but it is less of a
Figure 2. Multinucleated giant cell lung biopsy specimen (stain, hematoxylin-eosin: magnification. X400).
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 18, 2015
problem in adults. In a large study of 3,220 cases of measles in Air Force recruits, 106 cases of pneumonia (3.3%) were found [5J. Since radiography was done only for patients with pulmonary signs or symptoms. this study may have underestimated the true incidence of measles pneumonia. No fatalities were reported. Barkin [6] reviewed 454 death certificates of patients who died with measles. Only 16 ofthese patients were> 15 years of age. and pneumonia was listed as the cause of death for six. Further clinical data on these patients were not given, except that II had an "underlying disease" (mostly mental retardation). Giant cell pneumonia in an adult was first reported in 1961 by McConnell [7]. The author described a 34-year-old man with "malignant reticulosis" who died; at autopsy the patient was found to have giant cell pneumonia. There are other reports of fatal measles pneumonia in immunosuppressed adults [4, 8]. To our knowledge, there have been only two prior reports of severe measles pneumonia in adults who do not have evidence ofimmunosuppression. Fasler [9] reported the case ofa 28-yearold woman with severe pneumonia who required intubation and who recovered. The diagnosis of measles was made by serology, with a rise in the antibody titer from 1:8 to I:256 by day 24. Stavale et al. [2] described an 83-year-old man who died with
CID 1992; 15 (August)
Correspondence
Edward K. Chapnick, Jeremy D. Gradon, Yong-doo Kim, Aida Narvios, Perry Gerard, Michele Till, and Douglas V. Sepkowitz
Recovery from Myasthenia Gravis of a Patient Infected with Human Immunodeficiency Virus
SIR-Myasthenia gravis (MG) is an autoimmune disorder clinically characterized by fluctuating weakness of voluntary muscles. The role of the thymus in this disease is still a matter of debate [1] even though morphological abnormalities in the organ, production of antibodies to the acetylcholine receptor (AChR) by thymocytes, and the presence ofabnormal amounts of B cells [2] suggest a crucial role of this organ. The case we report that occurred in a patient infected with the human immunodeficiency virus (HIV) supports such a role. A 38-year-old homosexual man living in Paris who had complained oftransient diplopia since 1972 was referred to a neurologist in June 1976 after he developed fluctuating bilateral ptosis, uncomfortable diplopia, and slight proximal muscle weakness. A dramatic resolution ofsymptoms occurred when he received pyridostigmine bromide (360 mg/d). In 1980 he attempted to stop treatment but relapse occurred immediately. In November 1984, when HIV infection became epidemic in Paris, he had a fever for 3 weeks that was associated with persistent lymphadenopathy. In April 1987 he developed herpes zoster and serum antibodies to HIV were detected. At this time the daily dose of pyridostigmine bromide was decreased, and this
Correspondence: Dr. D. Vittecoq, Department of Immunology. Hopital Necker. 161 rue de Sevres, 75015 Paris. France.
Clinical Infectious Diseases 1992;15:379-80 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0029$02.00
Division oj InJectious Diseases. Departments ofPathology and Radiology, Maimonides Medical Center. Brooklyn, New York; and Section oj Infectious Diseases, Northwestern University Medical School, Chicago, Illinois
References I. Centers for Disease Control. Measles-United States. 1989 and first 20 weeks 1990. MMWR 1990;39:353-5. 2. Stavale IN. Dias JC, Pereira Junior W. Lorenti Neto N, Amato Neto V. Guidugli Neto J. Measles giant cell pneumonia in adults: a rare disease occurring in normal as well as immunosuppressed hosts. Rev lnst Med Trop Sao Paulo 1982;24:257-61. 3. Whetsell AJ. Drew JB. Milman G. et al. Comparison of three nonradioisotopic polymerase chain reaction-based methods for detection ofhuman immunodeficiency virus type I. J Clin Microbiol 1992;30:84553. 4. Koffler D. Giant cell pneumonia. Fluorescent antibody and histochemical studies on alveolar giant cells. Arch Pathol 1964;78:267-73. 5. Gremillion DH, Crawford GE. Measles pneumonia in young adults. An analysis of 106 cases. Am J Med 1981;71:539-42. 6. Barkin RM. Measles mortality. Analysis of the primary cause of death. Am J Dis Child 1975; 129:307-9. 7. McConnell EM. Giant cell pneumonia in an adult. BMJ 1961;2:288-9. 8. Akhtar M, Young l. Measles giant cell pneumonia in an adult following long-term chemotherapy. Arch Pathol 1973;96: 145-8. 9. Fasler JJ. Measles pneumonia in an adult. BMJ 1977; I:615-6.
