- Email: [email protected]
Sputum substance P in aspiration pneumonia
the efficacy of milder cases.
atropine eyedrops
H Nozaki, *N Aikawa Department of Emergency and Critical Keio University, Tokyo 160, Japan
is
questionable
even
in
substance P concentration in sputum may be a marker for increased risk of aspiration pneumonia in the elderly. Takuma Nakagawa, Takashi Ohrui, *Hidetada Sasaki
Care Medicine, School of Medicine,
*Department of Geriatric Medicine, Tohoku University School of Medicine, Sendai 980, Japan
1 Rengstorff RH. Vision and ocular changes following accidental exposure to organophosphates. J Appl Toxicol 1994; 14: 115-18. 2 Lotti M. Treatment of acute organophosphate poisoning. Med J Aust
1 2
1991; 154: 51-55.
3
Sputum substance
P in
aspiration pneumonia 4
SIR—Morbidity and mortality from aspiration pneumonia are major health problems in the elderly. There is a marked depression of cough reflex, an important respiratory defence mechanism, in patients with aspiration pneumonia.’ In animal studies, depletion of substance P in the larynx and tracheobronchial tree causes impairment of the cough reflex." However, substance P in the airway has not been studied in elderly patients at risk of aspiration. We therefore examined substance P concentration in hypertonic-salineinduced sputum’ in elderly patients with aspiration pneumonia, and compared the results with those in agematched healthy controls. 32 patients, mean age 77 (SE 1) years had at least one episode of aspiration with chest radiographic evidence of inflammation in the lower pulmonary segments. Computed tomographic scans revealed various degrees of cerebral atrophy and lacunar infarction. The 10 controls, mean age 75 (3) years, were healthy volunteers. To eliminate diurnal variation, studies were done at the same time of day. Each subject refrained from taking ethanol, sedatives, or drugs
I
UUWIIW .
Figure: Substance P in sputum of control subjects and patients with
aspiration pneumonia
Sekizawa K, Ujiie Y, Itabashi S, Sasaki H, Takishima T. Lack of cough reflex in aspiration pneumonia. Lancet 1990; 355: 1228-29. Karlsson JA, Sant’Ambrogio G, Widdicombe J. Afferent neural pathways in cough and reflex bronchoconstriction. J Appl Physiol 1988; 65: 1007-23. Fahy JV, Liu J, Wong H, Boushey HA. Cellular and biochemical analysis of induced sputum from asthmatic and from healthy subjects. Am Rev Respir Dis 1993; 147: 1126-31. Yanaihara C, Sato H, Hirohashi M, et al. Substance P radioimmunoassay using Na-tyrosyl-substance P and demonstration of the presence of substance P-like immunoreactivities in human blood and porcine tissue extracts. Endocrinol Japan 1976; 23: 457-63.
Severe
that affected the autonomic nervous system for at least 72 h before the study. Three percent saline was administered for 20 min via an ultrasonic nebuliser. Subjects were encouraged to cough throughout the procedure. Substance P-like immunoreactivity was measured in 1 mL of sputum.4 An antiserum used for measuring substance P-like immunoreactivity showed no cross-reactivity with neurokinin A and bradykinin. Mean substance P concentration was 7-fold higher in controls (mean 142-2 [8-4] fmol/mL compared with patients (21-2 [2.4] fmol/mL; p<0-001) (figure). A reduction of
VVllLlVlv
Kiyohisa Sekizawa,
chickenpox in anabolic steroid
user
SIR-In view of the association between severe chickenpox infection and systemic corticosteroids’ and the report of candida endophthalmitis in a patient who used anabolic steroidswe report a case of life-threatening varicella pneumonia in an anabolic steroid user. A young man presented to his general practitioner with a vesicular rash that was typical of varicella on the abdomen and chest. The next day he presented to hospital with epigastric pain. He had a 2-year history of abuse of anabolic steroids. His regimen consisted of 2 months of 250 mg intramuscular depot testosterone every 2 days, 125 mg intramuscular depot nandrolone every 2 days, 50 mg of what is believed to be norethandrolone orally daily, oxymetholone 50 mg orally daily, and ephedrine 8 mg orally before each gym session every 2 days. He then had 3 months when he weaned down his steroid use while taking intramuscular human chorionic gonadotropin. During these 2 years his weight had increased from 76-108 kg. He also smoked 25 cigarettes per day. On admission he was commenced on cefuroxime for suspected cholecystitis and intravenous hydrocortisone initially 50 mg once daily. 3 days after admission he became short of breath and cyanosed. Chest auscultation revealed bilateral crepitations and a chest radiograph showed bilateral infiltrates. A diagnosis of chickenpox pneumonitis was made. He was started on intravenous acyclovir 500 mg three times daily which he received for 5 days. He was transferred to the intensive care unit where he required artificial ventilation. His oxygenation was poor despite maximum pressures. His subsequent course was complicated by a Staphylococcus aureus chest infection and 2 episodes of Pseudomonas aeruginosa septicaemia due to distinct strains. He also developed renal failure which required dialysis. He needed 34 days of intensive care but recovered and was discharged from hospital. The diagnosis of chickenpox was confirmed by seroconversion in a varicella-zoster virus complement fixation test. Cigarette smoking is associated with a higher risk of pneumonia in adults with chickenpox3 and it is possible that this patient’s use of anabolic steroids also contributed to his severe infection. A patient with chickenpox who reports anabolic steroid use should be monitored closely and there should be a low threshold for use of acyclovir. Whether varicella-zoster immunoglobulin is warranted for nonimmune anabolic steroid users who are exposed to chickenpox, as is the case for patients on systemic corticosteroids, is uncertain. Our patient reported his use of anabolic steroids promptly but this may not always be the
1447
atropine eyedrops
H Nozaki, *N Aikawa Department of Emergency and Critical Keio University, Tokyo 160, Japan
is
questionable
even
in
substance P concentration in sputum may be a marker for increased risk of aspiration pneumonia in the elderly. Takuma Nakagawa, Takashi Ohrui, *Hidetada Sasaki
Care Medicine, School of Medicine,
*Department of Geriatric Medicine, Tohoku University School of Medicine, Sendai 980, Japan
1 Rengstorff RH. Vision and ocular changes following accidental exposure to organophosphates. J Appl Toxicol 1994; 14: 115-18. 2 Lotti M. Treatment of acute organophosphate poisoning. Med J Aust
1 2
1991; 154: 51-55.
