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Restrictive pattern of lung function following psittacosis treated with corticosteroids
Br.J.
RESTRICTIVE FOLLOWING
Chest
(1982)
76, 199
PATTERN OF LUNG FUNCTION PSITTACOSIS TREATED WITH CORTICOSTEROIDS
M. E. Department
Dis.
PRICE of Chest
AND
B. D. W.
Medicine,
West
HARRISON Norwich
Hospital
Psittacosis is a well recognized cause of pneumonia, although in most cases infection remains mild or subclinical. Some patients are more severely ill with involvement of the respiratory, cardiovascular and central nervous systems. The chest radiograph often shows areas of consolidation greater than the physical signs would suggest. Recovery may be prolonged. A case of severe pneumonia due to psittacosis is reported in which a severe restrictive pattern of lung function complicated recovery. This has been described following mycoplasma pneumonia with evolution into diffuse interstitial fibrosis (Kaufman et al. 1980) but not as far as we can discover following psittacosis. Treatment with corticosteroids was associated with complete resolution of the lung function and chest radiograph abnormalities after nine months.
Case Report A 53-year-old woman presented with a two-week history of dyspnoea and night sweats. On examination, she was very ill and cyanosed with a respiratory rate of 60:minute. Her temperature was 38 C, pulse rate 120/minute and blood pressure 1.50/90. There were reduced breath sounds at both lung bases and coarse crackles were heard throughout both lung fields. Investigations revealed: Haemoglobin 12.7 g/dl; white cell count 22 loo/mm3 with 98”:) neutrophils. Breathing air arterial oxygen tension (Paoe) was 4.9 kPa and carbon dioxide tension (Paces) 4.7 kPa. IIer chest radiograph showed widespread bilateral consolidation (Fig. 1). After sputum had been obtained for culture and blood for culture and serology, treatment was started with oxygen and intravenous ampicillin, cloxacillin and gentamicin. Forty-eight hours later her Paos was 3.9 kPa and Pacoz 6.0 kPa on 6Oya oxygen and she was transferred to the intensive care unit. Mechanical ventilation was started with a tidal volume of 770 ml and a minute volume of 10.8 litres and despite an inflation pressure of 35 cmHs0 an F,Oa of SOO;, and 5 mmHg PEEP, Paoz remained low at 5.6 kPa. By day 8, with a tidal volume of 800 ml and a minute volume of 16.0 litres, her arterial blood gases had improved so that an F10a of 38:” was required to maintain her Paoa at 8.5 kPa and her Paces at 5.6 kPa. By day 8 her hacmoglobin had fallen to 9.2 g/d1 and on day 10 she was transfused 3 units of packed red cells and a tracheostomy was performed. Within 24 hours of transfusion, her respiratory condition became much worse, clinically, physiologically and radiologically. She was ventilated with a tidal volume of 800 ml and minute volume of up to 20 litres and required an inflation pressure of 48 cmHa0 and an FiOz of 50”,) to maintain her Paoz of 7.4 kPa. Thereafter she recovered, sufliciently to stop mechanical ventilation after 26 days and her tracheostomy was allowed to close, but she remained breathless (respiratory rate jO/minute) with a tachycardia (pulse rate 120/minute) and on air her Paoz was 7.1 kPa. Oxptetracycline 500 mg six-hourly was started. A week later when she was still breathless, spirometry showed FElTi 1.1 litrcs, FVC 1.1 litres (predicted 2.6 litres)
M. E. Price and B. D. W. Harrison and peak flow rate 325 litres/minute. The chest radiograph showed patchy residual shadowing throughout both lung fields and prednisone was started at a dose of 30 mg daily. Four weeks after admission the diagnosis of psittacosis was made on an eight-fold rise in complement-fixation test titre and further questioning revealed that she had eviscerated four from which it is thought she contracted the rough-plucked ducks 10 days before admission, disease.
