Letters to the Editor
Pulmonary Mucormycosis in a Patient with COPD
TO THE EDITOR: Patients who have chronic obstructive pulmonary disease (COPD) are commonly treated with corticosteroids. This treatment may predispose such patients to opportunistic infections, including invasive fungal infections, that may initially manifest as hemoptysis. I would like to present the case of a patient with emphysema who had recently begun treatment with corticosteroids and who died as a result of hemoptysis due to invasive mucormycosis.
The patient was a 66-year-old man with alpha1-antitrypsin deficiency and severe emphysema. He smoked two packs of cigarettes per day for 35 years. The only medications he used were inhaled beta-agonists and ipratropium bromide. He had never been treated with corticosteroids. Four months earlier, he was treated with oral antibiotics and several courses of prednisone for increasing dyspnea and a productive cough. He did not use corticosteroids as maintenance between treatment courses.
Secondary to persistent symptoms, the patient was hospitalized. Physical examination revealed that he was in moderate respiratory distress with a temperature of 99°F, a heart rate of 98 beats per minute, a blood pressure 110/95 mm Hg and a respiratory rate of 24 breaths per minute. The cardiac examination was normal, lung sounds were diminished with expiratory wheezing, and there was no accessory muscle use or pulmonary consolidation. Chest radiograph revealed diffuse parenchymal abnormalities, and the patient was started on a course of intravenous antibiotics, methylprednisone and nebulized beta-agonist.
On day 10, massive hemoptysis developed and the patient was transferred to our institution. Repeat chest radiographs revealed a new opacity in the left lung, and bronchoscopy showed blood throughout the tracheobronchial tree. Pulmonary angiography demonstrated vascular ectasia and prominent bronchial vessels that corresponded with the opacity in the upper lobe of the left lung. Sputum and bronchoscopy cultures from the transferring hospital revealed the presence of Mucor species, and the patient was started on treatment with amphotericin B. Because of poor underlying lung function, the patient was not a suitable candidate for surgery.
Despite continued use of antibiotics, the patient died nine days after being transferred. Microscopic examination of the lungs at autopsy revealed tissue invasion with fungal hyphae, broad and ribbon-like with irregular wall thickness and non-septate hyphae, characteristic of Mucor species.
Invasive fungal infections are rare, but often fatal complications in patients with COPD. Such patients are often treated with corticosteroids, which predisposes them to the development of opportunistic infections through the depression of cell-mediated immunity and the impairment of macrophage killing.1 Some authors suggest that the risk of infection is minimal if patients who are treated with prednisone receive less than the equivalent of 10 mg per day, or a cumulative dose not exceeding 700 mg.2,3
Mucormycosis is not commonly reported in patients with COPD who are treated with corticosteroids. Common pulmonary pathogens in patients with COPD include Aspergillus, Pneumocystis carinii and Legionella pneumophila.2 Sixty-six percent of cases of pulmonary mucormycosis occur in patients with hematologic malignancies, and another 25 percent of cases occur in patients with diabetes.4,5 Antifungal treatment with amphotericin B is typically not effective. Occasionally, surgical resection has been successful; however, many patients with COPD are not candidates for lung resection, given their poor underlying lung function.5
This case illustrates that even low doses of corticosteroids, given for limited periods of time, may predispose patients with COPD to invasive fungal infections. This diagnosis should be considered in the differential diagnosis of patients with unexplained hemoptysis, in order to identify patients who are potential candidates for surgery.
ALBERT KLEMPTNER, M.D.
St. Joseph Mercy Hospital
5333 McAuley Dr. R-3009
Ypsilanti, MI 48197REFERENCES
- Vrenon-Roberts B. The effects of steroid hormones on macrophage activity. Int Rev Cytol 1969;25: 131-59.
- Rodrigues J, Niederman MS, Fein AM, Pai PB. Nonresolving pneumonia in steroid-treated patients with obstructive lung disease. Am J Med 1992;93:29-34.
- Stuck AE, Minder CE, Frey FJ. Risk of infectious complications in patients taking glucocorticosteroids. Rev Infect Dis 1989;11:954-63.
- Morrison VA, McGlave PB. Mucormycosis in the BMT population. Bone Marrow Transplant 1993; 11:383-8.
- Wright RN, Saxena A, Robin A, Thomas PA. Pulmonary mucormycosis (Phycomycetes) successfully treated by resection. Ann Thorac Surg 1980;29:166-9.
Single vs. Multiple Daily Dosing of Aminoglycosides
TO THE EDITOR: I congratulate Drs. Spencer and Gonzalez on their timely article, "Aminoglycosides: A Practical Review."1
On the basis of seven different studies, the authors scientifically address the issue of single versus multiple daily dosing regimens of aminoglycosides. The results of these studies were variable, indicating no difference in the regimens, a trend that favored single daily dosing, or significantly better results with single daily dosing as it relates to clinical response, nephrotoxicity or ototoxicity.