3
Sputum substance
P in
aspiration pneumonia 4
SIR—Morbidity and mortality from aspiration pneumonia are major health problems in the elderly. There is a marked depression of cough reflex, an important respiratory defence mechanism, in patients with aspiration pneumonia.’ In animal studies, depletion of substance P in the larynx and tracheobronchial tree causes impairment of the cough reflex." However, substance P in the airway has not been studied in elderly patients at risk of aspiration. We therefore examined substance P concentration in hypertonic-salineinduced sputum’ in elderly patients with aspiration pneumonia, and compared the results with those in agematched healthy controls. 32 patients, mean age 77 (SE 1) years had at least one episode of aspiration with chest radiographic evidence of inflammation in the lower pulmonary segments. Computed tomographic scans revealed various degrees of cerebral atrophy and lacunar infarction. The 10 controls, mean age 75 (3) years, were healthy volunteers. To eliminate diurnal variation, studies were done at the same time of day. Each subject refrained from taking ethanol, sedatives, or drugs
I
UUWIIW .
Figure: Substance P in sputum of control subjects and patients with
aspiration pneumonia
Sekizawa K, Ujiie Y, Itabashi S, Sasaki H, Takishima T. Lack of cough reflex in aspiration pneumonia. Lancet 1990; 355: 1228-29. Karlsson JA, Sant’Ambrogio G, Widdicombe J. Afferent neural pathways in cough and reflex bronchoconstriction. J Appl Physiol 1988; 65: 1007-23. Fahy JV, Liu J, Wong H, Boushey HA. Cellular and biochemical analysis of induced sputum from asthmatic and from healthy subjects. Am Rev Respir Dis 1993; 147: 1126-31. Yanaihara C, Sato H, Hirohashi M, et al. Substance P radioimmunoassay using Na-tyrosyl-substance P and demonstration of the presence of substance P-like immunoreactivities in human blood and porcine tissue extracts. Endocrinol Japan 1976; 23: 457-63.
Severe
that affected the autonomic nervous system for at least 72 h before the study. Three percent saline was administered for 20 min via an ultrasonic nebuliser. Subjects were encouraged to cough throughout the procedure. Substance P-like immunoreactivity was measured in 1 mL of sputum.4 An antiserum used for measuring substance P-like immunoreactivity showed no cross-reactivity with neurokinin A and bradykinin. Mean substance P concentration was 7-fold higher in controls (mean 142-2 [8-4] fmol/mL compared with patients (21-2 [2.4] fmol/mL; p<0-001) (figure). A reduction of
VVllLlVlv
Kiyohisa Sekizawa,
chickenpox in anabolic steroid
user
SIR-In view of the association between severe chickenpox infection and systemic corticosteroids’ and the report of candida endophthalmitis in a patient who used anabolic steroidswe report a case of life-threatening varicella pneumonia in an anabolic steroid user. A young man presented to his general practitioner with a vesicular rash that was typical of varicella on the abdomen and chest. The next day he presented to hospital with epigastric pain. He had a 2-year history of abuse of anabolic steroids. His regimen consisted of 2 months of 250 mg intramuscular depot testosterone every 2 days, 125 mg intramuscular depot nandrolone every 2 days, 50 mg of what is believed to be norethandrolone orally daily, oxymetholone 50 mg orally daily, and ephedrine 8 mg orally before each gym session every 2 days. He then had 3 months when he weaned down his steroid use while taking intramuscular human chorionic gonadotropin. During these 2 years his weight had increased from 76-108 kg. He also smoked 25 cigarettes per day. On admission he was commenced on cefuroxime for suspected cholecystitis and intravenous hydrocortisone initially 50 mg once daily. 3 days after admission he became short of breath and cyanosed. Chest auscultation revealed bilateral crepitations and a chest radiograph showed bilateral infiltrates. A diagnosis of chickenpox pneumonitis was made. He was started on intravenous acyclovir 500 mg three times daily which he received for 5 days. He was transferred to the intensive care unit where he required artificial ventilation. His oxygenation was poor despite maximum pressures. His subsequent course was complicated by a Staphylococcus aureus chest infection and 2 episodes of Pseudomonas aeruginosa septicaemia due to distinct strains. He also developed renal failure which required dialysis. He needed 34 days of intensive care but recovered and was discharged from hospital. The diagnosis of chickenpox was confirmed by seroconversion in a varicella-zoster virus complement fixation test. Cigarette smoking is associated with a higher risk of pneumonia in adults with chickenpox3 and it is possible that this patient’s use of anabolic steroids also contributed to his severe infection. A patient with chickenpox who reports anabolic steroid use should be monitored closely and there should be a low threshold for use of acyclovir. Whether varicella-zoster immunoglobulin is warranted for nonimmune anabolic steroid users who are exposed to chickenpox, as is the case for patients on systemic corticosteroids, is uncertain. Our patient reported his use of anabolic steroids promptly but this may not always be the
1447