gold standard for diagnosis of BOOP. Some authors argue that TBB is inadequate for diagnosis because of the small specimens obtained and the patchy nature of the disease.' Nevertheless, as has been shown previously, good transbronchial specimens in conjunction with an appropriat~· clinical context may be adequate to establish a clinical diagnosis of BOOP.•·• Moreover, as in recipients of heart-lung transplants, 7 •8 TBB may offer a safe and repeatable method to obtain tissue for histologic study from patients with BOOP and a relapsing course, as the one whose case was reported herein. When our patient presented a lingular infiltrate after the diagnosis of lymphoma had been established, we were forced to confirm its true nature histologically, since both conditions, BOOP and non-Hodgkins lymphoma (NHL), share the roentgenographic appearance of multiple patchy alveolar opacities. NHL rarely presents with pulmonary infiltration in the absence of involvement outside the chest (5.5 percent as initial site), but in case of relapse, with postmortem study this figure may increase to 37.8 percent. • To the best of our knowledge, in only one previous article is mention made of two patients in whom lymphoma coexisted with bronchiolitis obliterans. 2 Both cases had . added pathologic conditions: diabetes in one and idiopathic thrombocytopenic purpura in the other. Additional information on these cases is scanty, and neither the type of bronchiolitis nor its cause can be determined from the report. Whether a true pathogenic relationship exists between these two infrequent diseases remains to be defined. The immunosuppressive role of corticosteroids in our patient must be considered. Although the relationship between the use of other immunosuppressive agents such as cyclosporine and the development of NHL have been demonstrated, such a link has not been observed with corticosteroids. 10 On the other hand, these agents may facilitate infection by viruses with oncogenic properties, but neither multinucleate giant cells nor intranuclear inclusions typical of viral infection were noted in our patient. Genetic and acquired immune deficiency and autoimmune disorders predispose to the development oflymphoid malignant neoplasms. The dramatic response of BOOP to corticosteroids' and the association of BOOP with both connective tissue diseases and organ transplantation provide circumstantial support for an autoimmune pathogenesis. In our patient, a single autoimmune mechanism cannot be excluded.

W7:382-94 6 Bartter T, Irwin RS, Nash G, Balikian JP, Hollingsworth HH. Idiopathic bronchiolitis obliterans organizing pneumonia with peripheral infiltrates on chest roentgenogram. Arch Intern Med 1989; 149:273-79 7 Higenbottam T, Stewart S, Penketh A, Wallwork J. Transbronchial lung biopsy for the diagnosis of rejection in heart-lung transplant patients. Transplantation 1988; 46:532-39 8 Yousem SA, Paradis IL, Dauber JH, Griffith BP. Efficacy of transbronchial lung biopsy in the diagnosis of bronchiolitis obliterans in heart-lung transplant recipients. Transplantation 1989; 47:893-95 9 Straus Dj, Filippa DA, Lieberman PH, Koziner B, Thaler HT, Clarkson BD. The non-Hodgkin's lymphomas, I: a retrospective clinical and pathologic analysis of 499 cases diagnosed between 1958 and 1969. Cancer 1983; 51:101-09 10 Keown PA, Stiller CR. Cyclosporine: a double edged sword. Hosp Pract 1987; 22:W7-20

Reversible Left Ventricular Dysfunction Induced by Recurrent Ventricular Tachycardia* Ka!Vi lga,

M.D.; Kenjiro Hori, M.D.; and Tadashi Matsumura, M.D., F.C.C.P.

Two cases of transient LV dysfunction associated with VT are described. Both patients had a history of palpitations of several years' duration without symptoms of congestive heart failure. The reason for presentation was an increase in frequency and duration of palpitation. Decreased LV wall motion, observed by 2DE, normalized shortly after treatment of the VT. Diffusely decreased LV wall motion is associated with frequent episodes of VT and may mimic DCM except that signs and symptoms of heart failure are absent. (Chest 1992; 102:1897-98) 2DE =two-dimensional echocardiography; DCM =dilated cardiomyopathy; %FS=fractional shortening; LV= left ventricular; LVDd=LV end-diastolic dimension; LVDs=LV end-systolic dimension; vr =ventricular tachycardia

S

evere myocardial disease associated with VT has a poor prognosis. We present two cases with LV wall motion impairment which normalized shortly after treatment of frequent episodes ofVT. CASE REPORTS

REFERENCES

1 Epler GR, Colby Tv, Mcloud TC, Carrington CB, Gaensler EA. Bronchiolitis obliterans organizing pneumonia. N Eng! J Med 1985; 312:152-58 2 Gosink BB, Friedman PJ, Liebow AA. Bronchiolitis obliterans: roentgenologic-pathologic correlation. AJR 1973; 117:816-32 3 National Cancer Institute. National Cancer Institute sponsored study of classification of non-Hodgkin's lymphomas: summary and description of a working formulation for clinical usage. Cancer 1982; 49:2112-35 4 Muller NL, Staples CA, Miller RR. Bronchiolitis obliterans organizing pneumonia: Cf features in 14 patients. AJR 1990; 154:983-87 5 Davison AG, Heard WA, McAllister WAC, Turne!'-Warwick MEH. Cryptogenic organizing pneumonitis. Q J Med 1983;

CASE

1

A 41-yeaJ'-old man had a history of transient rapid palpitations for several years. The palpitations became more frequent and severe, lasting for more than 24 h, and he presented to our outpatient department two days after one such episode. He had not received any medication for arrhythmia. Two-dimensional echocardiography showed diffusely decreased LV motion at a time when the patient had normal sinus rhythm. Left ventricular end-diastolic and end-systolic dimensions were 45 and 37 mm, respectively (Fig 1, top left). The patient was treated with verapamil, 1W mglday, *From the Department of Cardiology, Tenri Hospital, Tenri City, Japan. Reprint requests: Dr. Iga, Department ofCardiology Tenri Hospital Tenri 632, japan ' ' CHEST I 102 I 6 I DECEMBER, 1992

1897

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~- ----_-=:-

-:--"~eclively (Fig 2, /Q]I left ). Huns of repelili\e 11HliiOmurphic of (I maximum of sewn were doc11mcnted on e lectrocardio)!raphic moni toring (F ig 2, bottom). Tlw arrhyt hmia wa~ C."nlrolled b) mexiletine, 300 mg, and metoprorul, .JO m)tfclay. ThP LV motion nonualized after three days of tre;tlnwn t. Coronary angiograph) showed no abnormalities.

vr

D ISCUSS ION

\'e ntricular tachycardia sometimes is associated with myocardial disl•ase. especially in the presence of congestive heart ((,ilure. ll is an important indicator of prognosis in pati(•nts wi th DCM. ' On the othe r hand, sustained monomorphic \ T associated with no rmal LV wall motion has heen called idiopathic\ Taud its clinicaJ course has heen reported to he hen i~1. J lle nee, it is important to detem1ine w hether or not L\' wall motion is disturbed in patie nts with ventricular urrhythmias. Both patients reported he re had an increase in the frequency and severity of palpitation which had been present f{)l' a number of years. Because of the long-standing history of VT, acute viml myocarditis was excluded. Although all antiarrh ythmic a~ents wo rk as myoca rdiaJ depressants, druginduced lrausie ut myocardial depression is not possible because of the negative h istory. ormal coronary angio1898

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2 . Diffusely decreased LV motion (top left) normalized three days afte r termination of recurre nt Vf (top right). Tht' LVDd is unchanged, but % FS is improved. Monomorphic re pe titi ve Vf wilb three