Table 1-Auociated DiBeaaes in 32 Patients with Pulmonary HamartomaCardiovascular diseases Hypertension Coronary disease Iliofemoral stenosis Venous insufficiency in the lower extremities Heart conduction defects Aortic and mitral stenosis and insufficiency Abdominal aortic aneurysm Gastrointestinal diseases Appendicitis Hiatal hernia Peptic ulcer Cholelithiasis Gastritis Esophageal diverticula Hernias Inguinal Umbilical Skeletal diseases Arthrosis Scoliosis Sudeeks disease of the ankle Herniated disk Genitourinary diseases Nephrolithiasis Renal cyst Acute glomerulonephritis Prostatic hypertrophy Testicular atrophy Neurologic diseases Chronic subdural hematoma Metabolic diseases Hyperlipidemia Diabetes mellitus Benign tumors Prostatic adenoma Adrenocortical hyperplasia Lipoma Ovarian cyst Cystic breast Serous tumor of the ear Malignant tumors Lung cancer Dermatologic cancer Laryngeal cancer

ated with a larger series of pulmonary hamartomas would be required in order to confirm the hypothesis developed by Gabrail and Zara.

v

M. Vallena, M.D., L. Hemdndez-Blasco, M.D., M. lzquierdo-Iutron; M.D.,

6 5 1 1 1 1 1 3 3 2 1 1 1

1 1 3 1 1 1 2

1 1 1 1

3 4

3 1 1 1 1 1 2 2 1

F. Gonzalez-Garrido, M.D., and

J

Echaoe-Sustaeta, M. D.,

Pneumology Seroice,

Hospital 12 de Octubre,

Madrid, Spain

REFERENCES 1 Gabrail NY, Zara BY. Pulmonary hamartoma syndrome. Chest

1990;97:962-65

2 Van der Bosch JMM, Wagenaar SS, Corrin B, Elbers JRJ,

Knaepen PJK, Westermann CJJ. Mesenchymoma of the lung (so called hamartoma): a review of 154 parenchymal and endobronchial cases. Thorax 1987; 42:790-93

1b the Editor:

All retrospective studies and observations have to be subjected to scrutiny. Scientific accuracy is always questioned in such studies. This is true both in positive studies, like our report describing pulmonary hamartoma syndrome, as well as the negative studies, such as the kind of report presented by Villena et ala Pulmonary hamartomas are very rare, and most series involve small numbers of patients seen over a period of several years or decades. Obviously the quality of data preservation, collection, and review will have a dramatic impact on the results of the study. Hence, it is not surprising that some series will fail to show the dramatic associations that we observed in our series. In fact, we have completed study of a second series of pulmonary hamartomas from a different institution, and it is to be submitted for publication. We were surprised again to observe most of the congenital anomalies and benign tumors reported in our 6rst series in addition to some new anomalies. We hope that other institutions will review their cases so that the identity of this syndrome can be clarified more accurately.

Nashat 1: Gabrail, M.D., and Barbara 1: Zara, M.D.,

nmken Mercy Medical Center, Canton, Ohio

Role of Clprofloxacln in Fatal seizures

*Valuesare numbers of patients with a given disease. Some patients had more than one other disease in addition to pulmonary hamartoma.

1b the Editor:

matic in 17 of the cases, since it was diagnosed while other diseases were being investigated; that fact would surely affect the incidence of concomitant pathologic conditions in this population. Similarly, 16 of the 24 patients (67 percent) studied by Gabrail and Zara were over 55 years of age, an age group in which the aforementioned pathologic conditions are frequently identified by means of physical examination or anamnesis. The increased incidence of associated malignant pulmonary tumors, as noted earlier," was con6rmed in our report by two concurrent cases. However, it may well be that the actual incidence of pulmonary hamartoma is greater than we realized, being underdiagnosed due to the few symptoms and being detected only when specific diagnostic procedures are conducted (chest roentgenography and fiberoptic bronchoscopy) or when tumor spread is being examined. Therefore, a review of the pathologic conditions associ-

Elevation of serum theophylline levels by concomitant administration of cipro8oxacin and theophylline has been well described. Less well known is the ability of ciprofloxeein to cause seizures. I would like to report a case of a fatal episode of status epilepticus associated with concomitant administration of these drugs, despite a normal serum theophylline level. A 60-year-old man with severe COPD and a history of active cavitary Mycobacterium avium-intraceUulare (MAl) infection experienced a grand mal seizure while receiving eiprofloxaein and theophylline for treatment of a community-acquired pneumonia. He had no history of prior seizure disorder, and the serum theophylline level measured at the time of the seizure was 18 J.Lglml. Electroencephalographic findings were normal, and phenytoin sodium (Dilantin; Parke-Davis, Morris Plains, NJ) therapy was discontinued four weeks after the seizure. It was assumed that CHEST I 101 I 3 I MARCH, 1992

