Pleural disease and acquired immune deficiency syndrome

Patients with acquired immune deficiency syndrome (AIDS) do not frequently have pleural complications. However, pneumothorax is a troublesome complication of patients with AIDS. At some medical centres, more than 50% of patients with spontaneous pneumothorax have AIDS. Most patients with spontaneous pneumothorax and AIDS have Pneumocystis carinii infection and necrotic subpleural blebs. The pneumothoraces in these patients usually cannot be managed with tube thoracostomy alone. Patients who do not respond to tube thoracostomy are best managed with a Heimlich valve or with thoracostomy with stapling of blebs and pleural abrasion. Approximately 2% of human immunodeficiency virus (HIV)-positive individuals will have a pleural effusion. Parapneumonic effusions or empyema, tuberculosis and Kaposi's sarcoma are the three leading causes. P. carinii infection is frequently responsible for pulmonary infections, but is only occasionally responsible for a pleural effusion. Pleural effusions may also develop from non-Hodgkin's lymphoma (NHL). There is one relatively rare NHL that is associated with the Kaposi's sarcoma associated virus that produces a lymphoma confined to the body cavity.     

Significance of p53 and VEGF expression in liver metastasis from colorectal cancer

BACKGROUND: Children with large anterior mediastinal masses frequently present with severe respiratory compromise and often pose a difficult diagnostic dilemma. A biopsy is preferred for diagnosis before treatment can begin; however, many of these children are at risk of acute clinical deterioration and cardiovascular arrest with the induction of anesthesia. The authors noted a correlation between pleural effusions and lymphoblastic lymphoma and recently diagnosed three cases of lymphoblastic lymphoma in children with a large anterior mediastinal mass and pleural effusion through cytological and flow cytometric examination of the pleural fluid. METHODS: To focus on this problem, 101 pediatric patients presenting with an anterior mediastinal mass between January 1980 and September 1994 were reviewed to determine if pleural effusions occur more frequently at initial presentation with lymphoblastic lymphoma than with Hodgkin's disease, thus offering a means of diagnosis in children with severe respiratory compromise. The patients' chest radiographs and/or computed tomograms for the 88 cases in which they were available were reviewed retrospectively in a blinded fashion to identify those children with pleural effusions at the time of presentation. RESULTS: In this study, 71% of patients with lymphoblastic lymphoma (10 of 14) had a pleural effusion at presentation, whereas only 11.7% of patients with Hodgkin's disease (7 of 60) had a pleural effusion on initial presentation. (P < .002 Fisher's Exact test). CONCLUSION: This retrospective review suggests that there is a significantly greater association of pleural effusions in patients with lymphoblastic lymphoma than with Hodgkin's disease. Our experience supports the conclusion that thoracentesis may provide a means of diagnosis in children presenting in severe respiratory compromise obviating the need for anesthesia and open biopsy.     

Premorbid hair growth over the trunk and severity of alcohol-related liver disease

OBJECTIVE: To evaluate the clinicopathologic features of malignant pleural effusions secondary to pulmonary adenocarcinoma in patients who have undergone surgical resection of the primary tumor. STUDY DESIGN: Clinical, pathologic and cytologic material from 19 patients who developed malignant pleural effusions after resection of pulmonary adenocarcinoma was reviewed. RESULTS: Malignant effusions developed only in patients with either lymph node or pleural involvement by neoplasm. Time to development of the effusion after resection and overall survival correlated with histologic findings. Malignant effusions in patients who survived > 24 months were secondary to another primary tumor (either breast or a new pulmonary carcinoma). Malignant effusions developed significantly sooner after resection (mean 5.0 +/- 2.0 months, median 5) in patients with lymph nodal metastases than in those with pleural involvement by neoplasm (mean 11.2 +/- 2.5 months, median 12) (Student's t test P = .01, Mann-Whitney U test .04). Nevertheless, survival after resection for patients with lymph node involvement (mean 9.0 +/- 3.6 months, median 8) and those with pleural involvement (mean 12.3 +/- 2.5 months, median 12) was not significantly different. CONCLUSION: Malignant effusions developing in patients more than two years following resection of a pulmonary adenocarcinoma are likely to be secondary to another primary neoplasm. Lymph node and pleural involvement at the time of resection are risk factors for the development of a malignant effusion. Patients with lymph node involvement develop malignant effusions sooner than those with pleural involvement, but the overall survival is not significantly different.     

