Peter M Wiest, MD; Timothy Flanigan...

Peter M Wiest, MD; Timothy Flanigan, MD; Robert A. Salata, MD; David M Shlaes, MD PhD.,[unkeyable] Michael Katzman, MD; and Michael M Lederman, MD

We report seven somewhat old patients with COPD who unfolded serious infectious complications during postponeed treatment with high doses of corticosteroids. Infections included invasive pulmonary aspergillosis, Herpes simplex stomatitis and esophagitis, cytomegalovirus pneumonia, bacterial sepsis, fungemia and meningitis owing to Cryptococcus neoformans. Each of the three patients who bring outed invasive aspergillus pneumonia died. The efficacy of extended therapy with high doses of corticosteroids in patients with COPD is not proven These cases illustrate the potential for serious infections in patients with COPD treated with corticosteroids. (Chest 1989;95:1180-84)

The administration of corticosteroids is an accepted therapeutic modality for status asthmaticus and chronic asthma.[1-3] With limited data to support their efficacy, corticosteroids are also used in outpatient and inpatient management of COPD[4-11] We report here seven patients with COPD who expanded serious infections while receiving continue lengthen in timeed treatment with high doses of corticosteroids.

CASE REPORTS

CASE 1

A 68-year-old man with COPD (Table 1) was receiving prednisone, 40 to 50 mg/day, for five month (Table 2) as an outpatient. He cause to growed dysphagia and shortness of breath and was hospitalized. Pulmonary function exhibitions were remarkable for reduced [FEVsub1] and FVC; the [FEVsub1]/FVC ratio was 47 percent suggesting accurate airway obstruction. The [FEVsub1] increased solely 8 percent after administration of inhaled bronchodilators. Physical examination forward admission revealed oral thrush. Potassium hydroxide smear was positive for Candida. Esophagoscopy revealed a friable ulcerated mucosa. Biopsy showed multinucleated giant enclosed spaces consistent with Herpes simplex infection. civilizations grew Herpes simplex virus. The patient was treated with acyclovir, aminophylline, beta-agonists, and tapering doses of prednisone. His esophagitis and dyspnea resolv and he was discharged to home

CASE 2

A 54-year-old man with insulin-dependent diabetes mellitus and COPD not absented with increasing shortness of breath and hypoglycemia. His symptoms were attributed to an exacerbation of his lung disease with superimposed congestive heart failure. He was treated with aminophylline, diuretics, beta agonists, and methylprednisolone, 60 mg intravenously each six hours. Shortly after admission, he required intubation. He perform the operations indicated ined Staphylococcus aureus and Morganella morgagni sepsis three weeks after admission and was treated with oxacillin and cefotaxime. Renal failure bring to maturityed and was attributed to sepsis. Methylprednisolone was continued at a dose of 50 mg/day. athwart the next six weeks, he required ventilator support and intermittent hemodialysis. agricultures of blood and a femoral catheter tip civilization grew Candida albicans. Treatment included vancomycin, tobramycin, amphotericin B acyclovir, and methylprednisolone, 20 to 40 mg by day. Fifty-four days after admission, a cultivation of sputum grew Aspergillus fumigatis. throughout the next several days, he cause to growed progressive bilateral pulmonary infiltrates, gastrointestinal bleeding, and intractable generalized seizures. He died 63 days after admission. Autopsy revealed bilateral necrotizing pneumonia. The left upper lobe of the lung showed extensive invasion of the vasculature by the agency of Aspergillus. In addition, solitary abode; squalids containing inclusion bodies suggestive of cytomegalovirus were erect throughout the lungs, lymph nodes, and duodenum

CASE 3

A 90-year-old man with a history of COPD who had been treated with prednisone, 10 to 40 mg through day for more than couple years, was admitted for dyspnea. Previous pulmonary function touchstones had demonstrated a baseline [FEVsub1] of 125 L that increased to 149 L after administration of bronchodilators. He was treated with aminophylline, beta-agonists, and methylprednisolone, 60 mg intravenously each six hours. His respiratory symptoms rapidly improved. Five days after admission, he complained of a painful left shoulder. Examination revealed a delicate warm and erythmatous shoulder with decreased range of motion. Aspiration of the joint revealed festering material. Gram-positive cocci in clusters were seen forward Gram stain and were later identified as Staphylococcus aureus. He was treated favorably with intravenous nafcillin, surgical drainage of his shoulder, and a reduction in the dose of corticosteroids. [TABULAR DATA OMITTED]

CASE 4

A 61-year-old man with a history of Mycobacterium kansasii pneumonia and COPD was hospitalized for hemoptysis and weight los Pulmonary function ordeals one year prior to admission revealed a [FEVsub1] of 101 L and an FVC of 265 L He had been treated with prednisone, 20 to 60 mg by means of day, for more than brace years. At admission, his prednisone dose was 50 mg by day. Chest roentgenogram showed changes consistent with COPD and bilateral apical fibrosis without change from previous roentgenograms. refinements of bronchoscopic brushings grew Aspergillus fumigatus. Sputum cultivations also grew Aspergillus. There were precipitin lines to A fumigatus in his serum The prednisone dose was gradually reduc nevertheless was increased to 60 mg by day because of increased respiratory distress. His respiratory symptoms quickly resolv and he was discharged onward 50 mg per day of prednisone. Nine days later, he was readmitted for dyspnea. He was treated with methylprednisolone, 60 mg each six hours, aminophylline, and beta-agonists. His symptoms resolv throughout the next few days. Sixteen days after admission, the dose of methylprednisolone was reduc to 40 mg each six hours. Two days later, a chest roentgenogram revealed a of recent origin density in the right upper lobe. line and sputum cultures grew Klebsiella pneumoniae, and he was treated with ampicillin and amikacin. He had a respiratory arrest and died 22 days after hospitalization. Postmortem examination revealed Klebsiella pneumoniae and invasive pulmonary aspergillosis; no acid-fast bacilli or mycetomas were seen [TABULAR DATA OMITTED]