with

the

smaller

which

minimizes

result

of this,

Shiley

prosthesis

valvular

the

not

around

a single has

ease

of

occurred

left

coronary

cusp,

of the hinge.

Bj#{246}rk-

consecutive

1973

to

sizes

and

REFin r s

As a

a thrombosed

in 270

of all prosthetic

aortie

October

1975),

in many

eases

that

experience

1 Eshelman FN: Isoniazid with corticosteroids with previous positive tuberculin test? (letter tor) . Chest 69 :805, 1976 2 Gabrielsen AE, Good HA : Chemical suppression tive

anticoagulation.

recognize

our

the

the area

(October

use

marginal

We far

towards

stasis

replacements

despite with

aperture

3

longer with

follow-up

the

is needed,

valve

so oriented

but has

so

Isoniazid

with

Patients

4

Fernandez,

Corticosteroids

Infected

with

Immunol

Malomut

6:91,

N : Effects

of tubereulous

modification 62:337,

Kaplan

of

lesions

by

of adop-

1967 cortisone

on

the

de-

streptomycin

in guinea pigs and on therapy. Am Rev

D,

P:

1950

MH,

Armstrong

Rosen

Tuberculosis

compli-

neoplastic disease : A review of 201 eases. Cancer 1974 5 MacGregor RR, Sheagren JN, Lipsett MB, et al : Alternate day prednisone therapy: Evaluation of delayed hypersensitivity responses, control of disease and steroid side effeets. N Engi J Med 280: 1427, 1969 6 Fauci AS, Dale DC, Bulow JE : Glucocortico-steroid therapy: Mechanism of action and clinical considerations. Ann Intern Med 84:304, 1976 7 ALA/ATS/CDC Statement: Preventive therapy of tubereulous infection. Am Rev Respir Dis 110:371, 1974 eating 33:850,

in

Mycobacterium

tuberculosis To the

DM,

their Tubere

been

M.D., F.C.C.P. Associate Chief of Thoracic and Cardiovascular Surgery Deborah Heart and Lung Center Browns Mills, NJ

Department

Spain

Adv

velopment

good. Javier

immunity.

in patient to the edi-

Editor:

Dr.

Eshelman’s’

recent

interesting

questions

ment

isoniazid

with

bacterium

communication

about for

the

role

who

infected

are

is

can exert

evidence

that

a variety

tuberculous

therapy

therapy

with

of undesirable

with

To

infection

and

corticosteroids

prescribed,

underlying given,

disease and

from

tuberculosis

present

which

other in

defined.

and

from

for the

absence

of data

with

corticosteroids

preventive

be

followed.

therapy

clearly

are receiving prolonged should be considered at

therapy increased

or

considered therapy

the

whether

alternate-day as with

that

persons

infected

steroids

basis,

a priority isoniazid.

factors

indicating for

a positive

daily

steroids

risk

group This

the

infection

with risk

for

should test

who

corticosteroids of developing

administered

should,

preventive

risk with

or is reduced by current guidelines tuberculin

are

and

nizes the potential consequences patients, as well as for persons

71:

pleural

undergo

finding

of

caseous tuberculous

necrosis cause

effusion

needle

granulomatous

is presented

to

tuberculosis

may

of

biopsy

unknown of

the

pleuritis

with

etiology pleura.

or

The

without

is considered strong evidence of the effusion. 2 The following

demonstrate be

that

responsible

on

therefore,

receiving approach

of tuberculosis exposed to them.