Pleural effusions in the medical ICU: prevalence, causes, and clinical implications

OBJECTIVE: To determine the prevalence and causes of pleural effusions in patients admitted to a medical ICU (MICU). DESIGN: Prospective. SETTING: MICU in a tertiary care hospital. PATIENTS: One hundred consecutive patients admitted to the MICU at the Medical University of South Carolina whose length of stay exceeded 24 h had chest radiographs reviewed daily and chest sonograms performed within 10 h of their latest chest radiograph. RESULTS: The prevalence of pleural effusions in 100 consecutive MICU patients was 62%, with 41% of effusions detected at admission. Fifty-seven of 62 (92%) pleural effusions were small. Causes of pleural effusions were as follows: heart failure, 22 of 62 (35%); atelectasis, 14 of 62 (23%); uncomplicated parapneumonic effusions, seven of 62 (11%); hepatic hydrothorax, five of 62 (8%); hypoalbuminemia, five of 62 (8%); malignancy, two of 62 (3%); and unknown, three of 62 (5%). Pancreatitis, extravascular catheter migration, uremic pleurisy, and empyema caused an effusion in one instance each. Heart failure was the most frequent cause of bilateral effusions (13/34 [38%]). When compared with patients who never had effusions during their MICU stay, patients with pleural effusions were older (54+/-2 years, mean+/-SEM, vs 47+/-2 years [p=0.04]), had lower serum albumin concentration (2.4+/-0.1 vs 3.0+/-0.01 g/dL [p=0.002]), higher acute physiology and chronic health evaluation II scores during the initial 24 h of MICU stay (17.2+/-1.1 vs 12+/-1.2 [p=0.010]), longer MICU stays (9.8+/-1.0 vs 4.6+/-0.7 days [p=0.0002]), and longer mechanical ventilation (7.0+/-1.3 vs 1.9+/-0.7 days [p=0.004]). No patient died as a direct result of his or her pleural effusion. Chest radiograph readings had good correlation with chest sonograms (p<0.0001). CONCLUSION: Pleural effusions in MICU patients are common, and most are detected by careful review of chest radiographs taken with the patient in erect or semierect position. When clinical suspicion for infection is low, observation of these effusions is warranted initially, because most are caused by noninfectious processes that should improve with treatment of the underlying disease.     

Pleural fluid characteristics in hantavirus pulmonary syndrome

Hantavirus pulmonary syndrome (HPS), is a rodent-borne, acute, often fulminant cardiorespiratory illness. Noncardiogenic pulmonary edema is prominent in HPS as is cardiac dysfunction. Pleural effusions are commonly noted in patients with HPS and have been thought to be exudative. This report describes the prevalence and characteristics of pleural effusions by an assessment of chest radiographs for the presence of pleural fluid and reviews all pleural fluid specimens obtained from patients with HPS. Of 23 patients treated at the University of New Mexico Hospital for HPS, 22 had evidence of pleural fluid while 4 had sampling of their pleural fluid. Two samples met criteria for an exudate by pleural fluid protein to serum protein ratio of more than 0.5; one was clearly a transudate and the other had inconsistent characteristics. The two exudative samples were obtained 7 days after admission, while the other 2 were obtained within 1 day of admission. Pleural fluid cultures were sterile, and the total of nucleated cells was less than 170/mm3, and predominately mononuclear. A hypothesis may be formulated that the pleural fluid in HPS is initially transudative, consistent with the observed cardiopulmonary dysfunction. However, following aggressive resuscitative efforts and as the acute illness resolves, fluid shifts occur as cardiac function normalizes; the pleural fluid may take on characteristics of an exudate.     