treatment was stopped in April 1989 (figure I). At this time. antibodies to AChR were not detectable in serum. Thirty months later the patient is still HIV-positive and neurologically asymptomatic. The association of MG to HIV infection has been reported twice [3. 4]; in both cases MG and AIDS-related conditions were diagnosed at the same time. Our case is different since MG well preceded (by 12 years) HIV primo-infection. The findings at autopsy of complete atrophy of the thymus in both pediatric and adult patients with AIDS [5] and increased thymosin-o I levels in patients with AIDS [6] suggest that the gland might be involved in the development of MG. The key role of this organ in the maturation, differentiation, and function of T cells is known. Recently, it has been demonstrated that thymic lymphocytes and even intrathymic T cell precursors and their progeny that express low levels of CD4 may be infected [7]. Antibodies to AChR were undetectable in our patient as in those previously reported [3, 4]. They are present in most patients with MG, but the correlation between antibody levels and severity of disease is not good, except in neonates [8]. Despite several follow-up studies, there is still no agreement on the relationship between changes in the clinical course of disease and serum levels of antibody to AChR after thymectomy. The conditions of about two-thirds of patients without thymomas who experience early onset of MG (before 40 years of age) improve following thymectomy, and a decrease in antibodies to AChR is reported in some cases [9] but not in all [10]. Despite the fact that patients with MG can experience remissions spontaneously during the first years of the disease, our case suggests durable recovery after a long course, which is apparently linked to the evolution of HIV infection. This recovery may be due to B cell dysfunction generated by HIV infection but
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 18, 2015
giant cell pneumonia; measles inclusion bodies were found by electron microscopy. Our patient did not have any known dysfunction of the immune system. She did not have any risk factors for infection with HIV, but it is unfortunate that a serum antibody test was not performed. However, since formalin-fixed, paraffin-embedded lung tissue was available, analysis for the presence of HIV type 1 DNA was performed on this tissue with use of the polymerase chain reaction, which can detect < 10 copy numbers of the viral genome. Since the patient's lung biopsy specimen contained inflammatory infiltrates that included mononuclear cells, one would expect this tissue to be positive for HIV DNA if the patient had been infected. We have described a case of fatal measles pneumonia in an otherwise healthy young adult. The diagnosis was supported by the clinical illness and the serological, histologic, and radiographic findings. The occurrence offatal measles pneumonia in an otherwise healthy adult further emphasizes the need to immunize susceptible individuals. This is especially relevant in light of the recent measles epidemic.
379
Correspondence
377
the other two did not have any risk factors for infection with the human immunodeficiency virus type I (HIV -I ). The four patients with AIDS had other serious pulmonary infections that were concomitantly present at the time of B. bronchiseptica isolation (two had P. carinii pneumonia, one had cytomegalovirus pneumonia, and one had pneumonia due to Pseudomonas species). Each of the four patients was treated with therapy specific for their pulmonic infectious disease (gentamicin for the Pseudomonas species infection, ganciclovir for the cytomegalovirus infection, and trimethoprim-sulfamethoxazole for the P. carinii infection). None of the four patients were treated with erythromycin. Symptoms ofchronic cough resolved during the course of therapy for all four individuals. (Since Bordetella is susceptible to trimethoprim-sulfamethoxazole [2], the bordetella infection in the two individuals with P. carinii pneumonia may have inadvertently been treated simultaneously.) Of the two patients who did not have risk factors for infection with HIV-I, one had an exacerbation of his chronic asthma and the other had pulmonary tuberculosis when B. bronchiseptica was recovered from respiratory specimens. The first individual's symptom of shortness of breath resolved spontaneously after appropriate therapy for asthma, and the second individual showed clinical improvement after institution of therapy for tuberculosis. Subsequent respiratory specimens were not submitted for bacterial culture from either individual. Severe pulmonary infection with B. bronchiseptica has primarily been reported to occur in immunocompromised patients [512]. Our retrospective experience is noteworthy in that two of our isolates were from individuals who were not obviously immunocompromised. Furthermore, our isolates obtained from four patients with AIDS did not appear to correlate with clinical infection since at least two of the patients recovered spontaneously without specific therapy for bordetella infection. Although we believe that the first patient's nagging persistent cough was attributable to incurable B. bronchiseptica infection, our retrospective experience coupled with a lack ofspecific clinical symptoms, laboratory values, or radiologic features of previously described cases of pulmonary disease due to B. bronchiseptica has
unfortunately demonstrated that the clinical significance of an isolate of B. bronchiseptica cannot always be readily assessed.