Fig. 1. Chest
radiograph
on admission
showing
widespread
areas
of consolidation
due
to psittacosis
pneumonia
A month later, nine weeks after the onset of her illness, her FVC was still only 1.15 litres. Over the next three and a half months her condition slowly improved, FVC increased to 2.0 litres and prednisone was tailed off. Oxytetracycline was continued while she was receiving steroids in an attempt to prevent recrudescence. Six months after admission, lung function tests showed FEVr 1.9 litres FVC 2.0 litres (predicted 2.6 litres), TLC 3.2 litres (predicted 3.9 litres) indicating residual restriction and carbon monoxide transfer factor was 4.5 mmol/minute/kPa (predicted 7.0 mmol/minute/kPa). The inspiratory volume flow curve showed reduced flow, reflecting either some extrathoracic upper airway narrowing or residual restriction. There was no evidence of intrapulmonary airway narrowing. After nine months lung volumes and carbon monoxide transfer factor were normal (FEVr 2.3 litres, FVC 2.7 litres, TLC 3.9 litres, carbon monoxide transfer factor 5.6 mmol/minute/kPa). Her volume-flow loop and chest radiograph were also normal.
Restrictive Pattern of Lung Function
201
DIscussroN This case illustrates a severe case of psittacosis complicated by severe pneumonia, with features of the adult respiratory distress syndrome and during convalescence a severe restrictive pattern of lung function. Apart from psittacosis, additional factors leading to adult respiratory distress syndrome in this patient were thought to be prolonged oxygen therapy (Fro, > 4Oq/, for five days and > SO0(, for two days), intermittent positive pressure ventilation and blood transfusion. Pulmonary fibrosis following severe acute respiratory failure from diverse causes is recognized (Zap01 et al. 1979). Pulmonary function after prolonged mechanical ventilation with high concentrations of oxygen has also been studied but complications due to oxygen toxicity are thought to be rare (Gillbe et al. 1980). A restrictive pattern of lung function is commonly seen during the acute stage of atypical pneumonia (5204) but it is very rare during convalescence although an obstructive pattern may persist for some weeks (Renusiglio et al. 1980). D i ff use interstitial fibrosis has been described following mycoplasma pneumonia and it it possible that high doses of corticosteroids may prevent the evolution of pulmonary fibrosis by influencing fibroblast proliferation. Our patient had a severe restrictive pattern of lung function following her psittacosis pneumonia with persistent tachycardia, tachypnoea and hypoxaemia. It was felt possible that she had a post-infective alveolitis which was likely to progress to pulmonary fibrosis and she was therefore started on prednisone 30 mg daily. This was tailed off over four and a half months and by nine months her lung function and chest radiograph had returned to normal. We think it likely that steroid therapy favourably influenced her clinical course but cannot exclude the alternative explanation that her complete recovery was due to slow spontaneous improvement. This patient is part of a recent outbreak of psittacosis in Norfolk (Andrews et al. 1981). REFERENCES ANDHEWS, H. E., hIAJOR, R. &PALMER, S. R.(l981)0 rnithosis in poultry workers. Lancet I, 632. RENUSIGLIO, L. N., STADLER, H. & JUNOD, A. F. (1980) Time course of long function changes in atypical pneumonia. Thorax 35, 586. GILLBE, C. E., SALT, J. C. 8L BRANTHWAITE, hf. A. (1980) Pulmonary function after prolonged mechanical ventilation with high concentration of oxygen. Thorax 35, 907. KAUFMAN, J. WI., CUVELIER, C. A. &VAN DER STRAETEN, M.(1980)iMycoplasma pneumoniawith fulminant evolution into diffuse interstitial fibrosis. Thorax 35, 140. ZAPOL, TV. AI., TRELSTAD, R. L., COFFEY, J. MT., Ts.41, C. & SALVADOR, R. A. (1979) Pulmonary fibrosis in severe acute respiratory failure. Am. Rev. resp. Dis. 119, 547.