Usefulness of chromosome examination in the diagnosis of malignant pleural effusions

To determine whether chromosome analysis could facilitate the diagnosis of malignant pleural effusions, we examined chromosomes in effusions from 104 unselected patients. An effusion was regarded as malignant if at least three of 30 metaphase cells were hyperdiploid or contained a marker chromosome. Results were compared with standard cytologic diagnoses. All 22 benign effusions were diagnosed correctly by cytologic examination, but one nosed correctly by cytologic examination, but one (acute rheumatoid lung disease) was misclassified as positive by chromosome criteria. Of the 82 malignant effusions, 53 (65 per cent) were diagnosed correctly by cytologic tests, as compared with 58 (71 per cent) by chromosome analysis (P greater than 0.2). Among patients with malignant neoplasms, 13 had leukemia or lymphoma; only four of these (31 per cent) were diagnosed by cytologic tests as compared with 11 (85 per cent) by chromosome analysis (P less than 0.01). The combination of standard cytologic and chromosome analyses correctly identified 83 per cent of the neoplasms, a result significantly better than that with either technic alone (P less than 0.01).     

Primary cardiac lymphoma. No evidence for an etiologic association with Epstein-Barr virus

OBJECTIVES: To report two cases of primary cardiac lymphoma, a rare extranodal lymphoma with an unknown pathogenesis, and to compare them to secondary B-cell cardiac lymphoma. DESIGN: Clinicopathologic features are described, using histologic and immunophenotypic examinations. The Epstein-Barr virus genome is detected by in situ hybridization. PATIENTS: Of 80 autopsied cases of malignant lymphoma identified at Nagoya (Japan) University Hospital, two patients with primary cardiac lymphoma and five patients with secondary cardiac B-cell lymphoma were selected. RESULTS: None of the seven selected cases showed immunodeficiency, autoimmune disorders, or chronic inflammatory processes. Primary cardiac lymphomas had B-cell phenotypes with mu and lambda chain monoclonality. Immunostaining for Epstein-Barr virus (latent membrane protein-1) and Epstein-Barr virus-encoded RNA-1 in situ hybridization did not demonstrate an association of these lymphoma with Epstein-Barr virus infection. The majority of secondary cardiac B-cell lymphomas were extranodal lymphomas and extranodal or serosal involvement was more prominent than nodal involvement. CONCLUSION: These findings suggest that primary cardiac lymphoma, unlike pyothorax-associated pleural lymphoma, appears to have no association with chronic inflammation or Epstein-Barr virus infection.     

Effects of wheat germ agglutinin on tunicate egg activation and fertilization: is there a plasma membrane sperm receptor system on Ascidia ceratodes eggs?

Pneumocystis carinii causes life-threatening pneumonia in immunocompromised patients. The inability to culture P. carinii has hampered basic investigations of the organism's life cycle, limiting the development of new therapies directed against it. Recent investigations indicate that P. carinii is a fungus phylogenetically related to other ascomycetes such as Schizosaccharomyces pombe. The cell cycles of S. pombe and homologous fungi are carefully regulated by cell-division-cycle molecules (cdc), particularly cell-division-cycle 2 (Cdc2), a serine-threonine kinase with essential activity at the G1 restriction point and for entry into mitosis. Antibodies to the proline-serine-threonine-alanine-isoleucine-arginine (PSTAIR) amino-acid sequence conserved in Cdc2 proteins specifically precipitated, from P. carinii extracts, a molecule with kinase activity consistent with a Cdc2-like protein. Cdc2 molecules exhibit differential activity throughout the life cycle of the organisms in which they occur. In accord with this, the P. carinii Cdc2 showed greater specific activity in P. carinii trophic forms (trophozoites) than in spore-case forms (cysts). In addition, complete genomic and complementary DNA (cDNA) sequences of P. carinii Cdc2 were cloned and found to be most closely homologus to the corresponding sequences of other pathogenic fungi. The function of P. carinii cdc2 cDNA was further documented through its ability to complement the DNA of mutant strains of S. pombe with temperature-sensitive deficiencies in Cdc2 activity. The P. carinii cdc2 cDNA restored normal Cdc2 function in these mutant strains of S. pombe, and promoted fungal proliferation. These studies represent the first molecular analysis of the cell-cycle-regulatory machinery in P. carinii. Further understanding of P. carinii's life cycle promises novel insights for preventing and treating the intractable infection it causes in immunocompromised patients.     

