A 40-year-old woman from the Upper Midwest was admitted to the hospital with the chief complaints of cough and hemoptysis. One month before admission, a cough productive of scant amounts of yellowish sputum had developed. The cough continued to worsen during the next 4 weeks. She also noted shortness of breath on exertion and difficulty with ordinary housework. Her local physician prescribed orally administered erythromycin, which provided no relief. She denied having rigors or night sweats but did have occasional fevers (temperatures as high as 38.3°C) during this time. One day before admission, she noted a small amount of bright blood mixed with sputum produced during a coughing spell. She was transferred to our inpatient service the next day. Past medical history was remarkable for cirrhosis of the liver, which was diagnosed 1 year earlier but was currently asymptomatic and stable. The cirrhosis was considered secondary to alcoholism and chronic hepatitis C. Other medications on admission included vitamin K, thiamine, folate, and lactulose. The patient had smoked a pack of cigarettes daily for the past 22 years. Although she had consumed alcohol heavily, she had been abstinent for the past year. The patient had used intravenous drugs between 8 and 11 years before admission but none since. She had visited southern California twice in the 2 years before admission, each visit lasting approximately 1 month. The patient denied being exposed to tuberculosis or having seizures, blackouts, hematuria, recent dental procedures, sinusitis, night sweats, or weight loss. Physical examination showed the following: heart rate 80 beats/min and regular, blood pressure 110/60 mm Hg, temperature 37.0°C, and respiratory rate 14/min. The patient was a thin woman in no apparent distress. Multiple spider angiomas were present on the face and thorax. She had no edema, clubbing, or lymphadenopathy. Examination of the chest revealed normal percussion over both lung fields but decreased breath sounds in the left upper lobe. No crackles, rubs, or amphoric breath sounds were heard. Cardiovascular examination disclosed no murmurs or extra sounds. Abdominal examination revealed a liver span of 12 cm, a palpable spleen tip, and a small amount of ascites. Neurologic findings were normal. A chest roentgenogram was obtained on admission (Fig. 1). 1.Which one of the following statements is false concerning the physical examination in this patient? a.Amphoric breath sounds may be distinguished from tracheal breath sounds by the relative lengths of the inspiratory and expiratory phasesb.The presence of amphoric breath sounds is specific for cavitary lung diseasec.The absence of amphoric breath sounds might be expected in this patientd.The decreased breath sounds over the left upper lobe of the lung in this patient may be due to her underlying cavitary diseasee.The absence of clubbing does not exclude lung cancer in this patient Although both amphoric breath sounds and tracheal breath sounds have inspiratory and expiratory phases that are relatively equal in duration and loudness, they differ in that amphoric breath sounds have a more resonant and harmonious timbre. They are indicative of an air-containing space in the lung that communicates with the bronchial tree. The sensitivity of this finding is unknown, but the specificity is 100%.1Sapira JD The Art and Science of Bedside Diagnosis. Baltimore Urban & Schwarzenberg, 1990: 258-266Google Scholar Thus, amphoric breath sounds may be absent in patients with cavitary lung disease. A cavity that does not communicate freely with major airways during respiration may account for the absence of this sign in some patients with a significant fluid level, as was noted in this patient. Decreased breath sounds may be found over a cavity, as was shown in this patient. The absence of clubbing does not rule out lung cancer; in addition, the presence of clubbing would not be specific for bronchogenic carcinoma because many other conditions such as lung abscess, empyema, and cirrhosis may also cause clubbing. Admission laboratory studies revealed a hemoglobin level of 9.8 g/dL, leukocyte count of 4.2 × I09/L, platelet count of 94 × 109/L, prothrombin time of 17 seconds (international normalized ratio = 1.7), serum creatinine of 0.8 mg/dL., positive hepatitis C antibody by recombinant immuno blot assay, and normal findings on urinalysis. 