Correspondence EXTRACTION OF FOREIGN BODIES WITH FIBEROPTIC BRONCHOSCOPY IN MECHANICALLY VENTILATED PATIENTS
To the Editor: We enjoyed reading the interesting article by Lan and colleagues (1) showing the efficiency and safety of endobronchial extraction of foreign bodies using a flexible fiberoptic bronchoscope. Two of their 33 patients were on mechanical ventilation, but they do not refer to a procedure that must be considered before the retrieval of a foreign body in intubated patients. If the size of the foreign body is greater than the internal diameter of the tracheal tube, it will be necessary to remove simultaneously the tube, the fiberoptic bronchoscope, and the forceps grasping the foreign body. Then, the patient must be immediately re-intubated and ventilated. We have performed this procedure in two patients receiving mechanical ventilation via orotracheal Macllinkrodt tubes (inner diameter, 8.5 mm). Both patients, 15 and 18yr of age, were in a coma due to craniofacial trauma. In one, weextracted a fragment of maxilla (2.3 x 1.6 em) situated in the intermediate bronchus. In the second, who also had a right pneumothorax, we removed a tooth (2 x 0.9 em) from the left main bronchus. Both patients recovered satisfactorily. In both cases, we used an intersurgical 2503 swivel connector, an Olympus BF type 10bronchoscope, and an Olympus W-shape FG-4L forceps. We also attended a comatose 65-yr-old patient who was ventilated through a tracheostomy. He had aspirated two teeth, one located in the intermediate bronchus, which we extracted, and the other in the upper left lobe, which we were unable to remove due to the lack of suitable forceps. The patient died of sepsis and respiratory distress due to pneumonia. The procedure that we described for patients using orotracheal tubes has not been reported by other investigators (2). It avoids the extraction of large foreign bodies through a rigid bronchoscope and the impaction of the foreign body in the endotracheal tube. But we insist this procedure requires a perfect coordination of a skillful team prepared for immediate re-intubation. HEClOR VERBA-HERNANDO, M.D. RAMON CONEJERO GARCIA-QUIJADA, M.D. ANA AYUCAR RUIZ DE GALARRETA, M.D.
Pulmonary and Intensive Care Units Juan Canalejo Hospital La Coruiia
Spain I. Lan RS, Lee CH, Chiang YC, Wang WJ. Use of fiberoptic bronchoscopy to retrieve bronchial foreign bodies. Am Rev Respir Dis 1989; 140:1734-7. 2. Barrte CR, Vecchione 11, Loomis Bell AL. Flexible fiberoptic bronchoscopy for airway management during acute respiratory failure. Am Rev Respir Dis 1974; 109:429-34.
THE SEARCH FOR CONSENSUS ON MYCOBACTERIAL NOMENCLATURE: A STUDY IN CHAOS (AND POWER)
From the Editor: Dr. John Grange, a distinguished scientist, recently proposed adopting the term "nyrocine" (due to ducklike qualities) as the aggregate designation for mycobacterial species other than Mycobacterium tuberculosis. The editors counterproposed the simpler designation Mycobacterioses Qther Than (M.) Tuberculosis, or MarT, but opened the question for debate (1). From the following outstanding figures in the field of mycobacterial diseases, we have received the following suggestions: from Ernest Runyon, Ph.D., a pioneer who organized the widely used classification system that bears his name, 258
"mycobacteriosis"; from Margaret H. D. Smith, M.D., a leading clinician in the area of childhood mycobacterial diseases, "environmental"; from David Dawson, a senior microbiologist who has performed extensive investigations on mycobacteria found in Australia, "atypical." These were the only responses we received on this scintillating topic. Weare talking big-time apathy, not to mention the antithesis of consensus! Undaunted, however, we persevere.Unwillingto tolerate semantic anarchy and not confronted with a clear voice from our constituency, the previous editors of the AMERICAN REVIEW OF RESPIRAlORY DISEASE exercised arbitrary authority in selecting the acronym MOlT as the preferred collective designation for mycobacteria(osis) other than M. tuberculosis. Such raw power is heady stuff! But, we pause a mere moment to savor the tingle of combat before returning to the word processor and tamer, more mundane affairs. MICHAEL D. ISEMAN, M.D.