Computed tomography in a case of pseudomembranous colitis

Pseudomembranous colitis (PMC) is an infectious colitis usually occurring as a complication of antibiotic therapy. The computed tomography (CT) findings of 10 patients with PMC are reviewed. All patients demonstrated an abnormal large bowel wall with an average thickness of 13 mm (range 7-31 mm). Additional, but less frequent findings included mesenteric inflammation, ascites, pleural effusions, and dilatation of the large or small bowel. Pancolonic involvement was seen in 7 cases, while three patients had focal colitis. Although the CT appearance of PMC is not specific, the diagnosis may be suggested in the proper clinical setting.     

Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas

In the treatment of multiloculated pleural effusions and empyemas tube thoracostomy often fails and more aggressive surgical therapy is required. Intrapleural administration of fibrinolytics is a valuable alternative. Between October 1994 and December 1995 28 patients (aged 22 to 62 years) with multiloculated pleural effusions were treated with intrapleural instillations of streptokinase after unsuccessful conventional chest tube drainage. Twenty-three pleural effusions were grossly purulent, others were loculated effusions with low pH. The most common cause of the pleural effusions was pneumonia. Duration of illness before hospitalization was 3 to 105 (mean 21.8) days. Treatment with streptokinase was started most commonly one day after chest tube placement. Once a day after clamping the chest tube streptokinase was administered intrapleurally for 10-15 minutes as a solution of 250,000 units in 100 ml normal saline. The tube remained clamped for 3 hours. Two to 8 (mean 3.7) instillations per patient were needed. Twenty-one cases (72.4%) showed excellent resolution of pleural effusion and needed no more therapy. However, one patient died in hospital due to purulent meningitis and bilateral pneumonia. Eight patients needed further surgical treatment, e.g. decortication, in 5 cases together with wedge lung resection. Eleven patients experienced some adverse effects of streptokinase therapy, most frequently chest pain and elevation of body temperature in one case pleural effusion became hemorrhagic, and one patient had nasal bleeding. We conclude that usage of intrapleural streptokinase in the treatment of multiloculated pleural effusions (including pleural empyemas) reduces the need for major surgical interventions in quite a large group of patients.     

Long-term alterations in growth factor mRNA expression following seizures

Pneumocystis carinii pneumonia (PCP) is one of the most predominant opportunistic infectious diseases in patients with AIDS. Nested PCR has been described as a sensitive and specific tool for detecting P. carinii DNA in clinical specimens. Little is known about the correlation of positive PCR results and clinical evidence of PCP in patients with different forms of immunosuppression. One hundred and thirty-six sputum samples, 26 tracheal-bronchial aspirate samples, 35 bronchoalveolar lavage samples, and 11 lung biopsy samples from (i) human immunodeficiency virus (HIV)-infected patients with AIDS, (ii) immunocompromised patients with leukemia or lymphoma, and (iii) immunocompetent control patients were investigated by a nested PCR amplifying DNA from the mitochondrial large subunit of P. carinii. All patients suffered from acute episodes of respiratory disease. The resulting data were correlated with clinical evidence of PCP. A high degree of association of positive P. carinii PCR results and clinical evidence of PCP in HIV-infected patients with AIDS was found. When calculated for bronchoalveolar lavage and lung biopsy samples, the positive and the negative predictive values of P. carinii PCR for PCP diagnosis in HIV-infected patients with AIDS were 1 and the specificity and the sensitivity were 100%. In contrast, in the group of patients with leukemia or lymphoma, the positive predictive value of the nested PCR for these materials was found to be as low as 0.09, the negative predictive value was 0.73, the specificity was 44.4%, and the sensitivity was 25.0%. No P. carinii DNA could be detected in specimens from immunocompetent patients. In summary, in contrast to patients with leukemia and lymphoma, nested PCR seems to be a sensitive and specific tool for PCP diagnosis in HIV-infected patients with AIDS.     