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"multiple metabolic factors:' including hypoxemia and a high normal theophylline level, had caused the seizure. One year later a bronchopleural fistula developed at the bronchial stump of a prior upper lobectomy (performed for control of cavitary MAl infection ten years previously). Hospitalization ensued, and the patient was treated for lower lobe pneumonia with cefuroxime. An infectious disease consultation suggested that he be discharged on a regimen of ciprofloxacin, 500 mg twice daily. to treat both active MAl and community-acquired pathogens. One week after discharge the patient presented to the emergency room in status epilepticus. Administration of diazepam to control seizures caused a respiratory arrest. and intubation and mechanical ventilation were unsuccessful due to rupture of the bronchopleural fistula. The serum theophylline level was 10.8 tLWml, and the serum sodium concentration was 131 tLglml. No other cause of seizure could be located. although the head cr scan was not completed due to his cardiac arrest in the cr room. The Physicians' Desk Referencel lists seizures as a possible adverse reaction associated with ciproftoxacin, but it should be emphasized that they can occur in the presence of a normal serum theophylline level. A recent literature review revealed only one case of seizures associated with a quinolone antibiotic." With the increasing use of this class of antibiotics," I believe it is critically important that physicians be aware of the potential for seizure activity in the absence of an elevated serum theophylline level. Michael B. Bader; M.D., F.C.C.f,

Stoneham, Massachusetts

REFERENCES Physicians' desk reference, 44th ed. Oradell, NJ: Medical Economics Company, 1990; 1496-99 2 Anastasio CD. Norftoxacin and seizures. Ann Intern Med 1988; 109:169-70 3 Frieden TR, Manji RJ. Inappropriate use of oral ciprofloxacin. JAMA 1990; 264:1438-40

Long-term Postthoracotomy Pain 1b the Editor:

Dajczman et all deserve our thanks and congratulations for their superb study of protracted postthoracotomy pain, which appeared in the February 1991 issue of Chest. Though common, postthoracotomy intercostal neuralgia is rarely mentioned in the medical literature and is dismissed by many thoracic surgeons as a banal, very transient postoperative sequela. Patients, however, often interpret it as a recurrence of their malignancy or are puzzled by its accompanying symptoms (eg, intense hyperesthesia or paresthesia in an anesthetic area, muscular twitches, intercostal hernia). The diagnosis is easily confirmed by bupivacaine intercostal blocks at the operative-site interspace. Complete, albeit transient, relief should reassure the patient that the pain is indeed incisional. But providing definitive relief is difficult, as the authors rightly point out. Neurolysis, cryolysis or thermocoagulation, and peripheral neurosurgery have been disappointing. Such failures after successful local anesthetic blocks are typical of deaJJerentation syndromes. i Indeed, Sunderland" has attributed postthoracotomy neuralgia to avulsion of the intercostal nerve during surgery. However, some symptoms, such as trigger points and aggravation of the pain with chest wall movements, point to scar or suture entrapment of the nerve or of a neuroma. The treatments for. deafferentation pain (transcutaneous electrical nerve stimulation, anticonvulsants, tricyclic antidepressants, nonsteroidal anti-inflammatory drugs) may be helpful. Dorsal root entry zone ablation seems not to have been tried.'

884

Surgeons have ignored a 1973 report" that postthoracotomy intercostal neuralgia is rare when rib resection is avoided and deep muscle relaxation is used for access to the lung. These results need to be confirmed.

Hay]. Defalque, M.D., and

Gwendolyn L. Boyd, M.D., F.C.C.l, Department ofAnesthesiology, U,dversUy of Alabama,

Birmingham

REFERENCES 1 Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term postthoracotomy pain. Chest 1991; 99:270-74 2 Tasker RR. Neurostimulation and percutaneous neural destructive techniques. In: Cousins MJ, Bridenbaugh PO, eds. Neural blockade. Philadelphia: JB Lippincott, 1988; 1085-117 3 Sunderland S. Nerves and nerve injuries. New York: Churchill Livingstone, 1978; 1018 4 Davar G, Mackewicz RJ. Deafferentation pain syndromes. Neurol Clin 1989; 7:289-304 5 Hansen JL. Intercostal neuralgia following thoraco-abdominal surgery. Acta Chir Scand SuppI1973; 433:180-82

1b the Editor:

In response to the informative letter from Drs Defalque and Boyd, we are in agreement on the need to con6rm benign protracted postthoracotomy pain in those patients suspected of suffering from this syndrome. By doing this, two purposes would be served. First, it would relieve the concern of the patient that be has recurrent cancer. Second, it would stimulate concentrated effort to find therapeutic interventions that may have some benefit for the individual. We agree that attention should now be focused on strategies and therapeutic modalities to prevent or treat this troublesome syndrome. Transcutaneous electrical nerve stimulation, anticonvulsants, tricyclic antidepressants, nonsteroidal anti-inflammatory drugs, and dorsal route entry zone ablation require investigation. However, it must be remembered that in most cases the intensity of pain is such that only simple analgesics are required. For those with more severe pain, the above treatments warrant study. Since those with severe pain constitute only a small proportion of all those with chronic postthoracotomy pain, any prospective randomized trial to determine the efficacy of a treatment might require multicenter participation to achieve sufficient sample size. Hopefully, these communications will create interest in such endeavors within the medical community. Wolkove, M.D., F.C.C.f, and Esther DajezmaR, M.Sc.AN., Division of Pulmonary Diseases, Sir Mortimer B. Davis-Jewish General Hospital, Montreal NonntlR

Bronchoscopy Begets Bronchoscopy Use of Flberoptlc Bronchoscope to Remove a Foreign Body Left Behind after Previous Bronchoscopy 7b the Editor: Since the invention of the flexible 6beroptic bronchoscope (FFB) by Ikeda' in the late 196Os, its advantages over the rigid bronchoscope (RB) have quickly become apparent, not only in diagnosis of pulmonary disorders but also in removal of foreign bodies from the Communications to the Editor