2.Which one of the following pulmonary diagnoses is least likely in this patient? a.Tuberculosisb.Anaerobic lung abscessc.Primary adenocarcinoma of the liver with lung metastatic lesiond.Primary squamous cell carcinoma of the lunge.Wegener's granulomatosis The differential diagnoses in this patient are many and varied and include both infectious and noninfectious etiologic factors. Cough, fever, and hemoptysis in the presence of an upper lobe cavity would be highly suggestive of reactivation of tuberculosis; thus, any exposure to tuberculosis as well as past purified protein derivative (PPD) testing results would be important information. Although most patients with an anaerobic lung abscess would have risk factors for aspiration such as poor dental hygiene, seizure disorder, alcoholic blackouts, and other disorders, approximately 10% will not have a predisposing condition.2Battled JG Lung abscess.in: Baum GL Woltnsky E 5th ed. Textbook of Pulmonary Diseases. Vol 1. Little Brown, Boston1994: 607-620Google Scholar Hence, anaerobic abscess should be considered in this patient. Metastatic neoplasms uncommonly cavitate and usually result in multiple lesions. In addition, cavitating lung metastatic lesions are usually from a head and neck or genitourinary primary lesion as opposed to a hepatic primary tumor.3Reed JC Chest Radiology: Plain Film Patterns and Differential Diagnoses. 3rd ed. Mosby Year Book, St. Louis1991: 359-381Google Scholar Although her cirrhosis would put her at greater risk for an occult hepatic adenocarcinoma, this diagnosis would be the least likely. Because of the patient's history of smoking, bronchogenic carcinoma is a diagnosis for strong consideration. Cavitation occurs in 2 to 15% of bronchogenic carcinomas;4Chaudhuri MR Primary pulmonary cavitating carcinomas.Thorax. 1973; 28: 354-366Crossref PubMed Scopus (126) Google Scholar most are squamous cell type, although adenocarcinomas may also cavitate. Vasculitic disorders such as Wegener's granulomatosis may also result in lung cavities. Although multiple cavitary lesions are more characteristic of Wegener's granulomatosis, and other related symptoms (that is, sinusitis and hematuria) were absent, limited pulmonary Wegener's granulomatosis could still be possible. 3.At this point, which one of the following is not indicated in this patient? a.Testing for human immunodeficiency virus (HIV)b.Respiratory isolation of the patientc.Sputum for cultures and stains (including fungal and acid-fast)d.Bronchoscopye.Tuberculin skin test (PPD) Permission for HIV testing should be obtained, in light of her history of drug abuse. A lung cavity in an HIV-positive-positive host would broaden the differential diagnosis to include organisms such as Nocardia, Pneumocystis, atypical mycobacteria, and Cryptococcus. With these roentgenographic and clinical features, tuberculosis must be the first diagnosis to be excluded. To minimize the risk of nosocomial transmission, one must immediately place this patient in respiratory isolation while multiple (usually three) sputum samples are collected. Examination of three sputum specimens (induced if necessary) usually results in a smear positive for acid-fast bacilli in patients with cavitary disease. Bronchoscopy would not be indicated at this time because exposing the personnel in the bronchoscopy suite to tuberculosis would not be justified if the diagnosis could be made noninvasively. Bronchoscopy should be delayed until her prothrombin time has been corrected with vitamin K, to allow biopsy of any suspicious endobronchial lesions. Nevertheless, if initial noninvasive testing fails to provide an answer, bronchoscopy would be helpful in diagnosing paucibacillary tuberculosis, other infections, or cancer. PPD with anergy controls and sputum analysis should be performed. Of note, however, neither a negative PPD nor three negative sputum smears for acid-fast bacillus rule out the diagnosis. Our patient was placed in respiratory isolation. Clindamycin and ceftazidime therapy was initiated to cover anaerobes and gram-negative organisms. Because the patient was unable to produce adequate sputum samples, three induced sputum specimens were examined. On all three samples, Gram stain showed mixed flora with many leukocytes, acidfast stain was negative, and fungal stain revealed yeast on two of three samples. Previous roentgenograms were obtained for comparison. In retrospect, they demonstrated a nodular density associated with a smaller thin-walled bulla or cavity 4 months earlier. Computed tomography of the chest, performed during the current assessment to determine the presence of a fungus ball or additional occult lesions or masses, revealed a large cavitating lesion in the left lung apex. The patient also had an illdefined infiltrate in the right middle lobe but no adenopathy. In view of the multiple negative sputum smears for acid-fast bacilli, tuberculosis became a less likely diagnosis. Other causes, particularly mycoses, were then considered. 