Pneumocystis Carinii Pneumonia—Problems in Diagnosis and Therapy in 24 Cases

Twenty-four instances of Pneumocystis carinii pneumonia were recognized in 23 patients at the Stanford University Hospitals between 1962 and 1970. The affected persons could be broadly characterized as “compromised” hosts. All but one were receiving immunosuppressive drug therapy for such underlying disease as hematopoietic malignant disease, collagen vascular disorder, and organ transplant rejection. The one patient not receiving immunosuppressant medication had congenital dysgammaglobulinemia and suffered two discrete bouts of pneumocystis pneumonia. Most of the patients were concomitantly infected with other “opportunistic” pathogens.Open lung biopsy remained the most reliable method of antemortem diagnosis of pneumocystis infection during this eight-year period. It resulted in little morbidity. Unfortunately, direct examination of appropriately stained sputum specimens for cysts was almost uniformly nonproductive.The majority of patients received specific antipneumocystis drug treatment (pentamidine isethionate or pyrimethamine and sulfadiazine). “Cure” was achieved when institution of therapy was prompt and duration of therapy approached the empirically recommended two-week course.The fact that pneumocystis pneumonia can be controlled if recognized early is compelling reason to pursue diagnosis of pneumocystosis in an appropriate clinical setting, namely, in patients with impaired host defenses who have pulmonary infection unresponsive to conventional therapy. There is hope that a noninvasive (serological) technique will be developed shortly to simplify identification of this not uncommon cause of diffuse interstitial pneumonitis.     

URINARY TRACT INFECTIONS—Problems in Medical Management

The lesion principally responsible for chronic, or recurrent, urinary tract infection is a focus in the interstitial tissue of the kidney. Most cursory antimicrobial therapy suppresses the manifestations of lower urinary tract involvement but does not eradicate the renal focus. In order to cure rather than merely suppress the infection, it is imperative that, as early as possible, steps be taken to isolate and identify the etiologic microorganism and to determine its sensitivity to antimicrobial agents. Based on this information sufficient amounts of drug should be given for an adequate period (probably at least two weeks) to eradicate the infection within the renal tissue. Such a program would tend to reduce the number of cases in which irreversible renal failure develops from chronic pyelonephritis.     

RHEUMATOID ARTHRITIS—Diagnosis in Peripheral Joint Affliction

The diagnosis of rheumatoid arthritis in a typical case depends upon a history of pain and swelling of various joints throughout the body. In the first stages the disease usually involves only the small joints of the hands and feet, but sooner or later it spreads to the larger joints. This may be accompanied by fibrosis of one or more joints, causing disability ranging from disuse of one joint up to total incapacity. Diagnosis in early or atypical cases is often impossible until the patient has been under observation a long time. It is important that diagnosis be made as early as possible, in order that appropriate therapy may be started and ankylosis and disability of the joints prevented.Since laboratory procedures and roentgen films do not show early changes, emphasis is placed on the history and physical examination for diagnosis.     

REFRACTORY HYPOTENSION—Diagnosis and Management in Surgical Patients

Refractory hypotension is circulatory collapse of obscure cause which occurs in surgical patients who are thought to have a normal blood volume but in whom adequate circulation cannot be maintained. Such patients are usually treated empirically by the administration of intravenous vasopressor agents, and the mortality rate is relatively high.A specific diagnosis of the underlying cause for the refractory hypotension can be made by thorough clinical evaluation. Specific treatment aimed at correcting the underlying cause of the vascular collapse will lower the mortality rate in this serious type of circulatory failure.     

VIRAL AND RICKETTSIAL DISEASES—Laboratory Methods in Diagnosis

Factors contributing to the development of viral diagnostic services have been: (1) technical advances, and (2) increasing demand for services due to relative and actual increases in the prevalence of these illnesses. This increase has been both relative, as in the case of diphtheria, etc., and actual as in the cases of poliomyelitis. Technical advances have been numerous and frequent. One of the most spectacular has been the development of methods for the culture of living cells for the propagation of viruses. Emphasis must be placed on the fact that the diagnosis of many viral diseases requires close teamwork between local, state, federal, and privately supported agencies. Laboratory procedures remain expensive but are frequently the only way to determine the exact nature of a particular illness. The available or practical procedures are emphasized in this discussion.     

PARATHYROID TUMORS—Intermittent Function,a Pitfall in Diagnosis

Seventy cases of functioning parathyroid tumors encountered at Columbia-Presbyterian Medical Center were reviewed. The clinical and chemical findings in parathyroid tumors were variable and were suggestive of intermittent function. The indirect diagnostic tests available today usually paralleled the basic serum calcium and phosphorus determinations. Urolithiasis was the most common complication observed, but the symptoms of it varied from simple colic and single calculus problem to extensive calculus disease. There were two instances of hyperparathyroid crisis or “hypercalcemic poisoning.”     

PALM THORN INJURIES—Difficulty in Diagnosis of Late Sequelae

Injuries in which palm thorns become embedded in soft tissues or cartilage, leaving no external evidence of their presence, sometimes present a baffling diagnostic problem. A high index of suspicion is the most important aid in diagnosis. Laboratory findings are not helpful and rarely can conclusive diagnosis be made from clinical examination. Surgical excision of the buried thorn is the only satisfactory treatment.     

NONOBSTRUCTIVE OLIGURIA—Differential Diagnosis

A review is presented of ten years'' experience with the differential diagnosis of oliguria, utilizing the standard tests of renal function with the addition of the phenolsulfonphthalein excretion and urinary chloride measurements. The histories of 60 patients seen in consultation because of 24-hour urinary volume of less than 400 ml were studied in order to clarify the value of these tests. Particular attention was given to the postoperative “dilution state,” the oliguria of which tends to mimic that of “acute tubular necrosis.”In only 25 per cent of the 60 cases was “acute tubular necrosis” responsible for the oliguria. In the remaining 75 per cent of patients, oliguria was due either to the effects of simple dehydration without tubular damage, or to tubular dysfunction on a physiologic rather than an organic basis. Thus, three out of four patients with oliguria required aggressive and specific fluid-electrolyte therapy, often with the intensive use of potassium. One out of four required the opposite in therapy—controlled dehydration without added potassium and, on occasion, peritoneal or extracorporeal dialysis, in order to allow six to ten days for tubular repair.     

Ischemic Heart Disease—Use of Serum Enzyme Determinations in Diagnosis

The world literature since 1962 gives further substantiation of the usefulness of serologic measurement of glutamic-oxalacetic transaminase (GOT) activity and lactic dehydrogenase (LDH) activity in the diagnosis of myocardial infarction. LDH has not been found superior to GOT. The isoenzymes of LDH are now creating more and more interest because of their specificity for damage in various organs. This specificity, however, is not fully established.     

Pain Syndromes—The Use of Nerve Block in Diagnosis and Treatment

There are four distinct pain entities which may be treated by injection of local anesthetic or neurolytic agents. These entities are somatic, visceral, sympathetic mediated and myofascial pain. Each entity should be recognized as separate from other types of pain and the appropriate therapeutic approach prescribed.