Adding to this evidence is another large meta-analysis2 involving 3,091 patients and 21 randomized trials. Results of this meta-analysis indicated that single daily dosing is at least as effective as multiple daily dosing and is associated with a moderate reduction in the risk of nephrotoxicity, with no difference in ototoxicity.
The concept of single daily dosing of antibiotics is particularly relevant for elderly patients, who are also at greater risk for acute hospitalization or treatment in a skilled nursing unit (independent, nursing home affiliated or hospital affiliated). In light of the findings of these meta-analyses, the issue of cost in nursing time, supplies and laboratory monitoring should be considered when choosing either single or multiple daily dosing of aminoglycosides.
In a setting with a well-equipped skilled nursing unit, an experienced nursing staff and a medically stable patient, single daily dosing of aminoglycosides can be a critical factor when deciding whether to hospitalize the patient or treat him or her in the skilled nursing unit. This may be particularly relevant in the case of a terminally ill patient, for whom palliative care is requested, either by the patient or the family, without the use of heroics in the form of respirator support or intensive care monitoring.
With the aging population, the trend away from acute hospitalization, the increasing role that corporate medicine plays in health care and the realization that nursing homes will become the acute hospitals of the future, single daily dosing of aminoglycosides and other antibiotics will receive increasing attention and use.
CHARLES A. CEFALU, M.D., M.S.
Louisiana State University School of Medicine in New Orleans
1542 Tulane Ave.
New Orleans, LA 70112REFERENCES
- Spencer JP, Gonzalez LS. Aminoglycosides: a practical review. Am Fam Physician 1998;58: 1811-20.
- Barza M, Ioannidis JP, Cappelleri JC, Lau J. Single or multiple daily doses of aminoglycosides: a meta-analysis. BMJ 1996;312: 338-45.
IN REPLY: We would like to thank Dr. Cefalu for his comments about our article. We agree that single daily dosing of aminoglycosides would facilitate their use in the nursing home. In addition, we would like to mention another aspect of monitoring aminoglycosides that deserves attention.
A review of the literature from 1975 through 1982 showed that vestibulotoxicity occurred in about 3 percent of 1,976 patients receiving aminoglycosides.1 In another series of 36 patients who had been exposed to gentamicin and were seeking subspecialist care for vestibular hypofunction, gait ataxia was discovered when patients tried to resume normal activity after leaving the hospital.2
Risk factors that predispose the patient to aminoglycoside ototoxicity may include taking other ototoxic medications, such as loop diuretics, cyclosporine, vancomycin, amphotericin B and cisplatin, previous exposure to aminoglycoside, hyperthermia and impaired renal function.
Even though outcome studies are lacking, clinicians might consider baseline and daily tests of vestibular function in patients who are able to cooperate. These tests would include the Romberg test, tests of visual acuity, observation of postural stability and the head thrust test.3 Because these are bedside tests, they could be performed in the nursing home, although obviously not on the most debilitated patients. If toxicity appears, stopping the use of aminoglycoside may prevent further deterioration of the patient's condition.
LUIS S. GONZALEZ III, PHARM.D.
JEANNE P. SPENCER, M.D.
Conemaugh Memorial Medical Center
1086 Franklin Street
Johnstown, PA 15905REFERENCES
- Kahlmeter G, Dahlager JI. Aminoglycoside toxicity: a review of clinical studies published between 1975 and 1982. Antimicrob Chemother 1984; 13(Suppl A):9-22.
- Halmagyi GM, Fattore CM, Curthoys IS, Wade S. Gentamicin vestibulotoxicity. Otolaryngol Head Neck Surg 1994;111:571-4.
- Minor LB. Gentamicin-induced bilateral vestibular hypofunction. JAMA 1998;279:541-4.
Anticipatory Grief in Parents of Dying Children
TO THE EDITOR: In a recent "Curbside Consultation" feature,1 Dr. Grossman's comments on the case scenario dealing with anger in parents of dying children were excellent. I would add another thought to the author's advice on direct communication with parents. The mother's anger reflects her anticipatory grief. Her grieving and her fears about the death of her child should be openly and compassionately discussed. This type of communication would be very difficult for any professional without the proper training and support. Sometimes, the grieving parent may benefit by talking with other parents who have survived such grief, perhaps in a support group setting. Another approach would be to extend hospice services to more children.
GEORGE F. DAVIS, M.D.
The Community Hospice of Albany County
315 S. Manning Blvd.
Albany, NY 12208Dr. Davis is medical director of the Community Hospice of Albany County, Albany, NY.
REFERENCE
- Grossman LS. Understanding anger in parents of dying children [Curbside Consultation]. Am Fam Physician 1998;58:1211-2.
Corrections*
Table 3 of "Primary Care of International Adoptees" (December 1998, page 2028) was incorrectly attributed. The credit line should read as follows: "Adapted from the American Academy of Pediatrics 1997 Red Book and other sources."
Two figures in the article "Neurologic Complications of Systemic Cancer" (February 15, 1999, page 878) were misnumbered. Figure 3, showing epidural tumor, should appear in place of Figure 2, and Figure 2, showing leptomeningeal metastases, should appear in place of Figure 3.
*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
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