clinical picture is similar to that produced by other organisms, such complete septic shock score, using a hyperventilation (PaCOJ

as mycobacteria, although Nocardia is also capable of inducing a criterion of 28 mm Hg or less in the arterial blood gas sample, and
granulomatous reaction in tissue. This gives rise to the possibility propose that the PaCO I level should be adjusted to altitude in order
of making an erroneous diagnosis of tuberculosis, above all in areas not to inadvertently include some non-SIRS patients.
such as Spain where this disease is relatively frequent.
Although ceftriaxone has been shown to be active in vitro,3 its jose J Elizalde, M.D., F.C.C.E, and
clinical efficacy has been demonstrated only in isolated cases." A JesUs Martinez, M.D.,
clear clinical and radiologic initial response was obtained in the Critical Cam Department,
present case, which was maintained over time. Other studies on American British Cowdray Hospital,
the clinical utility of ceftriaxone in cases of Nocardia infection National University of Mexico,
should be carried out. Mexico City, Mexico

jose I. Garcia delltJlacio, M.D., and REFERENCES

Inmaculada Martin Perez, M.D., 1 Bone RC, Fisher CJ, Clemmer n Slotman GJ, Metz CA, Balk
"Virgen de la Salulf' Hospital, RA. Sepsis syndrome: a valid clinical entity. Crit Care Med 1989;
1biedo, Spain 17:389-93
2 Bone RC. The lung in MOSF. Presented at the 21st Society of
REFERENCES Critical Care Medicine Educational and Scientific Symposium,
San Antonio, Texas, May 1992
1 Holtz HA, Lavery D~ Kapila R. Actinomycetales infection in 3 ACCPISCCM Consensus Conference Committee. Definitions
the acquired immunodeficiency syndrome. Ann Intern Med 1985; for sepsis and organ failure and guidelines for the use of innovative
102:203-05 therapies in sepsis. Chest 1992; 101:1644-55
2 Kramer MR, Uttamchandani RB. The radiographic appearance 4 Michel CC, Milledge JS. Respiratory regulation in man during
of pulmonary nocardiosis associated with AIDS. Chest 1990; acclimatization to high altitude. J Physioll963; 168:631-34
98:382-85 5 Cherniack NS, Pack AI. Control of ventilation. In: Fishman ~
3 Gombert ME, Aulicino TM, duBouchert L, Berkowitz LR. ed. Pulmonary diseases and disorders. New York: McGraw-Hill,
Susceptibility of Nocardia asteroides to new quinolones and 1988; 131-44
betalactams. Antimicrob Agents Chemother 1987; 31:2013-14 6 West JB. Respiratory physiology in unusual environments. In:
4 Kim], MinamotoGY, Hoy CD, Grieco MH. Presumptive cerebral West JB, ed. Respiratory physiology: the essentials. Baltimore:
Nocardia asteroides in AIDS: treatment with ceftriaxone and Williams ~ Wilkins, 1990; 131-45
minocycline. Am J Med 1991; 90:656-58

Pneumothorax During Pulmonary

Tuberculosis In an HIV-infected Patient
Ventilatory Criteria for Systemic
Inflammatory Response Syndrome 7bthe EdUor:

