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Optimum Steroid Dosage in Status Asthmaticus
Disseminated Tuberculosis Caused by Mycobacterlum lntracellulare (Update) To the Editor:
We read with interest our case report in the December issue of Chest (1982; 82:800-01), and reaffirmed in our own minds what a unique case this indeed was. However, since some discussion of the uniqueness of the case seemed in order, and, in fact, was apparently inadvertently omitted from the case report, we would like to offer the following: Pulmonary infections caused by atypical mycobacteria have increased in recent years, while those due to Mycobacterom tuberculosis continue to decline.' However, disseminated infection remains an extremely uncommon manifestation of disease due to atypical mycobacteria, usually occurring in immunocompromised patients with a mortality rate of approximately 75 percent.• Our patient, as presented in our case report, had no evidence of malignancy and had not received steroids prior to her illness. This appears to be more characteristic of disseminated infection associated with M intracellulare. In his review, Wolinsky' found that 20 of 30 patients with disseminated M intracellulare did not have an underlying illness. The importance of the elevated antibody titer against Legionnella pneumophila is not clear. Recently, a patient was described with concurrent Legionnaires' disease and active pulmonary tuberculosis' indicating a possible association between the two diseases. In addition, studies have demonstrated cross-reactivity with significant elevation of Legionella titers in patients with certain other infections,"' as well as problems with standardization of the antigen for L pneumophila. • While this may represent a nonspecific elevation ofLegionella antibodies in our patient, the possibility remains of an antecedent infection with L pneumophila which predisposed our otherwise healthy patient to disseminated infection with M intracellulare. Patrick]. Savage, MAJ, USAF, MC; and R. Phillip Dellinger, LT COL, USAF, MC, Division of Pulmonary Medicine, USAF Medical Center, Keesler AFB, Mississippi All opinions stated are those of the authors and not necessarily those of the United States Air Force. Reprint requests: Dr. Savage, USAF Medical Center, Keesler AFB, Mississippi 39534 REFERENCES
1 Rosenzweig DY. Pulmonary mycobacterial infections due to Mycobacterium intracellulare-avium complex. Clinical features and course in 100 consecutive cases. Chest 1979; 75:115-19 2 Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979; 119:107-59 3 Milder JE, Rough RR. Concurrent Legionnaires' disease and active pulmonary tuberculosis. Am Rev Respir Dis 1982; 125:759-61 4 Tsai TR, Fraser DW. The diagnosis of Legionnaires' disease. Ann Intern Med 1978; 89:413-14 5 File TM, Tan JS. Concurrent antibody rises to C psittaci and L pneumophila in a patient with psittacosis. Chest 1982; 81:393-94 6 Lattimer G L. Legionnaires' disease. Indirect fluorescent antibody test in diagnosis. Ann Intern Med 1980; 92:708
Optimum Steroid Dosage In Status Asthmatlcus To the Editor:
Although t'Orticosteroids are widely used in the treatment of status asthmaticus, an optimum dose has not been established. The study by Tunaka et al (Chest 1982; 82:438-40) did little to clarify this issue.
118
As the authors noted, their study population was very small. Furthermore, the two groups were not identical, and the low dose group had a 25 percent higher baseline FEV1• Although no significant differences were present between the Po., pH, and Pco1 of the two groups, no statistical comparison of the FEV1 of the groups was offered. The reader must infer that they were significantly different. This lower baseline status of the high dose group may have obscured any additional benefits of the higher steroid dose. The studies cited by the authors in support of their findings are similarly flawed. The use of three different compounds administered by two different routes obscures any interpretation of the study by Britton et al. 1 In the study by Harfi et al,• peak expiratory flow rate (PEFR) was the sole spirometric parameter followed, and substantial differences in the baseline PEFR of the two groups were present. Unfortunately, the optimum dose of corticosteroids in status asthmaticus remains undefined. Larger study groups which are more closely matched will be required to settle this issue. Richard G. Laurens, Jr., Greenville, SC REFERENCES
Britton MG, Collins JV. Brown D, Fairhurst NBA, Lambert RG. High dose corticosteroids in severe acute asthma. Br Med J 1976; 2:73-74 2 Harfi H, Hanissian AS, Crawford LV. Treatment of status asthmaticus in children with high doses and conventional doses of methylprednisilone Pediatrics 1978; 61:829-31
To the Editor:
We concur that definition of the optimum dose of corticosteroids for status asthmaticus requires further investigation in a large, controlled study group. Dr. Laurens is incorrect in his assertion that the reader must infer significant statistical difference in the FEV1 of the two groups. By t-test, there was no significant difference between the FEV, of the two groups. Our bias has been that higher doses of corticosteroids are more effective in treatment of status asthmaticus. Statistical analysis of data as ranked values or raw values did not support the concept that steroid dose is related to the course or degree of improvement. The rate and degree of improvement only related to the degree of initial impairment. Data from our previously published study ofl6 patients given high dose methylprednisolone1 and data from an ongoing study of nine patients on a low dose regimen demonstrate the same pattern. Silverio M. Santiago, M.D., Chief, Pulmonary Acute Care Unit; and William B. Klaustermeyer, M.D., Chief, Allergy and Immunology Section, Wadsworth VA Medical Center, Los Angeles REFERENCE
Krouse HA, Santiago SM, Klaustermeyer WB. Intravenously given methylprednisolone in refractory asthma. West J Med 1980; 132:106-10
Antltussive Effect of Gualfenesin To the Editor:
In documenting how cough-counting has overcome earlier instrumental limitations, Kuhn and associates (Chest 1982; 82:713-18) have reaffirmed the poor correlation between this measurement and symptom estimates. While cough frequency is a reproducible objective index, it may not be the most appropriate to sense Communk:ationl to the Editor