Fatal Measles Pneumonia in an Immunocompetent Patient-Case Report
before admission. The patient was treated with lithium carbonate, fluphenazine, and benztropine mesylate, and her condition improved. On hospital day 12, she had an oral temperature of 102"F. She was asymptomatic, and a physical examination was unremarkable. The patient's medications were discontinued, but she remained febrile. Two days later, exudative pharyngitis was noted, and therapy with oral penicillin V, 500 mg every 6 hours, was started. On the following day, an acneform facial rash developed, and administration of penicillin V was discontinued. A chest roentgenogram obtained later that day revealed diffuse bilateral reticulonodular infiltrates (figure I), and the patient was transferred to the medical center. The patient's oral temperature on admission was 103.4°F, and her respirations were 22/min. Lung fields were clear to auscultation. The leukocyte count was 5,600/mm 3, with an automated differential cell count of 95%granulocytes, 1%mononuclear cells, and 4%lymphocytes. An analysis ofarterial blood gas performed while the patient was breathing room air revealed a
Correspondence: Dr. Edward K. Chapnick, Division of Infectious Diseases, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, New York 11219. Clinical Infectious Diseases 1992;15:377-9 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0028$02.00
Divisions ofInfectiousDiseases and Pulmonary Medicine, Departmentsof Medicine and Laboratory Medicine, University of California, San Francisco. and San Francisco GeneralHospital, San Francisco, California
References I. Amador C, Chiner E, Calpe JL, Ortiz de la Tabla V., Martinez C, Pasquau F. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:771-2. 2. Decker GR, Lavelle JP, Kuman PN, Pierce PF. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:1250-1. 3. Kurzynski TA, Boehm OM, Rott-Petri JA, Schell RF, Allison PE. Antimicrobial susceptibilities of Bordetella species isolated in a multicenter pertussis surveillance project. Antimicrob Agents Chemother 1988; 12:137-40. 4. Goodnow RA. Biology of Bordetella bronchiseptica. Microbiol Rev 1980;44:722-38. 5. Buggy BP, Brosius FC III, Bogin RM, Koller CA, Schaberg DR. Bordetella bronchiseptica pneumonia in a patient with chronic lymphocytic leukemia. South Med J 1987;80: 1187-9. 6. Ghosh HK, Tranter J. Bordetella bronchicanis(bronchiseptica) infection in man: review and a case report. J Clin PathoI1979;32:546-8. 7. Stoll DB, Murphey SA, BallasSK. Bordetella bronchiseptica infection in stage IV Hodgkin's disease. Postgrad Med J 1981;57:723-4. 8. Meis JF. van Griethuisjen AJ. Muytjen JL. Bordetella bronchiseptica bronchitis in an immunosuppressed patient. Eur J Clin Microbiol Infect Dis 1990;9: 366-7. 9. Chauncey JB. Schaberg DR. Interstitial pneumonia caused by Bordetella bronchiseptica in a heart transplant patient. Transplantation 1990;49:817-9. 10. Katzenstein DA. Ciofalo L. Jordan MC Bordetella bronchiseptica bacteremia. West J Med 1984; 140:96-8. II. Papasian CJ, Downs NJ. Talley RL, Romberger OJ, Hodges GR. Bordetella bronchiseptica bronchitis. J Clin MicrobioI1987;25:575-7. 12. Byrd LH, Anarna L, Gutkin M. et al. Bordetella bronchiseptica peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin MicrobioI1981;14:232-3.