3, 1977 MARCH,

CASE

diseases for

for

other

a case

than

granulomatous

a be

preventive recog-

for these

REPORT

A 62-year-old woman was referred to Confederate MemoriCenter for evaluation of a left pleural effusion. She had been well until two months prior to admission, at which time she developed a productive cough, malaise, chills, fever, and left-sided pleuritie chest pain. At this time the patient was treated with penicillin and rapidly became asymptomatie; however, several weeks later, she noted the insidious onset of dyspnea on exertion and fatigue. A subsequent chest x-ray film showed a large left pleural effusion. Physical examination at the time of admission revealed an

al Medical

afebrile

Jeffrey L. Glassroth, M.D. Laurence S. Farer, M.D., M.P.H. Tuberculosis Control Division Center for Disease Control, Atlanta

and

CHEST,

with

frequently

pleuritis.

for

these individuals. The use regimens, which seem to intact5 and to be atcomplications,6 further eon-

with

tuberculosis,

with

of tubereulous

Patients

of of is

variety

wide

therapy

tubercle bacilli is related to dosage alternate-day therapy, we believe that for

results,

preparations

the

Editor:

of

of alternate-day corticosteroid leave delayed hypersensitivity tended by fewer infectious founds the issue. In the

of the

This

concomitant

some

of therapy

on the course Unfortunately,

disease.24

exact risk to the patient is not well in part, from the varying dosages

the

Patients

corticosteroids

effects

Secondary

Myco-

corticosteroids. There

Pleuritis

to Blastomycosis

treat-

with

receiving

Gra nulomatous

several

of preventive

individuals

tuberculosis

raises

chronically

ill appearing

woman

with

signs

of

a left

pleural effusion. Several smears of sputum for acid-fast bacilli and fungi and the skin test with intermediate-strength purifled protein derivative of tuberculin ( PPD ) were negative. A thoracocentesis yielding 1,500 ml and a pleural biopsy were performed. The pleural fluid was yellow and had a protein level of 6.6 gm/100 ml, a glucose level of 117 mg/100 ml, and a lactic dehydrogenase level of 226 milliunits/ml, with a simultaneous serum protein level of 7.7 gm/100 ml and a lactic dehydrogenase level of 192 milliunits/ml. The cell count of the pleural fluid was 3,150/cu mm, and 85 percent were small lymphocytes. The pleural biopsy revealed multiple granulomas with minimal caseous necrosis centrally. Smears

COMMUNICATIONS TO THE EDITOR

433

of the pleural fluid and stains of sections of tissue from the pleural biopsy were negative for acid-fast bacilli and fungi. A presumptive diagnosis of tubereulous pleuritis was made, and the patient was discharged on a regimen of isoniazid and ethambutol. Three weeks later, cultures of both sputum and pleural fluid were reported to be positive for Blastomyces dermatitidis. The patient had lost 0.9 kg ( 4 lb ), and her left pleural effusion was still present. The fungal complement-fixation

test for

Blastomyces

was

positive

at a titer

The

of 1 :64.

was treated with 1,425 mg of amphoteriein months, her chest x-ray film was normal. strength PPD skin test remained negative.

patient

B, and after five Her intermediate-

A patient

with

in

213

an exudative

tients, Like

the

all

nally

thought

from

were

effusion

to have

one

series,

in

tubereulous

additional

previous

instances

Pleural

was

with blastomycosis. operative study6 only four patients the

pleuritis. origi-

patient

was

Brewer

and

Himmelwright

Sokolowski

found

at

is

believed

et

open

of pleural

fluid

positive

occur

centage

of patients will

with

noninfectious with

have

an

diseases.

sareoidosis8 exudative

Pulmonary

This award

requests: University,

434

COMMUNICATIONS

5

7

study was HL 70359

blastomyco-

hos.

A small

K:

Diagnosis

pleurisy.

Spivey

CC

and

Seand

Jr.

Baird

differential

J Respir

GD:

diag-

( Suppl)

Dis

Pleural

involvement

graphic

manifestations

Chest

of acute

69:345-349,

and

chronic

blastomycosis.

