Biomedical subjects
Publications and source records attributed to J T Macfarlane.
Fifteen adults (14 of whom were previously fit and 10 were aged less than 40) with pneumonia, in whom the only pathogen identified was Haemophilus influenzae, are described. One patient was bacteraemic. Clinical, radiographic and laboratory features were similar to other community-acquired pneumonias. H. influenzae should be considered as a cause of pneumonia even in previously fit, young adults.
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The annual number of confirmed cases of Legionnaires' disease in both Nottingham, and England and Wales, reached a peak in 1980 and has since declined. Legionella infection is a rare cause of community-acquired pneumonia managed at home (accounting for less than 1% of cases), more common in those admitted to hospital (5-15%) and more common still in patients with severe pneumonia as seen on an intensive care unit (up to 30% of cases). Antibiotic therapy for any patient with moderate or severe pneumonia of uncertain aetiology should cover legionella infection.
Sequential bacteriological observations were made on the cerebrospinal fluid (CSF) of 28 patients with pneumococcal meningitis treated with high doses of penicillin for 2 weeks. The organism was isolated from the CSF of four patients 48 h or more after the start of treatment and from a further patient 48 h after treatment was stopped. Positive cultures were obtained in spite of the demonstration in the CSF of penicillin at a concentration well above the minimum inhibitory concentration for the organism isolated. Persistence of bacteria and their products in the CSF of patients with pneumococcal meningitis contrasts with the rapid clearance of bacteria from the CSF of patients with meningococcal meningitis and may contribute to the difference in the prognosis of these forms of meningitis.
Seventy nine cases of sporadic, community acquired legionnaires' disease have been reviewed. Annual and seasonal variation in incidence was noted. The mean age of the patients was 53 years and 50 (63%) were male. Pre-existing chronic diseases were present in only 23 (29%), including two patients receiving immunosuppressive treatment. Common symptoms included unproductive cough, dyspnoea, chest pain, headache, confusion, nausea, vomiting, and diarrhoea. Respiratory symptoms were absent, however, in 17 (22%). Localising chest signs were present in 74 (95%) cases. Frequent laboratory findings included lymphopenia, high erythrocyte sedimentation rate, hyponatraemia, raised urea and creatinine concentrations, abnormal liver function, hypophosphataemia, hypoalbuminaemia, proteinuria, and haematuria. Thirteen patients died (16%), including nine of 20 who received assisted ventilation. The mortality rate in patients treated with erythromycin (11%) was lower than in those who received other antibiotics (23%), but this difference was not statistically significant. Of the features noted on admission, only a high plasma urea concentration was significantly associated with death. Sporadic community acquired legionnaires' disease is a not uncommon disorder, which with appropriate treatment has a prognosis similar to that of other forms of community acquired pneumonia.
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Twenty-four consecutive patients admitted to hospital with severe acute asthma were studied. Eleven were given 10 mg salbutamol by nebulizer followed 2 hours later by 500 micrograms of nebulized ipratropium bromide. These patients had a greater response in PEFR than 13 patients given two doses of 10 mg salbutamol 2 hours apart.
Between January 1972 and December 1981, 50 patients with severe community-acquired pneumonia were admitted to the intensive care unit of a district general hospital. A causal pathogen was identified in 41 cases (82%). Streptococcus pneumoniae (16 cases), Legionella pneumophila (15 cases) and Staphylococcus aureus (5 cases) were the commonest. Assisted ventilation was required in 44 patients, of whom 25 died (57%). All 5 patients with staphylococcal pneumonia and 12(75%) with pneumococcal pneumonia died. Only 5 (33%) with Legionnaires' disease died. Mortality was significantly associated with age. Recommendations for the management of severe pneumonia are made.
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The features of the chest radiographs of 49 adults with legionnaires' disease were compared with those of 91 adults with pneumococcal pneumonia (31 of whom had bacteraemia or antigenaemia), 46 with mycoplasma pneumonia, and 10 with psittacosis pneumonia. No distinctive pattern was seen for any group. Homogeneous shadowing was more frequent in legionnaires' disease (40/49 cases) (p less than 0.005), bacteraemic pneumococcal pneumonia (25/31) (p less than 0.01) and non-bacteraemic pneumococcal pneumonia (42/60) (p less than 0.05) than in mycoplasma pneumonia (23/46). Multilobe disease at presentation was commoner in bacteraemic pneumococcal pneumonia (20/31) than in non-bacteraemic pneumococcal pneumonia (15/60) (p less than 0.001) or legionnaires' disease (19/49) (p less than 0.025). In bacteraemic pneumococcal pneumonia multilobe disease at presentation was associated with increased mortality. Pleural effusions and some degree of lung collapse were seen in all groups, although effusions were commoner in bacteraemic pneumococcal pneumonia. Cavitation was unusual. Lymphadenopathy occurred only in mycoplasma pneumonia (10/46). Radiographic deterioration was particularly a feature of legionnaires' disease (30/46) and bacteraemic pneumococcal pneumonia (14/27), and these groups also showed slow radiographic resolution in survivors. Radiographic resolution was fastest with mycoplasma pneumonia; psittacosis and non-bacteraemic pneumococcal pneumonia cleared at an intermediate rate. Residual intrapulmonary streaky opacities remained in over a quarter of survivors from legionnaires' disease (12/42) and bacteraemic pneumococcal pneumonia (5/19).
Twelve patients with chronic asthma received either high dose beclomethasone once a day or standard doses of beclomethasone three times a day in a double blind crossover trial to determine whether inhalation once a day would be sufficient. With the once a day regimen peak expiratory flow rates fell significantly, symptoms of nocturnal asthma increased, and two patients withdrew from the study because of worsening asthma. Whether control can be achieved with steroids inhaled once a day by simply increasing the total daily dose remains to be seen.
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In a double blind trial erythromycin was compared with a combination of ampicillin and amoxycillin for treating adults admitted to hospital with primary pneumonia. The clinical course of 42 patients treated with ampicillin and amoxycillin was similar to that of the 49 in the erythromycin group. Fall in temperature, symptomatic recovery and radiographic improvement were similar (two-thirds made an uncomplicated recovery). Infusion-related phlebitis was more common with erythromycin. Otherwise adverse reactions were unusual. The outcome was related principally to the cause of the pneumonia with bacteraemic/antigenaemic pneumococcal pneumonia, Legionnaires' disease, other bacterial pneumonias and psittacosis having a poor prognosis. Both forms of antibiotic therapy gave similar results but we suggest that a combination of erythromycin with ampicillin may be logical initial treatment for severe pneumonia of unknown cause.