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 18, 2015
SIR-There has been a dramatic increase in the incidence of measles in the past 2 years [I]. Pneumonia is a recognized complication and is known to cause fatalities in immunosuppressed patients, but there are only rare reports offatal measles pneumonia in immunocompetent adults [2]. We report such a case. A 32-year-old woman with a history of bipolar affective disorder was admitted to our psychiatric hospital because of mania. She was born in Puerto Rico and moved to New York IS years
Valerie L. Ng, John M. Boggs, Mary K. York, Jeffrey A. Golden, Harry Hollander, and W. Keith Hadley
378
Correspondence
CID 1992: 15 (August)
Figure 1. Chest roentgenogram showing bilateral reticulonodular infiltrates.
pH of7.47. a Pco, of25 mm Hg, and a P0 2 of62 mm Hg. While the patient was breathing 60%O 2 via a face mask. the P0 2 rose to 159 mm Hg. Therapy with intravenous erythromycin. I g every 6 hours. was started. Approximately 12 hours later. the patient's facial rash became confluent and macular. An urticarial rash developed on her upper extremities. The patient remained febrile. with a maximum temperature of I04.6°F. On the following day. she was found to be pulseless and apneic. Efforts at resuscitation were unsuccessful. Cultures of blood and urine obtained at the onset of the patient 's illness were sterile. Throat cultures yielded no growth of group A l3-hemolytic streptococci or measles virus. The titer of IgM antibody to measles virus in serum was ;:.1:80. At autopsy. the only significant pathological findings were in the lungs. Multinucleated giant cells were present. and some of these cells contained intranuclear inclusion bodies (figure 2). In addition, there were occasional polymorphonuclear neutrophils and monocytes. Gram stain and acid-fast stain of lung specimens failed to reveal any organisms. Polymerase chain reaction for human immunodeficiency virus (HIV) antigen in lung tissue was done with use of primers in the gag region as described by Whetsell et al. [3]. No HIV antigen was found. Measles is complicated by pneumonia in 5% of cases [I J. The pneumonia may be due to the virus itself or to bacterial superinfections. Histologically, measles pneumonia is characterized by giant cells [4]. In a pediatric population, pneumonia accounts for 60% of fatalities in patients with measles, but it is less of a
Figure 2. Multinucleated giant cell lung biopsy specimen (stain, hematoxylin-eosin: magnification. X400).
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 18, 2015
problem in adults. In a large study of 3,220 cases of measles in Air Force recruits, 106 cases of pneumonia (3.3%) were found [5J. Since radiography was done only for patients with pulmonary signs or symptoms. this study may have underestimated the true incidence of measles pneumonia. No fatalities were reported. Barkin [6] reviewed 454 death certificates of patients who died with measles. Only 16 ofthese patients were> 15 years of age. and pneumonia was listed as the cause of death for six. Further clinical data on these patients were not given, except that II had an "underlying disease" (mostly mental retardation). Giant cell pneumonia in an adult was first reported in 1961 by McConnell [7]. The author described a 34-year-old man with "malignant reticulosis" who died; at autopsy the patient was found to have giant cell pneumonia. There are other reports of fatal measles pneumonia in immunosuppressed adults [4, 8]. To our knowledge, there have been only two prior reports of severe measles pneumonia in adults who do not have evidence ofimmunosuppression. Fasler [9] reported the case ofa 28-yearold woman with severe pneumonia who required intubation and who recovered. The diagnosis of measles was made by serology, with a rise in the antibody titer from 1:8 to I:256 by day 24. Stavale et al. [2] described an 83-year-old man who died with
CID 1992; 15 (August)
Correspondence
Edward K. Chapnick, Jeremy D. Gradon, Yong-doo Kim, Aida Narvios, Perry Gerard, Michele Till, and Douglas V. Sepkowitz
Recovery from Myasthenia Gravis of a Patient Infected with Human Immunodeficiency Virus
SIR-Myasthenia gravis (MG) is an autoimmune disorder clinically characterized by fluctuating weakness of voluntary muscles. The role of the thymus in this disease is still a matter of debate [1] even though morphological abnormalities in the organ, production of antibodies to the acetylcholine receptor (AChR) by thymocytes, and the presence ofabnormal amounts of B cells [2] suggest a crucial role of this organ. The case we report that occurred in a patient infected with the human immunodeficiency virus (HIV) supports such a role. A 38-year-old homosexual man living in Paris who had complained oftransient diplopia since 1972 was referred to a neurologist in June 1976 after he developed fluctuating bilateral ptosis, uncomfortable diplopia, and slight proximal muscle weakness. A dramatic resolution ofsymptoms occurred when he received pyridostigmine bromide (360 mg/d). In 1980 he attempted to stop treatment but relapse occurred immediately. In November 1984, when HIV infection became epidemic in Paris, he had a fever for 3 weeks that was associated with persistent lymphadenopathy. In April 1987 he developed herpes zoster and serum antibodies to HIV were detected. At this time the daily dose of pyridostigmine bromide was decreased, and this
Correspondence: Dr. D. Vittecoq, Department of Immunology. Hopital Necker. 161 rue de Sevres, 75015 Paris. France.