RESTRICTIVE FOLLOWING
Chest
(1982)
76, 199
PATTERN OF LUNG FUNCTION PSITTACOSIS TREATED WITH CORTICOSTEROIDS
M. E. Department
Dis.
PRICE of Chest
AND
B. D. W.
Medicine,
West
HARRISON Norwich
Hospital
Psittacosis is a well recognized cause of pneumonia, although in most cases infection remains mild or subclinical. Some patients are more severely ill with involvement of the respiratory, cardiovascular and central nervous systems. The chest radiograph often shows areas of consolidation greater than the physical signs would suggest. Recovery may be prolonged. A case of severe pneumonia due to psittacosis is reported in which a severe restrictive pattern of lung function complicated recovery. This has been described following mycoplasma pneumonia with evolution into diffuse interstitial fibrosis (Kaufman et al. 1980) but not as far as we can discover following psittacosis. Treatment with corticosteroids was associated with complete resolution of the lung function and chest radiograph abnormalities after nine months.
Case Report A 53-year-old woman presented with a two-week history of dyspnoea and night sweats. On examination, she was very ill and cyanosed with a respiratory rate of 60:minute. Her temperature was 38 C, pulse rate 120/minute and blood pressure 1.50/90. There were reduced breath sounds at both lung bases and coarse crackles were heard throughout both lung fields. Investigations revealed: Haemoglobin 12.7 g/dl; white cell count 22 loo/mm3 with 98”:) neutrophils. Breathing air arterial oxygen tension (Paoe) was 4.9 kPa and carbon dioxide tension (Paces) 4.7 kPa. IIer chest radiograph showed widespread bilateral consolidation (Fig. 1). After sputum had been obtained for culture and blood for culture and serology, treatment was started with oxygen and intravenous ampicillin, cloxacillin and gentamicin. Forty-eight hours later her Paos was 3.9 kPa and Pacoz 6.0 kPa on 6Oya oxygen and she was transferred to the intensive care unit. Mechanical ventilation was started with a tidal volume of 770 ml and a minute volume of 10.8 litres and despite an inflation pressure of 35 cmHs0 an F,Oa of SOO;, and 5 mmHg PEEP, Paoz remained low at 5.6 kPa. By day 8, with a tidal volume of 800 ml and a minute volume of 16.0 litres, her arterial blood gases had improved so that an F10a of 38:” was required to maintain her Paoa at 8.5 kPa and her Paces at 5.6 kPa. By day 8 her hacmoglobin had fallen to 9.2 g/d1 and on day 10 she was transfused 3 units of packed red cells and a tracheostomy was performed. Within 24 hours of transfusion, her respiratory condition became much worse, clinically, physiologically and radiologically. She was ventilated with a tidal volume of 800 ml and minute volume of up to 20 litres and required an inflation pressure of 48 cmHa0 and an FiOz of 50”,) to maintain her Paoz of 7.4 kPa. Thereafter she recovered, sufliciently to stop mechanical ventilation after 26 days and her tracheostomy was allowed to close, but she remained breathless (respiratory rate jO/minute) with a tachycardia (pulse rate 120/minute) and on air her Paoz was 7.1 kPa. Oxptetracycline 500 mg six-hourly was started. A week later when she was still breathless, spirometry showed FElTi 1.1 litrcs, FVC 1.1 litres (predicted 2.6 litres)
M. E. Price and B. D. W. Harrison and peak flow rate 325 litres/minute. The chest radiograph showed patchy residual shadowing throughout both lung fields and prednisone was started at a dose of 30 mg daily. Four weeks after admission the diagnosis of psittacosis was made on an eight-fold rise in complement-fixation test titre and further questioning revealed that she had eviscerated four from which it is thought she contracted the rough-plucked ducks 10 days before admission, disease.
