Cytomegalovirus (CMV) is frequently isolated from respiratory secretions of human immunodeficiency virus (HIV)-infected patients. Even in the presence of histopathologic evidence of CMV cytopathic abnormalities, the true clinical significance of CMV pneumonitis is not well established. Airways disease is increasingly recognized in HIV-infected patients, but its etiology is unclear. We describe an HIV-infected patient who presented with fever, wheeze, and micronodular interstitial infiltrates and developed severe hypercapnic and hypoxemic respiratory failure. Open lung biopsy showed necrotizing bronchiolitis with cytopathic changes characteristic of CMV infection; no other pathogens were isolated. He responded well to treatment with ganciclovir.

Lettersbe included among various disorders associated with triphasic waves.The pathogenesis of the waves in these disorders is not known, Triphasic waves in Moliaret's meningitis although impairment of dopaminergic system5 and abnormal cerebral glucose Sir: Triphasic waves are recognised findings metabolism4 have been proposed.In met- in EEGs of patients with metabolic encepharizamide encephalopathy, metrizamide in lopathy and Alzheimer's disease;' they are the cerebrospinal fluid is thought to interfere also known to occur in cerebrovascular acci-with the sodium-potassium ATPase cation d,ents,2 acute hyperthyroidism3 and met-pump and competitively inhibit glucose rizamide encephalopathy.'We now report a metabolism.4Mere presence of inflam- patient with Mollaret's meningitis whose matory cells in the cerebrospinal fluid is not EEG showed triphasic waves during likely to be related to the appearance of exacerbations.This association has not pre-triphasic waves because viral, bacterial and viously been described.tuberculous meningitis are not associated A 72-year-old female presented with acute with such waves.It appears that different fever and vomiting.Neurological exam-aetiologic factors (including the "agent" ination showed only neck stiffness.Cere-responsible for Mollaret's meningitis) pro- brospinal fluid was clear and revealed 103 duce dysfunction of a final anatomical or white cells (62% polymorphonuclears, 20% neurochemical mechanism at subcortical lymphocytes and 18% monocytes/mm3), level, resulting in triphasic waves.protein of 1 04 g/l (normal: 0-2 to 0-4) and Finally, we wish to emphasise that the glucose of 4 3 mmol/l (normal: 2 8 to 4.5); presence of triphasic waves in the EEG of bacterial, fungal and viral studies were nega-patients with acute encephalopathy does not tive.There was no laboratory evidence of necessarily indicate a metabolic aetiology.renal or hepatic dysfunction or hypoxia. MBM SUNDARAMEIxtensive work-up for any "hidden" septic P SIEMENS focus was negative.EEG showed frontally