4.On the basis of the results, which one of the following statements is false regarding our patient? a.She is at risk for development of cavitary histoplasmosisb.Her travel to southern California increases the risk for coccidioidomycosisc.Blastomycosis is highly unlikely in this patient because no travel to the southeastern United States was reportedd.Paracoccidioidomycosis is unlikely because she had not traveled to an endemic areae.The presence ofa thick-walled cavity in this patient does not exclude coccidioidomycosis Histoplasmosis and blastomycosis are both relatively common in the central United States (bordering the Ohio and Mississippi River valleys), and the patient is at risk for both of these mycoses. Coccidioidomycosis is more common in the desert Southwest of the United States (particularly the state of Arizona and the San Joaquin valley of southern California). Even though several mini-epidemics of blastomycosis have occurred in various regions of the United States, travel to a particular geographic area is not as important as it is in the case of coccidioidomycosis. Paracoccidioidomycosis (South American blastomycosis) usually manifests as a subacute pneumonia. It is more likely in the endemic areas of South and Central America as opposed to Arizona or California.5Davies SR Fungal pneumonia.Med Clin North Am. 1994 Sep; 78: 1049-1065PubMed Google Scholar Although thin-walled cavities are characteristic of coccidioidomycosis, thick-walled cavities may also occur. In our patient, 2 days after specimens were obtained, sputum cultures were positive for Coccidioides immitis. Pre sumably, she acquired the illness from her previous travel to California. 5.Which one of the following about our patient's diagnosis is false? a.Serologic tests are useful in diagnosisb.The isolated microorganism is highly contagious in the laboratoryc.The disease can occur in patients who have not visited an endemic aread.Our patient should be placed in respiratory isolatione.Fluconazole is an effective treatment Serologic tests for coccidioidomycosis have both a high sensitivity and a high specificity for the diagnosis of disease. Negative studies, however, do not exclude the diagnosis, particularly early in the course of primary infections or in immunosuppressed patients. C. immitis poses a definite risk to laboratory personnel because the organism is very fast growing and the mycelial phase is highly infectious. Visit to an endemic area is not a requisite for development of coccidioidomycosis. Indeed, many sporadic cases occur in nonendemic areas.6Gehlbach SH Hamilton JD Conant NK Coccidioidomycosis: an occupational disease in cotton mill workers.Arch Intem Med. 1973; 131: 254-255Crossref PubMed Scopus (19) Google Scholar Even though the mycelial phase of the organism in the laboratory is highly contagious, respiratory isolation of the patient is not indicated because the tissue phase (that is, yeast) is not infectious. Fluconazole has been shown to be effective in this condition. Coccidial complement fixation antibody testing was equivocal in our patient, but immunodiffusion antibody testing was positive. Respiratory isolation was discontinued, and amphotericin therapy was begun. Because of the size of the cavity in this patient, surgical removal was considered. The patient's coagulopathy and thrombocytopenia, however, made surgical intervention an unattractive option, and medical treatment was continued. After intravenous administration of 150 mg of amphotericin, the patient's serum creatinine rose to 3.8 mg/dL. The amphotericin therapy was discontinued, and she was dismissed with an oral regimen of fluconazole. On follow-up 5 weeks later, her cough had diminished, and the cavity had decreased in size by 50%. The initial diagnostic assessment in a patient with a single pulmonary lesion without severe immunosuppression should be a thorough history and physical examination. Attention should be directed toward eliciting the following: predisposing risks to aspiration, history of smoking, exposure to tuberculosis, intravenous drug abuse, history of sinusitis or hematuria, other systemic diseases, and travel to or residence in any endemic fungal region. On physical examination, clubbing, lymphadenopathy, or poor dentition should be noted. One should obtain a complete blood cell count, serum chemistry panel, and sputum examination for acid-fast bacilli, fungi, and cytology. In certain clinical situations, fungal serologies, PPD, antineutrophil cytoplasmic antibodies, and blood cultures may be indicated. A computed tomographic scan of the chest often better delineates the lesion and verifies the presence or absence of other relevant findings, such as lymphadenopathy, chest wall invasion, subtle diffuse infiltrative lung disease, and additional pulmonary lesions that may not be appreciated on the chest roentgenogram. In the case of a suspected anaerobic abscess with classic features, flexible bronchoscopy may be of limited value in improving drainage.2Battled JG Lung abscess.in: Baum GL Woltnsky E 5th ed. Textbook of Pulmonary Diseases. Vol 1. Little Brown, Boston1994: 607-620Google Scholar With any atypical features (or when the cavity fails to resolve), bronchoscopy with lavage and transbronchial biopsy is indicated to look for evidence of obstruction and to rule out other causes of a cavitary lesion, especially if risk factors for cancer are present. Rarely, one may need to resort to thoracoscopy or thoracotomy to make a diagnosis. The roentgenographic