The etiology of pleural effusions in an area with high incidence of tuberculosis

To investigate the etiology of pleural effusions in our region, we undertook a prospective study of patients with this condition in our centers. During a 5-year period, we studied 642 pleural effusion patients aged 57.1 +/- 21.1 years, of whom 401 were men aged 56.5 +/- 21 years and 241 were women aged 57.8 +/- 21.4 years; the male/female ratio was 1.6:1. The most frequent cause of pleural effusion was tuberculosis (25%), followed by neoplasia (22.9%) and congestive heart failure (17.9%). The etiology of 48 cases (7.5%) remained uncertain. In the neoplastic effusion group, the most frequent locations of the primary tumor were lung (32.6%), breast (11.5%), lymphoma (10.8%), and ovary (7.5%); in 21 cases (14.3% of the neoplastic group), it was not possible to identify the primary tumor. The 111 patients aged younger than 40 years with tuberculous effusions made up 69.4% of tuberculous effusion cases and the same percentage of patients younger than 40 years; the proportion of effusions that were tuberculous peaked in the 11- to 30-year-old age group and declined steadily thereafter. Of the patients with neoplastic effusions, 83% were older than 50 years; the proportion of effusions that were neoplastic rose steadily from zero in the 0- to 30-year-old age group to a peak among 60- to 70-year-olds. The age-wise distribution of effusions secondary to congestive heart failure was similar to that of neoplastic effusions. Of the effusions secondary to congestive heart failure, 86% (99/115) affected the right pleura or both, and 83% of effusions secondary to pulmonary thromboembolism (15/18) affected the right side. Neoplastic, tuberculous, parapneumonic, empyematous, and other exudative effusions showed no preference for either side. Of the 97 bilateral effusions, 77 (79.4%) were secondary to heart failure (59, 60.8%) or neoplasia (18, 18.6%). We conclude that in our region, the most frequent cause of pleural effusion is tuberculosis, followed by neoplasia and congestive heart failure. We suggest that all those interested in pleural disease should determine the etiologic pattern of pleural effusion in their region with a view to the adoption of regionally optimized diagnostic and therapeutic attitudes.     

Extrapulmonary and disseminated pneumocystosis in HIV infection

Three cases of extrapulmonary disseminated Pneumocystis carinii infection are reported. All 3 patients had HIV infection with less than 50 CD4 lymphocytes per cubic millimeter and were having aerosols of pentamidine as prophylactic treatment of pneumocystosis. P. carinii may invade numerous organs and in particular the liver, spleen and bone marrow. Extrapulmonary lesions, often pan-symptomatic, are to be feared in deeply immunodepressed patients receiving prophylactic aerosols of pentamidine. Infection of the choroid can be detected by systematic ophthalmoscopy. An early diagnosis raises hopes of a good, if temporary, response to treatment.     

AIDS: infections of the retina and choroid

Various viral, bacterial, parasitic and fungal agents have been found to cause infections of retina and choroidea in HIV-infected patients. Usually these infections are opportunistic infections caused by the profound immunodeficiency, which is a result of the decay of lymphocytes by HIV. Before the HIV epidemic only rare cases of cytomegalovirus (CMV) retinitis were known in the literature. Now CMV retinitis has become the most common infection of the eye in AIDS patients. Ocular toxoplasmosis in HIV-infected patients can have a severe clinical appearance without treatment. Spontaneous recovery, as it usually occurs in otherwise healthy patients, does not take place in HIV-infected patients, so that a lifelong maintenance therapy is mandatory. Pneumocystis carinii chorioiditis was unknown before the HIV epidemic. In 1987 Pneumocystis carinii were found in the choroidea and two years later the clinical appearance could be described. Infections of choroidea and retina associated with AIDS may not be seen as isolated diseases. Commonly other organs are infected by the same or another organism. In case of AIDS-associated eye infections other organs should be checked for opportunistic disease. Diagnosis can be difficult. Because most of all intraocular infections associated with AIDS are CMV retinitis, an effective therapy can be initiated in most cases and in the follow-up a diagnosis can finally be made. Serological testing may be inconclusive because of occasional false-negative findings. Treatment often only suppresses the infections and so ongoing maintenance therapy may be necessary, as in the cases of CMV retinitis and Toxoplasma retinochorioiditis. A variety of different diseases, which can be treated by a multitude of different substances with a lot of adverse effects and contraindications, can complicate the therapeutic modalities used for the management of each individual disorder. Additionally HIV-infected patients suffer from at least two or three different diseases and must be treated lifelong with plenty of substances, which often are given with higher doses than usual. Only by cooperation of HIV-experienced doctors of different specialities in hospitals and offices the complex subject of HIV infection can be managed.     