Associate Editor Emeritus I. Cherniack RM. Editor's note. Am Rev Respir Dis 1989; 140:561.
SURVIVAL AFTER ACTIVE TUBERCULOSIS IN PATIENTS WITH HIV INFECTION
To the Editor: Chaisson and Hopewell state in their excellent review (1) on the relationship between mycobacteria and HIV infection, on the basis of their experience (2), that despite the good response of Mycobacterium tuberculosisto standard chemotherapy, patients with AIDS and active tuberculosis have a median survival time as short as 6 months. At the Department of Infectious Diseases of the University of Verona, we recorded dissimilar findings in the follow-up of 14 patients with AIDS who experienced active tuberculosis. Seven subjects developed active disease, presumably as the result of reactivation of latent tuberculous infections, whereas the others acquired the disease after nosocomial exposure to the organism (3). Lung disease was present in all but two cases, and extrapulmonary sites were involved in four cases. The duration of follow-up from diagnosis ranges from 4 to 36 months (mean, 11.8 months) with 10cases being followed for a minimum of 11 months. Tho patients died, 4 and 12 months after the diagnosis of active tuberculosis, because of disseminated herpes simplex infection and wasting syndrome, respectively. Of the other 12subjects, one is currently in critical condition (wasting syndrome), while the remaining 11 have clinical and laboratory findings comparable to those recorded before the diagnosis of active tuberculosis. After tuberculosis was diagnosed, three patients only developed major opportunistic infections (two patients with Pneumocystis carinii pneumonia and the case with disseminated herpes simplex infection mentioned above). In the 12survivors, the mean time from diagnosis is 12.4months. Whether the long-term administration of azidothymidine led to a better outcome in the patients here described (Chaisson's subjects were unlikely to have taken the drug at that time) remains to be established. Some well-defined opportunistic events correlate with a poor prognosis of HIV infection, as they are hallmarks of a downgrading immunologic surveillance. According to staging criteria (4), nondisseminated, active tuberculosis does not have a fully defined position in this sense. Our cases demonstrate that active tuberculo-
259
sis in patients with AIDS does not necessarily imply a prognosis worse than otherwise expected. GIOVANNI DI PERRI, M.D., D.T.M.&H. MARIO CRUCIANI, M.D. SANDRO VENID, M.D. ROBERID LUZZATI, M.D. MARIA CHIARA DANZI, M.D. ROMUALDO MAZZI, M.D. ERCOLE CONCIA, M.D. DANTE BASSETTI, M.D.
Institute of Infectious Diseases University of Verona Verona Italy 1. Chaisson RE, Hopewell PC. Mycobacteria and AIDS mortality. Am Rev Respir Dis 1989; 139:1-3. 2. Chaisson RE, Schecter GF, Theuer CP, et 01. Tuberculosis in patients with the acquired immunodeficiency syndrome: clinical features, response to therapy, and survival. Am Rev Respir Dis 1987; 136:570-4. 3. Di Perri G, Cruciani M, Danzi MC, et 01. Nosocomial epidemic of active tuberculosis among HI V-infected patients. Lancet 1989; 2:1502-4. 4. Centers for Disease Control. Classification system for human Tlymphotropic virus type III/lymphadenopathy-associated virus infections. Ann Intern Med 1986; 105:234-7.