Clinical Infectious Diseases 1992;15:379-80 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0029$02.00
Division oj InJectious Diseases. Departments ofPathology and Radiology, Maimonides Medical Center. Brooklyn, New York; and Section oj Infectious Diseases, Northwestern University Medical School, Chicago, Illinois
References I. Centers for Disease Control. Measles-United States. 1989 and first 20 weeks 1990. MMWR 1990;39:353-5. 2. Stavale IN. Dias JC, Pereira Junior W. Lorenti Neto N, Amato Neto V. Guidugli Neto J. Measles giant cell pneumonia in adults: a rare disease occurring in normal as well as immunosuppressed hosts. Rev lnst Med Trop Sao Paulo 1982;24:257-61. 3. Whetsell AJ. Drew JB. Milman G. et al. Comparison of three nonradioisotopic polymerase chain reaction-based methods for detection ofhuman immunodeficiency virus type I. J Clin Microbiol 1992;30:84553. 4. Koffler D. Giant cell pneumonia. Fluorescent antibody and histochemical studies on alveolar giant cells. Arch Pathol 1964;78:267-73. 5. Gremillion DH, Crawford GE. Measles pneumonia in young adults. An analysis of 106 cases. Am J Med 1981;71:539-42. 6. Barkin RM. Measles mortality. Analysis of the primary cause of death. Am J Dis Child 1975; 129:307-9. 7. McConnell EM. Giant cell pneumonia in an adult. BMJ 1961;2:288-9. 8. Akhtar M, Young l. Measles giant cell pneumonia in an adult following long-term chemotherapy. Arch Pathol 1973;96: 145-8. 9. Fasler JJ. Measles pneumonia in an adult. BMJ 1977; I:615-6.
treatment was stopped in April 1989 (figure I). At this time. antibodies to AChR were not detectable in serum. Thirty months later the patient is still HIV-positive and neurologically asymptomatic. The association of MG to HIV infection has been reported twice [3. 4]; in both cases MG and AIDS-related conditions were diagnosed at the same time. Our case is different since MG well preceded (by 12 years) HIV primo-infection. The findings at autopsy of complete atrophy of the thymus in both pediatric and adult patients with AIDS [5] and increased thymosin-o I levels in patients with AIDS [6] suggest that the gland might be involved in the development of MG. The key role of this organ in the maturation, differentiation, and function of T cells is known. Recently, it has been demonstrated that thymic lymphocytes and even intrathymic T cell precursors and their progeny that express low levels of CD4 may be infected [7]. Antibodies to AChR were undetectable in our patient as in those previously reported [3, 4]. They are present in most patients with MG, but the correlation between antibody levels and severity of disease is not good, except in neonates [8]. Despite several follow-up studies, there is still no agreement on the relationship between changes in the clinical course of disease and serum levels of antibody to AChR after thymectomy. The conditions of about two-thirds of patients without thymomas who experience early onset of MG (before 40 years of age) improve following thymectomy, and a decrease in antibodies to AChR is reported in some cases [9] but not in all [10]. Despite the fact that patients with MG can experience remissions spontaneously during the first years of the disease, our case suggests durable recovery after a long course, which is apparently linked to the evolution of HIV infection. This recovery may be due to B cell dysfunction generated by HIV infection but
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 18, 2015
giant cell pneumonia; measles inclusion bodies were found by electron microscopy. Our patient did not have any known dysfunction of the immune system. She did not have any risk factors for infection with HIV, but it is unfortunate that a serum antibody test was not performed. However, since formalin-fixed, paraffin-embedded lung tissue was available, analysis for the presence of HIV type 1 DNA was performed on this tissue with use of the polymerase chain reaction, which can detect < 10 copy numbers of the viral genome. Since the patient's lung biopsy specimen contained inflammatory infiltrates that included mononuclear cells, one would expect this tissue to be positive for HIV DNA if the patient had been infected. We have described a case of fatal measles pneumonia in an otherwise healthy young adult. The diagnosis was supported by the clinical illness and the serological, histologic, and radiographic findings. The occurrence offatal measles pneumonia in an otherwise healthy adult further emphasizes the need to immunize susceptible individuals. This is especially relevant in light of the recent measles epidemic.
379