Three- to 5-year prospective follow-up of outcome in major depression

STUDY OBJECTIVES: Recurrent chylothorax as a complication of lymphoma has had unsatisfactory outcomes. Serial thoracentesis, tube thoracostomy, and pleurodesis via chest tube have been ineffective and compromise the nutritional and immune status of the patient. Medical thoracoscopic talc pleurodesis has been safe and effective in the treatment of some other varieties of recurrent pleural effusions. Our objective was to investigate the safety and efficacy of medical thoracoscopic talc pleurodesis in the palliation of chylothorax related to lymphoma. DESIGN: This is a report of 24 hemithoraces treated in 19 consecutive patients with lymphoma-related chylothorax, failing chemotherapy or radiation therapy. The average patient age was 55 years. INTERVENTIONS: Medical thoracoscopy was performed under local anesthesia and conscious sedation in a bronchoscopy suite. Sedation included midazolam (mean dose, 6 mg; range, 2-14 mg) with either meperidine (mean dose, 94 mg; range 25-140 mg), or morphine (mean dose, 18 mg; range 4-40 mg). Pleurodesis was performed with insufflation of sterile asbestos-free talc, (4-8 g). After pleurodesis, chest tubes were placed, with the mean duration of chest tube placement being 4 days, range 3 to 10 days. RESULTS: One patient died a few days after the procedure due to causes related to the primary disease process. Follow-up was for at least 90 days following the procedure. Patients were assessed at 30, 60, and 90 days following the procedure. At each of these endpoints, all patients remaining alive were without recurrence of pleural effusions, which was confirmed by chest radiography. Eight patients in the series died of the effects of their malignancy during the 90-day evaluation interval. Complications included medication reactions in two patients (8.3%) and ARDS in one patient (4.1%). CONCLUSION: Many patients with lymphoma-related chylothorax are refractory to chemotherapy and/or radiation therapy. In this group, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrence of pleural effusions at 30, 60, and 90 days following the procedure.     

Granulomatous Pneumocystis carinii pneumonia: DNA amplification studies on bronchoscopic alveolar lavage samples

Three HIV positive subjects presented with symptoms and radiographic changes suggestive of Pneumocystis carinii pneumonia. Methenamine silver staining of bronchoscopic alveolar lavage (BAL) fluid was negative (from one sample in one patient and two samples in the other two patients). Open lung biopsy was performed because of uncertain clinical progress and diagnosis; all three patients were found to have multiple pulmonary granulomata encasing numerous P carinii organisms. DNA amplification, using P carinii specific oligonucleotides, was performed on stored bronchoscopic BAL samples. P carinii specific amplification product was detected by ethidium bromide staining after electrophoretic separation on agarose gel in one case, and by the more sensitive technique of oligohybridisation in all three cases. In granulomatous P carinii pneumonia organisms are rarely identified in bronchoscopic alveolar lavage samples using histochemical staining, but are detectable by DNA amplification, although not at levels which can be readily distinguished from low, subclinical infection.     

Cytologically proved malignant pleural effusions: distribution of transudates and exudates

PURPOSE: This study attempts to determine the distribution of transudates vs exudates in pathologically proved malignant pleural effusions and the necessity for cytologic studies in patients with a transudative effusion. MATERIALS AND METHODS: A retrospective review of all cytologically positive malignant pleural effusions was performed at Duke University Medical Center over an 18-month period. All effusions were characterized as a transudate or an exudate based on standard criteria, including lactate dehydrogenase and protein values. RESULTS: Ninety-eight patients with a mean age of 62 years were identified as having a cytologically positive malignant pleural effusion and blood chemistry values available to distinguish an exudate from transudate. Ninety-seven patients (99%, 95% confidence interval; 0.94 to 0.99) had criteria for an exudative effusion. One patient (1%) with diffuse metastatic lung cancer had a borderline transudate and was in congestive heart failure at the time of thoracentesis. CONCLUSIONS: Cytologically positive pleural effusions for malignancy are almost always exudates. Cytologic evaluation for malignant cells of a transudative pleural effusion is not recommended.     

