A man with serologic evidence of HI...

A man with serologic evidence of HIV infection and a lowered T-helper:suppressor ratio developed fever, pulmonary infiltrates, and respiratory failure. Bronchoalveolar lavage and transbronchial biopsy failed to reveal an infectious cause; however, an exhibit lung biopsy demonstrated classic bronchiolitis obliterans organizing pneumonia. The patient be agreeable toed completely to corticosteroids. To the best of our knowledge, this shows a previously undescribed and readily treatable cause of respiratory failure in patients with HIV infections. (Chest 1989; 96:197-98)

Patients infected with HIV have been erect to have a variety of associated respiratory disorders including opportunistic infections,[1] nonspecific interstitial pneumonitis,[2] malignancies,[1] lymphoid interstitial pneumonitis,[3,4] and lymphocytic bronchiolitis.[5] In patients presenting with respiratory symptoms and a history of AIDS or ARC, diagnostic effort is generally directed toward identifying treatable infectious agents, principally commonly Pneumocystis carinii. The noninfectious, nonmalignant causes of respiratory disease associated with HIV infection previously reported in the literature are usually indolent or spontaneously regress[1] We describe a patient with ARC who existinged with progressive respiratory failure and no identifiable infection in whom an make open lung biopsy demonstrated typical bronchiolitis obliterans with organizing pneumonia. Treatment with a two-month course of corticosteroids conclusioned in resolution of all symptoms and x-ray abnormalities.

Case Report

A 40-year-old homosexual man was well until 12 month prior to admission when he was set to be HIV positive by dint of ELISA and Western blot analysis. He was asymptomatic until four weeks prior to admission when he unfolded dyspnea on exertion, nonproductive cough and febrile affection to 38.3[degrees]C. Two weeks prior to admission, a chest x-ray film showed cunning bibasilar infiltrates, and cefaclor was prescribed. Ten days prior to admission, a bronchoscopy with BAL was performed; stains for AFB, Pneumocystis, bacteria, inclusion bodies, and fungus as well as improvements were negative. He was given doxycycline and AZT unless continued to have worsening dyspnea, cough and heat to 39.4[degrees]C.

forward the day of admission, examination revealed a oscillation rate of 116, respiratory rate of 26 cervical adenopathy, and bibasilar parched crackles. The WBC was 10600/cu mm with 12 percent bands, 77 percent neutrophils, 7 percent lymphocyte and 4 percent macrophages; the T helper-supressor ratio was reduc (01) A chamber air arterial blood gas revealed a [Posub2] of 56 mm Hg rises from routine blood chemistries and liver function exhibitions were normal as were the antinuclear antibody, rheumatoid factor, cryoglobulins, hepatitis B surface antigen, fulfilment levels, and antiglomerular basement membrane antibody. A chest x-ray film demonstrated patchy alveolar and interstitial infiltrates (Fig 1) A inferior bronchoscopy revealed 46 percent macrophages, 48 percent lymphocyte 5 percent neutrophils, and 1 percent eosinophils in the repeat BAL. Stains for acid-fast bacilli, Pneumocystis, inclusion bodies, bacteria, and fungi were negative; viral, AFB, and fungal agricultures were again negative. A transbronchial biopsy was nondiagnostic. He was given empiric pentamidine, gentamicin, and vancomycin in addition continued to have high flushs increasing confusion, worsening hypoxemia, and increasingly close bilateral pulmonary infiltrates (Fig 2) Vigorous diuresis with furosemide was initiated; on the other hand resulted in hypotension and progressive prerenal azotemia. according to the tenth hospital day, the [Posub2] was 51 mm Hg in succession a 50 percent oxygen mask.

His unexplained progressive respiratory failure willinged an open lung biopsy which demonstrated bronchiolitis obliterans with organizing pneumonia as well as chronic interstitial penumonitis (Fig 2) Stains for Pneumocystis, bacteria, fungus, AFB, antibasement membrane antibody, immunoglobulin, and consummation were all negative; cultures for bacteria, fungus, AFB, and virus were similarly negative. Intravenous methylprednisolone, 80 mg daily, was begun upon the 11th hospital day, with defervescence in 48 hours as well as progressive improvement in oxygenation and the roentgenographic appearance. He was discharged forward the 32nd hospital day receiving oral prednisone, 80 mg by means of day, for an additional brace weeks followed by a tapering course with unbroken discontinuation six weeks after discharge from the hospital.

Five month after discharge, he had persistent bibasilar parched crackles but the symptom liberated The chest x-ray film was normal and arterial line gas demonstrated a [Po.sub.2] of 94 mm Hg onward room air.

Discussion

Bronchiolitis obliterans is the nonspecific end of the lung's response to a variety of stimuli and has been reported following toxic vapor inhalation, with connective tissue disorders, secondary to proximal airway obstruction, following respiratory infections (especially viral infection), following organ transplant, and as an idiopathic disorder.[6] Epler et al[7] have further described the histologic appearance of bronchiolitis obliterans organizing pneumonia as characterized from polypoid masses of granulation tissue extending into small airways and associated with interstitial infiltration by dint of mononuclear cells. Importantly, in their series, 24 of 37 patients with the idiopathic form of bronchiolitis obliterans organizing pneumonia treated with corticosteroids had entire recovery.