Fig. 1. Chest
radiograph
on admission
showing
widespread
areas
of consolidation
due
to psittacosis
pneumonia
A month later, nine weeks after the onset of her illness, her FVC was still only 1.15 litres. Over the next three and a half months her condition slowly improved, FVC increased to 2.0 litres and prednisone was tailed off. Oxytetracycline was continued while she was receiving steroids in an attempt to prevent recrudescence. Six months after admission, lung function tests showed FEVr 1.9 litres FVC 2.0 litres (predicted 2.6 litres), TLC 3.2 litres (predicted 3.9 litres) indicating residual restriction and carbon monoxide transfer factor was 4.5 mmol/minute/kPa (predicted 7.0 mmol/minute/kPa). The inspiratory volume flow curve showed reduced flow, reflecting either some extrathoracic upper airway narrowing or residual restriction. There was no evidence of intrapulmonary airway narrowing. After nine months lung volumes and carbon monoxide transfer factor were normal (FEVr 2.3 litres, FVC 2.7 litres, TLC 3.9 litres, carbon monoxide transfer factor 5.6 mmol/minute/kPa). Her volume-flow loop and chest radiograph were also normal.
Restrictive Pattern of Lung Function
201
DIscussroN This case illustrates a severe case of psittacosis complicated by severe pneumonia, with features of the adult respiratory distress syndrome and during convalescence a severe restrictive pattern of lung function. Apart from psittacosis, additional factors leading to adult respiratory distress syndrome in this patient were thought to be prolonged oxygen therapy (Fro, > 4Oq/, for five days and > SO0(, for two days), intermittent positive pressure ventilation and blood transfusion. Pulmonary fibrosis following severe acute respiratory failure from diverse causes is recognized (Zap01 et al. 1979). Pulmonary function after prolonged mechanical ventilation with high concentrations of oxygen has also been studied but complications due to oxygen toxicity are thought to be rare (Gillbe et al. 1980). A restrictive pattern of lung function is commonly seen during the acute stage of atypical pneumonia (5204) but it is very rare during convalescence although an obstructive pattern may persist for some weeks (Renusiglio et al. 1980). D i ff use interstitial fibrosis has been described following mycoplasma pneumonia and it it possible that high doses of corticosteroids may prevent the evolution of pulmonary fibrosis by influencing fibroblast proliferation. Our patient had a severe restrictive pattern of lung function following her psittacosis pneumonia with persistent tachycardia, tachypnoea and hypoxaemia. It was felt possible that she had a post-infective alveolitis which was likely to progress to pulmonary fibrosis and she was therefore started on prednisone 30 mg daily. This was tailed off over four and a half months and by nine months her lung function and chest radiograph had returned to normal. We think it likely that steroid therapy favourably influenced her clinical course but cannot exclude the alternative explanation that her complete recovery was due to slow spontaneous improvement. This patient is part of a recent outbreak of psittacosis in Norfolk (Andrews et al. 1981). REFERENCES ANDHEWS, H. E., hIAJOR, R. &PALMER, S. R.(l981)0 rnithosis in poultry workers. Lancet I, 632. RENUSIGLIO, L. N., STADLER, H. & JUNOD, A. F. (1980) Time course of long function changes in atypical pneumonia. Thorax 35, 586. GILLBE, C. E., SALT, J. C. 8L BRANTHWAITE, hf. A. (1980) Pulmonary function after prolonged mechanical ventilation with high concentration of oxygen. Thorax 35, 907. KAUFMAN, J. WI., CUVELIER, C. A. &VAN DER STRAETEN, M.(1980)iMycoplasma pneumoniawith fulminant evolution into diffuse interstitial fibrosis. Thorax 35, 140. ZAPOL, TV. AI., TRELSTAD, R. L., COFFEY, J. MT., Ts.41, C. & SALVADOR, R. A. (1979) Pulmonary fibrosis in severe acute respiratory failure. Am. Rev. resp. Dis. 119, 547.