To the Editor: Pneumothorax is becoming an increasingly important problem in

HIV-infected patients. It has been reported in 2 percent of
Concerned as we are about ARDS and its high mortality; we have hospitalized HIV-infected patients! and has been strongly linked to
followed for a number of years Dr. Bone's concepts about early Pneumocy8ti8 cannU pneumonia and aerosol pentamidine prophy-
ARDS diagnosis as a logical means of decreasing its morbidity and laxis. 1 This report describes an unusual case of spontaneous pneu-
mortality, which later resulted in his description of the septic mothorax during the course of pulmonary tuberculosis in a patient
syndrome. • We were most interested in his recent Society of Critical with HIV infection.
Care Medicine (SCCM) conference, I and we read with enthusiasm A 42-yeaN>ld HIV-seropositive former intravenous drug abuser
in the June 1992 issue of Chest the recent ACCP-SCCM Consensus was admitted to the hospital with a 3-week history of left-sided
Conference article," in which a notable group of colleagues describe chest pain and weight loss. There was no cough, fever, or night
systemic inflammatory response syndrome (SIRS) and offer an sweats. He bad no previous opportunistic infections and was not
important body of practical definitions. receiving any treatment. His vital signs were stable, and the physical
In essence, we fully support these definitions and believe that examination findings were unremarkable. The chest roentgeno-
they will improve our way of practicing medicine in the septic grams showed alveolar infiltrate in the lingular segment of the left
patient. However, since Mexico Citys metropolitan area, with its upper lobe. The puri6ed protein derivative test was positive, and
23 million inhabitants, is at high altitude (2,240 m above sea level), sputum could not be obtained.
we are obliged to use different ventilatory parameters, because the On the fifth hospital day the patient felt a pleuritic left-sided
proposed PaC 0 1 level of 32 mm Hg or less for diagnosis of chest pain. A chest roentgenogram revealed a left pneumothorax
hyperventilation (as appropriate at sea level) is fairly normal for our with persistent lingular infiltrate (Fig 1). A chest tube was placed,
patients, which creates the possibility of overdiagnosing SIRS. and the left lung reexpanded. Consequently, fiberoptic bronchos-
For a long time it has been recognized that people living at high copy was performed. The bronchoalveolar lavage fluid showed acid-
altitude, being exposed to lower barometric pressure (585 mm Hg fast bacilli, which on subsequent culture grew Mycobacterium
in our city) and so to relatively lower PAOI and PaO I , tend to tuberculosis. There was no evidence of P cannU, viroses, fungi, or
hyperventilate as an automatic mechanism of compensation. The malignancy The patient was started on a regimen of isoniazid (300
intrinsic physiopathologic mechanism involved in this regulatory mg daily), rifampin (600 mg daily), ethambutol (1,500 mg daily),
pattern is poorly understood, but it is supposed to be mediated and pyrazinamide (1,500 mg daily). The chest tube was removed 12
through the peripheral chemoreceptors, causing changes in blood days later, and the patient was discharged on antituberculosis
and cerebrospinal ftuid bicarbonate concentrations, which return medications.
pH to normal unless other factors account for ventilatory acclima- This is the first reported case in the English language literature,
tization.r" to my knowledge, to describe spontaneous pneumothorax in an
We are currently conducting a prospective trial correlating SIRS HIV-infected patient with pulmonary tuberculosis. It suggests that
mortality with the simplified acute physiologic score and the we should consider conditions other than P carinii pneumonia when