Doppler flowmetry in the planning of perforator flaps

Parapneumonic pleural effusions are associated with the presence of a variety of inflammatory cells whose influx into the pleural space is attributed to the presence of inflammatory cytokines. Macrophage inflammatory protein-1alpha (MIP-1alpha), an important mononuclear chemokine, plays a critical role in pulmonary parenchymal inflammatory disease, but its role in the recruitment and activation of mononuclear phagocytes in the pleural space is unknown. In this study we demonstrate that complicated parapneumonic pleural effusions (empyema) and uncomplicated parapneumonic pleural effusions contain significantly (P < .001) higher levels of MIP-1alpha with higher numbers of mononuclear cells when compared with effusions resulting from malignancy and congestive heart failure. The MIP- 1alpha was biologically active and contributed 43% and 37% of the mononuclear chemotactic activity of complicated and uncomplicated parapneumonic pleural fluids, respectively. In vitro, human mesothelial cells, when stimulated with interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), or bacterial lipopolysaccharide (LPS), produced MIP-1alpha. Northern blot analysis confirmed that both endogenous (IL-1beta or TNF-alpha) and exogenous (LPS) factors induce MIP-1alpha expression in mesothelial cells. Supernatants from activated mesothelial cells demonstrated chemotactic activity for mononuclear cells. This activity was blocked by MIP-1alpha antibody, indicating that the MIP-1alpha released was biologically active. We conclude that in parapneumonic pleural effusions, MIP-1alpha plays a major but not exclusive role in the recruitment of mononuclear leukocytes from the vascular compartment to the pleural space, and pleural mesothelial cells by production of MIP-1alpha actively participate in this process.     

Intravitreal large-cell lymphoma

Large-cell (non-Hodgkin's) lymphoma may occur in the eye as a cellular infiltrate in the vitreous, uveal tract (choroid), retina, or optic nerve. Lymphomatous involvement may be limited to the eye but also is frequently associated with lesions of the central nervous system. Ocular involvement may precede involvement of the central nervous system by months or, in some cases, years. Ocular large-cell lymphoma is bilateral in approximately 80% of cases but often is asymmetric. The mean age of patients with ocular large-cell lymphoma is 60 years, and women are affected almost twice as often as men. Intravitreal large-cell lymphoma may manifest as an infiltrate of large glassy-gray cells or clusters of cells, and it may mimic uveitis or other inflammatory and infectious conditions of the eye. The diagnosis is based on cytologic and immunocytochemical studies of a vitreous biopsy specimen obtained by aspiration or by vitrectomy through the pars plana. Advances in irradiation of the eyes and the central nervous system, supplemented with corticosteroids and intrathecally and intravenously administered chemotherapeutic agents, have resulted in improvement of the dismal prognosis for patients with large-cell lymphoma.     

Cavitary pulmonary lesions in patients infected with human immunodeficiency virus

The differential diagnosis of cavitary pulmonary lesions in individuals infected with human immunodeficiency virus (HIV) is broad, especially in patients with advanced disease. In patients with Pneumocystis carinii pneumonia, cavitation is an uncommon manifestation of a common disease. It is unusual in patients with pulmonary cryptococcosis, coccidioidomycosis, and histoplasmosis but occurs frequently in patients with invasive pulmonary aspergillosis. In patients with pulmonary tuberculosis, cavities are more common during earlier stages of HIV disease, when cellular immunity is relatively preserved. Mycobacterium avium complex is an uncommon cause of lung disease and infrequently produces cavities. However, Mycobacterium kansasii, is often associated with cavitation. Cavities can complicate any bacterial pneumonia and are especially common with pneumonia due to Pseudomonas aeruginosa, Nocardia asteroides, and Rhodococcus equi. Noninfectious causes of cavitary lesions are rare, but cavitary lesions caused by pulmonary Kaposi's sarcoma and non-Hodgkin's lymphoma have been reported. Because of the broad differential diagnosis and because most cavities are caused by treatable opportunistic infections, a definitive diagnosis is essential.