Amphotericin-induced stridor: a review of stridor, amphotericin preparations, and their immunoregulatory effects.

BACKGROUND: Various adverse effects have been reported with the use of amphotericin B. The respiratory adverse effects include dyspnea, tachypnea, bronchospasm, hemoptysis, and hypoxemia. Stridor has not been previously reported with the use of amphotericin B. OBJECTIVE: To review the mechanism of action and reports of respiratory adverse effects for amphotericin B, the liposomal preparations of amphotericin B, and the differential diagnosis of stridor. DATA SOURCES: A MEDLINE search from 1966 to 2002 was performed to review the current literature for possible mechanisms and immunoregulatory effects related to the infusion of amphotericin B. RESULTS: Amphotericin B has been shown to increase tumor necrosis factor alpha (TNF-alpha) concentrations in macrophages. In addition, it induces prostaglandin E2 synthesis and increases the production of interleukin 1beta (IL-1beta) in mononuclear cells. The immunoregulatory effects of amphotericin B include increases in apoptosis, production of monocyte chemoattractant protein 1, superoxide anion, nitric oxide, and intercellular adhesion molecule 1 expression. CONCLUSIONS: Amphotericin B induces the production of TNF-alpha, interferon-gamma, and IL-1beta, which may potentiate its toxic effects. Some liposomal preparations induced lower levels of TNF-alpha and nitric oxide and may be useful in patients unable to tolerate amphotericin B deoxycholate.     

Parainfluenza virus pneumonitis in an adult.

Parainfluenza virus uncommonly causes fatal giant cell pneumonia in immunocompromised infants and children. To our knowledge, this is the first adult case of parainfluenza virus pneumonia. A 77-year-old woman who was diagnosed as having small-cell carcinoma of the lung underwent chemotherapy. She died of lung edema. Analysis of her serum showed antibodies to parainfluenza virus types 2 and 3 at titers of 1:64 and 1:128, respectively. The postmortem examination revealed giant cell pneumonia, in which giant cells and detached alveolar lining cells had intracytoplasmic inclusions. On electron microscopic examination, the intracytoplasmic inclusions contained fuzzy-form nucleocapsids.     

Nocturnal stridor in olivopontocerebellar atrophy

We describe a patient with olivopontocerebellar atrophy (OPCA) who was referred for alleged "snoring." Polysomnogram with video and audio monitoring revealed that the patient actually had nocturnal stridor causing repetitive oxygen desaturations. Direct laryngoscopy while awake showed a unilateral vocal cord paralysis. The nocturnal stridor persisted after unilateral vocal cord pinning, suggesting that the patient had probably been experiencing bilateral vocal cord paresis while asleep. We conclude that state-dependent vocal cord dysfunction may be severe in OPCA and related multiple system atrophy. Nocturnal stridor has many causes and may mimic snoring and obstructive sleep apnea syndrome. Polysomnography with audio and video recordings are necessary to make the diagnosis.     

Progressive dyspnea in a 46-year-old woman.

BACKGROUND: Hypersensitivity pneumonitis (HP) is an inflammatory lung disease that requires a high index of suspicion and evaluation for potential causative antigens in the patient's environment. OBJECTIVE: To describe a patient referred for allergic rhinitis who was found to have progressive dyspnea and was ultimately diagnosed as having HP. METHODS: The history of progressive dyspnea with findings of diffuse pulmonary crackles on physical examination and restrictive pulmonary function testing prompted further radiologic, pathologic, laboratory, and home environment evaluations. RESULTS: The constellation of findings from these studies led to the diagnosis of HP secondary to parakeet antigens. Elimination of further antigen exposure and corticosteroid therapy led to resolution of the patient's symptoms. CONCLUSION: Prompt diagnosis and removal of the antigen source are of paramount importance in the management of HP.     

Adenovirus hepatitis in an immunosuppressed adult patient.

The role of adenovirus as an etiologic agent of hepatic damage has been controversial. A fatal case of adenovirus infection with fulminant hepatitis in a young immunosuppressed adult patient is presented. Intranuclear inclusions were confined to the liver. Electron microscopy revealed crystalline arrays of virions within hepatocytes. This is apparently the first reported case of adenovirus hepatitis occurring in an adult. Adenovirus hepatitis represents another hazard for the immunosuppressed patient.     

Micronema deletrix meningoencephalitis in an adult man.

This is apparently the second report of a case of human meningoencephalitis caused by the nematode Micronema deletrix. The patient had severe granulomatous meningoencephalitis with numerous foci of hemorrhage and encephalomalacia. Numerous adult female and larval M. deletrix were in the brain. The organisms probably inhabit decaying organic material, but occasionally parasitize the kidney, nose, or central nervous system of the horse. In its parasitic form the nematode replicates parthenogenetically.     

Acute Bordetella pertussis infection in an adult.

Bordetella pertussis was transmitted from an immunized boy to his father and possibly to other family members. This case report demonstrates that although unusual, acute adult B. pertussis infection can occur. B. pertussis immunization may not prevent infection but can reduce the severity. B. pertussis was detected in sputum from the adult by direct-fluorescent antibody staining and was grown on Regan-Lowe medium. Serology tests confirmed the infection in the adult.     

Infantile hemangioendothelioma of the liver in an adult.

Hepatic infantile hemangioendothelioma (IHE) is a rare benign vascular tumor of the liver found mostly in infancy and early childhood. We describe herein a tumor of the liver, morphologically indistinguishable from IHE, that presented in an adult. The patient is a 56-year-old woman with a history of ductal carcinoma in situ of the left breast and a mass in the liver. The patient underwent resection of the tumor, and after 23 months of follow-up she is alive with no evidence of expansion of the liver tumor.     

Post-traumatic Curvularia sp. arthritis in an immunocompetent adult

A 44-year-old woman, victim of a road accident in Mali was diagnosed with left knee arthritis. Joint effusion aspiration and subcutaneous surgical biopsies were positive for a melanized asexual ascomycete. Using microscopy and molecular biology, the fungus was identified as Curvularia sp. In vitro antifungal susceptibility was determined by the EUCAST broth microdilution reference technique and by E-test. The patient was treated with liposomal amphotericin B before posaconazole relay. Mycological samples obtained 10 days after starting the antifungal therapy by liposomal amphotericin B were negative in culture. Curvularia spp. are environmental fungi which can under certain conditions be pathogenic for humans.