tions in studies of AIDS and tuberculosis, the true survival experience is underestimated. Wehave recently studied adult patients with newly diagnosed tuberculosis in San Francisco and have found a 28% prevalence of HIV infection. Thberculosis was the first HIV-related opportunistic infection in all of the seropositive patients (3). Median CD4+ lymphocyte counts in the HIV seropositive patients was 326/mm 3 • The response to antituberculosis therapy was excellent, as previously reported in patients with AIDS and tuberculosis (1). Subsequently, other AIDS diagnoses were made in 4 of 17patients and one patient died, with a median follow-up of 17 months after completing tuberculosis therapy. Those patients who developed other AIDS-related infections had the lowest CD4 + lymphocyte counts detected. Thus, our experience is similar to that reported by Di Perri and coworkers. Classification of persons with tuberculosis and HIV infection is an important clinical and public health issue. The Centers for Disease Control currently classify HIV seropositive persons with extrapulmonary tuberculosis as AIDS cases (4). Because the best predictor of survival of individuals with advanced HIV disease appears to be the absolute CD4 + lymphocyte count, incorporating this measure into the AIDS case definition for persons with tuberculosis would more accurately reflect prognosis. RICHARD E. CHAISSON
Johns Hopkins University School of Medicine Baltimore, MD PHILIP C. HOPEWELL
From the Authors: Di Perri and associates make an important point regarding survival of persons with HIV infection and tuberculosis. Most previous studies, our own included (1), have included only individuals with tuberculosis and another AIDS-defining illness. As a consequence, survival in such reports is very short, similar to survival of patients with AIDS who do not have tuberculosis (2). It is now clear that many HIV-infected persons develop tuberculosis as an early complication of cellular immunodeficiency, well before other serious, life-threatening opportunistic infections, such as Pneumocystis carinii pneumonia, might develop. By not including these popula-
University of California, San Francisco San Francisco, CA 1. Chaisson RE, Schecter GF, Theuer CP, et 01. Tuberculosis in patients with the acquired immunodeficiency syndrome: clinical features, response to therapy, and survival. Am Rev Respir Dis 1987; 136:570-4. 2. Bacchetti P, Osmond D, Chaisson RE, et 01. Survival patterns of the first 500 patients with AIDS in San Francisco. J Infect Dis 1988; 157:1044-7. 3. Theuer CP, Hopewell PC, Elias D, et al. HIV infection in patients with tuberculosis. J Infect Dis 1990; (In Press). 4. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(Suppl:l).
To the Editor: We enjoyed reading the interesting article by Lan and colleagues (1) showing the efficiency and safety of endobronchial extraction of foreign bodies using a flexible fiberoptic bronchoscope. Two of their 33 patients were on mechanical ventilation, but they do not refer to a procedure that must be considered before the retrieval of a foreign body in intubated patients. If the size of the foreign body is greater than the internal diameter of the tracheal tube, it will be necessary to remove simultaneously the tube, the fiberoptic bronchoscope, and the forceps grasping the foreign body. Then, the patient must be immediately re-intubated and ventilated. We have performed this procedure in two patients receiving mechanical ventilation via orotracheal Macllinkrodt tubes (inner diameter, 8.5 mm). Both patients, 15 and 18yr of age, were in a coma due to craniofacial trauma. In one, weextracted a fragment of maxilla (2.3 x 1.6 em) situated in the intermediate bronchus. In the second, who also had a right pneumothorax, we removed a tooth (2 x 0.9 em) from the left main bronchus. Both patients recovered satisfactorily. In both cases, we used an intersurgical 2503 swivel connector, an Olympus BF type 10bronchoscope, and an Olympus W-shape FG-4L forceps. We also attended a comatose 65-yr-old patient who was ventilated through a tracheostomy. He had aspirated two teeth, one located in the intermediate bronchus, which we extracted, and the other in the upper left lobe, which we were unable to remove due to the lack of suitable forceps. The patient died of sepsis and respiratory distress due to pneumonia. The procedure that we described for patients using orotracheal tubes has not been reported by other investigators (2). It avoids the extraction of large foreign bodies through a rigid bronchoscope and the impaction of the foreign body in the endotracheal tube. But we insist this procedure requires a perfect coordination of a skillful team prepared for immediate re-intubation. HEClOR VERBA-HERNANDO, M.D. RAMON CONEJERO GARCIA-QUIJADA, M.D. ANA AYUCAR RUIZ DE GALARRETA, M.D.