1976

SB, Rabinowitz JG, Ulreich S, et al: Pleural involvement in sareoidosis. Am J Med 57:200-209, 1974 9 Von Hoff DD, LiVolsi V: Diagnostic reliability of needle biopsy of the parietal pleura. Am J Clin Pathol 64:2008 Wilen

1975

The

Professional Medical

Cardioversion and

Psychiafric

Enfify

may per-

Conversion countershock which may patients strong

of cardiac arrhythmias by electrical is a well-established medical treatment’ generate higher-than-justified hopes for

whose emotional

immediate tion geared abstract

cardiac factors.

medical toward

problems Such

are patients

interwoven need not

care, but also psychiatric crisis intervention. The

of a clinical

case

describes

such

with only

consultafollowing

a patient:

rheumatoid effusion

supported from the

Dr. Light, School of Medicine, P0 Box 33932, Shreveport 71130

TO THE EDITOR

Kokkola

in the 1958

To the Editor:

uncommon

or with pleural

RM,

A New

CASE

with

in part National

Owen NeLson, M.D. and Richard W. Light, M.D., F.C.C.?. Diseases Section, Department of Medicine School of Medicine Louisiana State University, Shreveport

State

4

Sehub

d AC : Pleural biopsy Lancet 2: 1349-1353,

MJ, Poll . effusion.

in histoplasmosis. Am Rev Respir Dis 94:225-232, 1966 Brewer PL, Himmelwright JP: Pleural effusion due to infection with Histoplosma capsulatum. Chest 58:76-79, 1970 Sokolowski JW Jr, Sehillaci 1W, Motley TE: Disseminated cryptococcosis complicating sarcoidosis. Am Rev Respir Dis 100:717-722, 1969 Blastomyeosis cooperative study of the Veterans Administration : Blastomycosis : 1 . A review of 198 collected cases in Veterans Administration Hospitals. Am Rev Respir Dis 89:659-672, 1964 Gush R, Light RW, George RB: Clinical and roentgeno-

Patient

granulomas on aspiration biopsy of the pleura. Although the great majority of patients with granulomatous pleuritis will have tuberculosis, a small percentage will have fungal disease. Therefore, fungal smears and cultures of the sputum and pleural fluid should be obtained from all such patients. ACKNOWLEDGMENT: by pulmonary academic Heart and Lung Institute.

3

reported

be

for

H,

to cryptoeach of the

a15

thoracotomy. to

Poppius

203,

the pleura can and associates3 pleuritis secon-

a recent report of 50 eases from our pleural changes in 13 (26 percent) be stated that granulomatous pleuritis

at times pleuntis9

pa-

In the Veterans Administration coof 198 patients with blastomycosis, had pleural effusion, and in only one

culture

sis; however, pital showed It should

even the

P, Purves of pleural

nosis in tubereulous 63:105-110, 1968

pleuritis.

case.

involvement

of

tuberculous

our

fungal disease of pleuritis. Schub of granulomatous and

2

evi-

and 109

of granulomatous pleuritis secondary The granulomatous pleuritis in

coccosis.

and

biopsies,

lacking

to have

in these

to histoplasmosis,

reported

was

was

considered

patients

It is known that produce granulomatous reported three cases

a case

pleural

by culture

proof

dary

pleural

granulomatous disease on pleural biopsy is presumed to have tuberculous pleuritis. In series, 2 granulomatous pleuritis was found specimens

though

1 Mestitz diagnosis

6

DIscussIoN

dence of generally two large

REFERENCES

Louisiana

On

Nov

7,

1974,

a

REPORT

54-year-old

of

a few

asthma the

last

hours’

for

the

18

duration.

The

last

three

years

for

which

months,

man came to the not-for-profit hospital and severe chest pains

white

emergency room of a large, voluntary, for treatment of shortness of breath past

history

and the

included

a cardiac patient

bronchial

for

arrhythmia

had

undergone

several unsuccessful eardioversions. He was rather vague as to specific details of where these procedures took place. On further questioning, the patient stated that he had been a patient at two leading hospitals in New York City for similar problems. His history of medications included quinidine,

aminophylline,

and

choline

theophyllinate

(Choledyl). The physical

examination revealed an obese white man in no acute distress, who seemed to be very much up-to-date in medical terminology. Expiratory wheezes were audible. The pulse rate was 90 beats per minute and irregular. The patient had two fresh marks on his chest that look like marks from cardioversion, but he refused to admit that he CHEST, 71: 3, MARCH,

1977