appearance of a typical cavitary lesion of the lung consists of a localized area of lucency surrounded by a radiodense border. A variety of infectious, vascular, immunologic, neoplastic, and congenital factors can cause a single cavitary lesion of the lung. A bacterial lung abscess from aspiration of pharyngeal flora is often due to multiple organisms: microaerophilic Streptococcus, Fusobacterium, peptococci, and Bacteroides melaninogenicus2Battled JG Lung abscess.in: Baum GL Woltnsky E 5th ed. Textbook of Pulmonary Diseases. Vol 1. Little Brown, Boston1994: 607-620Google Scholar Any condition that decreases the ability to protect one's airway predisposes to aspiration-for example, seizures, alcoholic blackouts, sedative or narcotic use, nasopharyngeal cancers, neuromuscular disorders, general anesthesia, dental surgical procedures, or esophageal cancer. Other predisposing factors are gingivitis and pyorrhea, likely because of the increased bacterial count of the aspirated material. These abscesses often occur in the dependent portions of the lung fields (superior segment of the lower lobe or posterior segment of the upper lobe) and are more common on the right side (presumably because of the less acute angle of the right main-stem bronchus). The manifestation is often indolent, with complaints of cough, fever, and malaise lasting weeks to months. Anemia and weight loss may also be present. Expectorated sputum is unsuitable for anaerobic culture because of its inevitable contamination through the upper airways. Another organism, Actinomyces, may also be associated with dental disease and dental procedures. It also has a predilection for the lower pulmonary lobes and may invade adjacent ribs. Abscesses from necrotizing gram-negative or staphylococcal pneumonia rarely have an indolent course. Affected patients often are acutely ill with a severe pneumonia that cavitates. Staphylococcal pneumonia may complicate an influenzal infection, whereas gram-negative infection is more commonly found in older men with alcoholism. S. pneumoniae uncommonly results in cavity formation. Reactivation tuberculosis results in cavitary disease with a predilection for the apical and posterior segments of the upper lobes. Tuberculosis may manifest with cough, sputum, and hemoptysis; the course is usually subacute or chronic. Because of the high concentration of tuberculous bacilli in the cavity (108 to 109 organisms/mL), patients usually have a smear strongly positive for acid-fast bacilli. A variety of fungi may cause cavitary lesions. Aspergil lus, Mucor, and Candida rarely cause severe disease in patients without neutropenia. The endemic fungi (Coccidi oides, Histoplasma, Blastomyces, and Paracoccidioidesi, however, may cause cavitary lesions in immunocompetent hosts. Thus, these organisms should be considered in the differential diagnosis of a cavitary lesion if travel to an endemic area has occurred, as in this patient. As discussed, neoplastic disorders may cause lung cavities. Both bronchogenic tumors and lymphomas may cavitate. Cavitation in metastatic squamous cell carcinoma (usually from head and neck primary lesions in men and genital tract tumors in women) is most common.3Reed JC Chest Radiology: Plain Film Patterns and Differential Diagnoses. 3rd ed. Mosby Year Book, St. Louis1991: 359-381Google Scholar Cavitating metastatic lesions from the gastrointestinal tract (usually colon) or sarcoma (especially osteogenic) are less common. Cavitation may rarely complicate a pulmonary embolus with infarction.7Morgenlhaler TI Ryu JH Utz JP Cavitary pulmonary infarct ir immunocompromised hosts.Mayo Clin Proc. 1995; 70: 66-68Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Wegener's granulomatosis often results in bilateral multiple cavitary lesions, single lesions being less common. A cytoplasmic staining pattern of antineutrophil cytoplasmic antibodies would help confirm the diagnosis. Other vasculitic disorders (rheumatoid arthritis or polyarteritis) may also result in cavitary lesions. In our patient, the diagnosis of cavitary coccidioidomycosis was made noninvasively through sputum analysis and culture. Coccidioidomycosis may result in a wide spectrum of pulmonary disorders, the most common manifestation being a self-limited respiratory syndrome. About two-thirds of the patients have such mild symptoms that medical attention is not sought. Others may have more severe pulmonary disease, including slowly resolving pneumonia, nodules, or cavities. Cavities occur in 2 to 8% of cases but are commonly asymptomatic; only 14% are multiple.8Winn RE Johnson R Galgiani JN Butler C Pluss J Cavitary coccidioidomycosis with fungus ball formation: diagnosis by fibcroplic bronchoscopy with coexistence of hyphae and spherules.Chest. 