Pulmonary and Intensive Care Units Juan Canalejo Hospital La Coruiia
Spain I. Lan RS, Lee CH, Chiang YC, Wang WJ. Use of fiberoptic bronchoscopy to retrieve bronchial foreign bodies. Am Rev Respir Dis 1989; 140:1734-7. 2. Barrte CR, Vecchione 11, Loomis Bell AL. Flexible fiberoptic bronchoscopy for airway management during acute respiratory failure. Am Rev Respir Dis 1974; 109:429-34.
THE SEARCH FOR CONSENSUS ON MYCOBACTERIAL NOMENCLATURE: A STUDY IN CHAOS (AND POWER)
From the Editor: Dr. John Grange, a distinguished scientist, recently proposed adopting the term "nyrocine" (due to ducklike qualities) as the aggregate designation for mycobacterial species other than Mycobacterium tuberculosis. The editors counterproposed the simpler designation Mycobacterioses Qther Than (M.) Tuberculosis, or MarT, but opened the question for debate (1). From the following outstanding figures in the field of mycobacterial diseases, we have received the following suggestions: from Ernest Runyon, Ph.D., a pioneer who organized the widely used classification system that bears his name, 258
"mycobacteriosis"; from Margaret H. D. Smith, M.D., a leading clinician in the area of childhood mycobacterial diseases, "environmental"; from David Dawson, a senior microbiologist who has performed extensive investigations on mycobacteria found in Australia, "atypical." These were the only responses we received on this scintillating topic. Weare talking big-time apathy, not to mention the antithesis of consensus! Undaunted, however, we persevere.Unwillingto tolerate semantic anarchy and not confronted with a clear voice from our constituency, the previous editors of the AMERICAN REVIEW OF RESPIRAlORY DISEASE exercised arbitrary authority in selecting the acronym MOlT as the preferred collective designation for mycobacteria(osis) other than M. tuberculosis. Such raw power is heady stuff! But, we pause a mere moment to savor the tingle of combat before returning to the word processor and tamer, more mundane affairs. MICHAEL D. ISEMAN, M.D.
Associate Editor Emeritus I. Cherniack RM. Editor's note. Am Rev Respir Dis 1989; 140:561.
SURVIVAL AFTER ACTIVE TUBERCULOSIS IN PATIENTS WITH HIV INFECTION
To the Editor: Chaisson and Hopewell state in their excellent review (1) on the relationship between mycobacteria and HIV infection, on the basis of their experience (2), that despite the good response of Mycobacterium tuberculosisto standard chemotherapy, patients with AIDS and active tuberculosis have a median survival time as short as 6 months. At the Department of Infectious Diseases of the University of Verona, we recorded dissimilar findings in the follow-up of 14 patients with AIDS who experienced active tuberculosis. Seven subjects developed active disease, presumably as the result of reactivation of latent tuberculous infections, whereas the others acquired the disease after nosocomial exposure to the organism (3). Lung disease was present in all but two cases, and extrapulmonary sites were involved in four cases. The duration of follow-up from diagnosis ranges from 4 to 36 months (mean, 11.8 months) with 10cases being followed for a minimum of 11 months. Tho patients died, 4 and 12 months after the diagnosis of active tuberculosis, because of disseminated herpes simplex infection and wasting syndrome, respectively. Of the other 12subjects, one is currently in critical condition (wasting syndrome), while the remaining 11 have clinical and laboratory findings comparable to those recorded before the diagnosis of active tuberculosis. After tuberculosis was diagnosed, three patients only developed major opportunistic infections (two patients with Pneumocystis carinii pneumonia and the case with disseminated herpes simplex infection mentioned above). In the 12survivors, the mean time from diagnosis is 12.4months. Whether the long-term administration of azidothymidine led to a better outcome in the patients here described (Chaisson's subjects were unlikely to have taken the drug at that time) remains to be established. Some well-defined opportunistic events correlate with a poor prognosis of HIV infection, as they are hallmarks of a downgrading immunologic surveillance. According to staging criteria (4), nondisseminated, active tuberculosis does not have a fully defined position in this sense. Our cases demonstrate that active tuberculo-
259
sis in patients with AIDS does not necessarily imply a prognosis worse than otherwise expected. GIOVANNI DI PERRI, M.D., D.T.M.&H. MARIO CRUCIANI, M.D. SANDRO VENID, M.D. ROBERID LUZZATI, M.D. MARIA CHIARA DANZI, M.D. ROMUALDO MAZZI, M.D. ERCOLE CONCIA, M.D. DANTE BASSETTI, M.D.