1926 Communications to the EcItor

 was decreased by 20 percent. Laboratory findings included hyper-
eosinophilia (7801mm 3) and an erythrocyte sedimentation rate (ESR)
of64 mm after the first hour. Pleural tap yielded an exudate (protein.
53 !¥L) with predominating eosinophils (42 percent). There was no
evidence of neoplas ia. The findings from fiberoptic bronchoscopy,
biopsy, and aspiration specimen analysis were normal . Electrocar-
diographic and echocardiographic findings were also normal . Nor-
mal lung perfusion scan and phlebography eliminated thrombo-
embolism . Abdominal ultrasonography ruled out subdiaphragmatic
disease. Serologic studies for the usual helminthic parasites and
stool analysis were negative . The clinical cour se was immediately
favorable, and the patient was discharged on April 14, 1989.
On July 26 the patient was readmitted with a 15-day history of
progressively worsen ing exertional dyspnea, dry cough , and left
chest pain . Physical signs included bilateral basilar rales and pleural
rubs. Chest radiography demonstrated recurrent bilateral basilar
interstitial infiltrates as well as bilateral pleural effusion. Chest
computed tomography confirmed the diffuse interstitial syndrome ,
especially at the level of the peribronchovascular sheath s. Broncho-
alveolar lavage was performed in the middle lobe . The aspirate was
hypercellular (110,000 cells/mm -) with 13 percent lymphocytes and
FIGURE 1. Chest roentgenogram showing an alveolar infiltrate in 9 percent neutrophils. Eosinophils were absent. The pleural tap
the lingular segment of the left upper lobe and a left-sided Ouid was exudative, and cytologic study showed predominantly
pneumothorax.
lymphocytic cells (68 percent). The patient was unable to undergo
functional respiratory test s because of the inten sity of his dyspnea.
a patient with HIV infection presents with spontaneous pneumo- Bacteriologic and mycologic investigations were negative .
thorax . The blood cell count was normal , and the ESR was 65 mm after
the first hour. Upon further questioning, the patient recalled that
Ayman Q Soubani; M.D.•
each of the three episodes of dyspnea (November 1988, April 1989.
Department of Medicine,
July 1989) occurred while taking dexfenOuramine prescribed to
Nassau County Medical Center,
help him lose weight . The drug was initially prescribed at a dose of
FASt Meadow, New York
15 mg twice daily in October 1988. Treatment was interrupted
after 6 weeks because of the "flultke " syndrome he experienced in
REFERENCES
November 1988. The drug was then prescribed from February to
1 Sepkowitz KA, Telzak EE, Cold JWM , et al. Pneumothorax in April 1989, interrupted only during his first hospital stay. The last
AIDS . Ann Intern Med 1991; 114:455-59 prescription began in July 1989 and was discontinued during his
2 McClellan MD , Miller SB. Parsons PE, Cohn DL. Pneumothorax second hospitalization.
with Pneumocystis carinii pneumonia in AIDS : incidence and
The patient was discharged in good health on August 1, 1989.
clinical characteristics. Chest 1991; 100:1224-28
Routine clinical and radiographic follow-ups in July 1991 were
normal.
This case strongly suggests a drug-induced lung disease because
Recurrent Interstitial Pneumonitis and of the sequence of events , the absence of pulmonary history. the
Dexfenfluramine exclusion of cancerous or infectious pulmonary pathology, and the
spontaneous regression of the interstitial pneumonitis, without
corticosteroid or antibiotic therapy (in April and July 1989).
To the Editor:
The responsibility of dexfenOuramine in this case of recurrent
Although fenOuramine (Pondimin, A. H . Robins, Richmond , Va: interstitial pneumonitis is quite likely. This possible corn plication
Ponderal Longue Action, Laboratoires Biopharma, Neuilly, France) widens the spectrum of pulmonary toxicity of this drug, to which
and dexfenOuramine (Isomeride, Laboratoires Ardix , Orleans, several cases of severe primary pulmonary hyperten sion have
France) are very widely prescribed as adjuvant therapy in obesity. already been ascribed.'"
we know of no reports of inte rstitial pneumonitis induced by these
Denis Braun, M .D . ,
drugs (racemic and dextrogyre forms). We have observed one such
Philippe Trechot, Ph.D. ,
case in a patient given dexfenOuramine.
lbtrick Netter, M .D .,
A 39-year-old man was admitted for the first time to the
veronique Danloy, M .D. ,
pneumology department on April 10. 1989, complaining of pro-
Daniel Antholne. M .V. • and
gressively worsening dyspnea and a dry, nonproductive cough . The
Girard Vaillant, M .D .,
patient's otherwise unremarkable medical history included obesity
Hapital Maillot .
(weight, 110 kg: height, 188 cm) and tobacco use evaluated at 36
Brieq, France. and
packs per year. In addition, he reported one previous episode of
CHUR .
dyspnea and coughing, which improved after antibiotic therapy, in
Nancy, France
November 1988. On admission the patient was afebrile. Physical
examination revealed bilateral basilar rales and a right basal pleural
rub . Arterial blood gas analysis showed hypoxemia and hypocapnia REFERENCES
(pH, 7.40; Pco., 22 mm Hg; Po. , 57 mm Hg). Chest radiography 1 Atanassoff PC, Weiss BM, Schmid ER , Tornic M. Pulmonary
showed a bilateral micronodular interstitial infiltrate and a small hypertension and dexfenOuramine . Lancet 1992; 1:436
right pleural effusion. The vital capacity was decreased by 30 2 Roche N, Labrune S, Braun JM, Huchon CJ. Pulmonary hyper-
percent, and the steady-state carbon monoxide diffusion capacity tension and dexfenOuramine. Lancet 1992; 1:436-37

CHEST I 103 I 6 I JUNE. 1993 1927