1994; 105: 412-416Crossref PubMed Scopus (28) Google Scholar Characteristically, they are thin walled and peripheral. Symptoms include cough, chest pain, and hemoptysis; fever, sweats, and weight loss may also occur. A rare but catastrophic complication of cavitary coccidioidomycosis is rupture into the pleural space; the manifestation is similar to a spontaneous pneumothorax.9Galgiani JN Coccidioidomycosis.West J Med. 1993; 159: 153-171PubMed Google Scholar One group has suggested that surgical intervention for a coccidial cavity be considered under the following circumstances: (1) rapidly expanding (more than 4 cm) cavity close to the visceral pleura, (2) severe hemoptysis, (3) bronchopleural fistula, (4) persistence beyond 1 year, and (5) culture-positive sputum. Surgical intervention, however, has a high rate of complications (30% bronchopleural fistula) and a significant recurrence rate (18%); thus, this option should not be undertaken lightly.8Winn RE Johnson R Galgiani JN Butler C Pluss J Cavitary coccidioidomycosis with fungus ball formation: diagnosis by fibcroplic bronchoscopy with coexistence of hyphae and spherules.Chest. 1994; 105: 412-416Crossref PubMed Scopus (28) Google Scholar

Objective: To compare molecular techniques with conventional diagnostic methods for evaluating nosocomial transmission of multidrug-resistant tuberculosis (MDR-TB).Design: We conducted a 12-week postexposure inception cohort study of health-care personnel who had been exposed to a patient with MDR-TB.Material and Methods: In addition to baseline and follow-up tuberculin skin tests and chest roentgenography, meekly pulmonary specimens were evaluated by (1) auramine-rhodamine fluorescent staining, (2) culture for mycobacteria, and (3) polymerase chain reaction (PCR) to amplify IS6110, a nucleic acid insertion sequence unique to the Mycobacterium tuberculosis complex.Results: The index patient's isolate of M. tuberculosis showed a mutation in codon 531 of the RNA polymerase beta subunit (rpoB) gene of M. tuberculosis, which is associated with rifampin resistance and considered a marker for this MDR-TB strain. All pulmonary and gastric specimens from study participants had negative auramine stains and cultures for mycobacteria. One person, however, had separate specimens with repeatedly positive PCR results for IS6110 sequences, but the specimens contained a wildtype M. tuberculosis rpoB codon 531 dissimilar from the index patient's strain.Conclusion: Although both molecular and conventional testing showed that no exposed person was infected with the MDR-TB strain, molecular test results were available sooner and seemed more sensitive for detecting M. tuberculosis in one exposed person, presumably in a preinfection or ''colonized'' stage. Molecular methods provided information that helped distinguish this person's M. tuberculosis strain from the index patient's MDR-TB strain. Additional prospective studies should assess the value of these molecular techniques in similar clinical settings.

OBJECTIVETo determine the effect of psychologic distress, measured with a commonly used screening questionnaire, on 6-month morbidity and rehospitalization costs in coronary patients.DESIGNPsychologic distress was determined by screening with the Symptom Checklist-90--Revised (SCL-90-R) self-report inventory during the second week of cardiac rehabilitation. Costs associated with cardiovascular rehospitalization during a 6-month follow-up period were recorded, and differences between "distressed" and "nondistressed" patients were analyzed statistically.MATERIAL AND METHODSThe study cohort consisted of 381 patients (311 men and 70 women) referred for cardiac rehabilitation after an index hospitalization for unstable angina, myocardial infarction, coronary angioplasty, or coronary bypass procedure. Patients with SCL-90-R scores above the 90th percentile for outpatient adults were considered distressed (N = 41); patients with scores below this level were considered nondistressed (N = 340).RESULTSThe 6-month follow-up was complete in all but 1 of the 381 patients. Distressed patients had significantly higher rates of cardiovascular rehospitalization, any recurrent events, and recurrent "hard events" (cardiac death, myocardial infarction, or cardiac arrest and resuscitation) within 6 months after dismissal from their index hospitalization in comparison with nondistressed patients. Adjustment for other factors associated with a risk of early rehospitalization and recurrent events did not reduce the strength or significance of the association between psychologic distress and early cardiovascular rehospitalization or recurrent events. The mean rehospitalization costs were significantly higher in the distressed than in the nondistressed patients ($9,504 versus $2,146).CONCLUSIONThese data add support to the hypothesis that psychologic distress adversely affects the prognosis in coronary patients, confirm the added morbidity and rehospitalization costs attributable to psychologic distress, and suggest the potential for improving the prognosis in selected coronary patients by identification and appropriate treatment of psychologic distress.