Institute of Infectious Diseases University of Verona Verona Italy 1. Chaisson RE, Hopewell PC. Mycobacteria and AIDS mortality. Am Rev Respir Dis 1989; 139:1-3. 2. Chaisson RE, Schecter GF, Theuer CP, et 01. Tuberculosis in patients with the acquired immunodeficiency syndrome: clinical features, response to therapy, and survival. Am Rev Respir Dis 1987; 136:570-4. 3. Di Perri G, Cruciani M, Danzi MC, et 01. Nosocomial epidemic of active tuberculosis among HI V-infected patients. Lancet 1989; 2:1502-4. 4. Centers for Disease Control. Classification system for human Tlymphotropic virus type III/lymphadenopathy-associated virus infections. Ann Intern Med 1986; 105:234-7.
tions in studies of AIDS and tuberculosis, the true survival experience is underestimated. Wehave recently studied adult patients with newly diagnosed tuberculosis in San Francisco and have found a 28% prevalence of HIV infection. Thberculosis was the first HIV-related opportunistic infection in all of the seropositive patients (3). Median CD4+ lymphocyte counts in the HIV seropositive patients was 326/mm 3 • The response to antituberculosis therapy was excellent, as previously reported in patients with AIDS and tuberculosis (1). Subsequently, other AIDS diagnoses were made in 4 of 17patients and one patient died, with a median follow-up of 17 months after completing tuberculosis therapy. Those patients who developed other AIDS-related infections had the lowest CD4 + lymphocyte counts detected. Thus, our experience is similar to that reported by Di Perri and coworkers. Classification of persons with tuberculosis and HIV infection is an important clinical and public health issue. The Centers for Disease Control currently classify HIV seropositive persons with extrapulmonary tuberculosis as AIDS cases (4). Because the best predictor of survival of individuals with advanced HIV disease appears to be the absolute CD4 + lymphocyte count, incorporating this measure into the AIDS case definition for persons with tuberculosis would more accurately reflect prognosis. RICHARD E. CHAISSON
Johns Hopkins University School of Medicine Baltimore, MD PHILIP C. HOPEWELL
From the Authors: Di Perri and associates make an important point regarding survival of persons with HIV infection and tuberculosis. Most previous studies, our own included (1), have included only individuals with tuberculosis and another AIDS-defining illness. As a consequence, survival in such reports is very short, similar to survival of patients with AIDS who do not have tuberculosis (2). It is now clear that many HIV-infected persons develop tuberculosis as an early complication of cellular immunodeficiency, well before other serious, life-threatening opportunistic infections, such as Pneumocystis carinii pneumonia, might develop. By not including these popula-
University of California, San Francisco San Francisco, CA 1. Chaisson RE, Schecter GF, Theuer CP, et 01. Tuberculosis in patients with the acquired immunodeficiency syndrome: clinical features, response to therapy, and survival. Am Rev Respir Dis 1987; 136:570-4. 2. Bacchetti P, Osmond D, Chaisson RE, et 01. Survival patterns of the first 500 patients with AIDS in San Francisco. J Infect Dis 1988; 157:1044-7. 3. Theuer CP, Hopewell PC, Elias D, et al. HIV infection in patients with tuberculosis. J Infect Dis 1990; (In Press). 4. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(Suppl:l).