We read with interest our case report in the December issue of Chest (1982; 82:800-01), and reaffirmed in our own minds what a unique case this indeed was. However, since some discussion of the uniqueness of the case seemed in order, and, in fact, was apparently inadvertently omitted from the case report, we would like to offer the following: Pulmonary infections caused by atypical mycobacteria have increased in recent years, while those due to Mycobacterom tuberculosis continue to decline.' However, disseminated infection remains an extremely uncommon manifestation of disease due to atypical mycobacteria, usually occurring in immunocompromised patients with a mortality rate of approximately 75 percent.• Our patient, as presented in our case report, had no evidence of malignancy and had not received steroids prior to her illness. This appears to be more characteristic of disseminated infection associated with M intracellulare. In his review, Wolinsky' found that 20 of 30 patients with disseminated M intracellulare did not have an underlying illness. The importance of the elevated antibody titer against Legionnella pneumophila is not clear. Recently, a patient was described with concurrent Legionnaires' disease and active pulmonary tuberculosis' indicating a possible association between the two diseases. In addition, studies have demonstrated cross-reactivity with significant elevation of Legionella titers in patients with certain other infections,"' as well as problems with standardization of the antigen for L pneumophila. • While this may represent a nonspecific elevation ofLegionella antibodies in our patient, the possibility remains of an antecedent infection with L pneumophila which predisposed our otherwise healthy patient to disseminated infection with M intracellulare. Patrick]. Savage, MAJ, USAF, MC; and R. Phillip Dellinger, LT COL, USAF, MC, Division of Pulmonary Medicine, USAF Medical Center, Keesler AFB, Mississippi All opinions stated are those of the authors and not necessarily those of the United States Air Force. Reprint requests: Dr. Savage, USAF Medical Center, Keesler AFB, Mississippi 39534 REFERENCES
1 Rosenzweig DY. Pulmonary mycobacterial infections due to Mycobacterium intracellulare-avium complex. Clinical features and course in 100 consecutive cases. Chest 1979; 75:115-19 2 Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis 1979; 119:107-59 3 Milder JE, Rough RR. Concurrent Legionnaires' disease and active pulmonary tuberculosis. Am Rev Respir Dis 1982; 125:759-61 4 Tsai TR, Fraser DW. The diagnosis of Legionnaires' disease. Ann Intern Med 1978; 89:413-14 5 File TM, Tan JS. Concurrent antibody rises to C psittaci and L pneumophila in a patient with psittacosis. Chest 1982; 81:393-94 6 Lattimer G L. Legionnaires' disease. Indirect fluorescent antibody test in diagnosis. Ann Intern Med 1980; 92:708
Optimum Steroid Dosage In Status Asthmatlcus To the Editor:
Although t'Orticosteroids are widely used in the treatment of status asthmaticus, an optimum dose has not been established. The study by Tunaka et al (Chest 1982; 82:438-40) did little to clarify this issue.
118
As the authors noted, their study population was very small. Furthermore, the two groups were not identical, and the low dose group had a 25 percent higher baseline FEV1• Although no significant differences were present between the Po., pH, and Pco1 of the two groups, no statistical comparison of the FEV1 of the groups was offered. The reader must infer that they were significantly different. This lower baseline status of the high dose group may have obscured any additional benefits of the higher steroid dose. The studies cited by the authors in support of their findings are similarly flawed. The use of three different compounds administered by two different routes obscures any interpretation of the study by Britton et al. 1 In the study by Harfi et al,• peak expiratory flow rate (PEFR) was the sole spirometric parameter followed, and substantial differences in the baseline PEFR of the two groups were present. Unfortunately, the optimum dose of corticosteroids in status asthmaticus remains undefined. Larger study groups which are more closely matched will be required to settle this issue. Richard G. Laurens, Jr., Greenville, SC REFERENCES
Britton MG, Collins JV. Brown D, Fairhurst NBA, Lambert RG. High dose corticosteroids in severe acute asthma. Br Med J 1976; 2:73-74 2 Harfi H, Hanissian AS, Crawford LV. Treatment of status asthmaticus in children with high doses and conventional doses of methylprednisilone Pediatrics 1978; 61:829-31
To the Editor:
We concur that definition of the optimum dose of corticosteroids for status asthmaticus requires further investigation in a large, controlled study group. Dr. Laurens is incorrect in his assertion that the reader must infer significant statistical difference in the FEV1 of the two groups. By t-test, there was no significant difference between the FEV, of the two groups. Our bias has been that higher doses of corticosteroids are more effective in treatment of status asthmaticus. Statistical analysis of data as ranked values or raw values did not support the concept that steroid dose is related to the course or degree of improvement. The rate and degree of improvement only related to the degree of initial impairment. Data from our previously published study ofl6 patients given high dose methylprednisolone1 and data from an ongoing study of nine patients on a low dose regimen demonstrate the same pattern. Silverio M. Santiago, M.D., Chief, Pulmonary Acute Care Unit; and William B. Klaustermeyer, M.D., Chief, Allergy and Immunology Section, Wadsworth VA Medical Center, Los Angeles REFERENCE
Krouse HA, Santiago SM, Klaustermeyer WB. Intravenously given methylprednisolone in refractory asthma. West J Med 1980; 132:106-10
Antltussive Effect of Gualfenesin To the Editor:
In documenting how cough-counting has overcome earlier instrumental limitations, Kuhn and associates (Chest 1982; 82:713-18) have reaffirmed the poor correlation between this measurement and symptom estimates. While cough frequency is a reproducible objective index, it may not be the most appropriate to sense Communk:ationl to the Editor