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During February 1987 an outbreak of nitrogen dioxide-induced respiratory illness occurred among players and spectators of two high school hockey games played at an indoor ice arena in Minnesota. The source of the nitrogen dioxide was the malfunctioning engine of the ice resurfacer. Case patients experienced acute onset of cough, hemoptysis, and/or dyspnea during, or within 48 hours of attending, a hockey game. One hundred sixteen cases were identified among hockey players, cheerleaders, and band members who attended the two games. Members of two hockey teams had spirometry performed at 10 days and 2 months after exposure; no significant compromise in lung function was documented. Nitrogen dioxide exposure in indoor ice arenas may be more common than currently is recognized; only three states require routine monitoring of air quality in ice arenas, and the respiratory symptoms caused by exposure to nitrogen dioxide are nonspecific and easily misdiagnosed.
JAMA 1989 Dec 01
PMID:An outbreak of nitrogen dioxide-induced respiratory illness among ice hockey players. 234 11

Infections with human immunodeficiency virus are common in areas of the world where laboratory testing and sophisticated diagnostic facilities are unavailable. A World Health Organization clinical case definition for acquired immunodeficiency syndrome was developed in 1985 for use in such areas. In 1987, we tested this definition on 1328 inpatients and outpatients in 15 hospitals throughout Uganda. Five hundred sixty-two patients (42%) were positive by enzyme-linked immunosorbent assay for human immunodeficiency virus antibody. The World Health Organization definition had a sensitivity of 55%, a specificity of 85%, and a positive predictive value of 73%. Modification of the case definition by excluding a known cough from tuberculosis as a minor criteria decreased sensitivity slightly to 52%, but specificity and positive predictive value increased to 92% and 83%, respectively. Amenorrhea, although not specifically asked about, was a symptom noted by many female patients (26% of females who were positive by enzyme-linked immunosorbent assay); as a symptom indicative of human immunodeficiency virus infection, amenorrhea had a specificity of 99%, with a positive predictive value of 89%. These findings support the generalizability of the World Health Organization clinical acquired immunodeficiency syndrome definition and its use (especially the modified version) in areas of Uganda without sophisticated facilities.
JAMA 1988 Dec 09
PMID:Evaluation of the WHO clinical case definition for AIDS in Uganda. 305 90

Ivermectin treatment was evaluated for efficacy and side effects in 40 patients in South India who had microfilaremia and bancroftian filariasis. Ivermectin was administered once orally at four dose levels (range, 25 to 200 micrograms/kg), and at each it was found to be completely effective in clearing blood microfilariae within five to 12 days. In most patients, microfilariae reappeared by three months; by six months the levels averaged 14% to 32% of pretreatment values in the four study groups, and all groups showed equivalent efficacy. Detailed monitoring identified some side effects in almost all patients: usually fever, headache, light-headedness, myalgia, sore throat, or cough that occurred most prominently 18 to 36 hours after treatment. These were most frequent and severe in patients with the greatest microfilaremia, but only when treated with the two higher doses of ivermectin (100 and 200 micrograms/kg). The low-dose (25 micrograms/kg) ivermectin group, despite equivalent efficacy in parasite killing, had clinical reaction scores that were minimal and that were not correlated with parasitemia. Since efficacy and side effects of ivermectin therapy compare favorably with those reported for treatment with the standard antifilarial drug diethylcarbamazine citrate, the major advantage of single-oral-dose administration makes ivermectin the best candidate to replace diethylcarbamazine as the treatment of choice for bancroftian filariasis.
JAMA 1988 Jun 03
PMID:Ivermectin for the treatment of Wuchereria bancrofti filariasis. Efficacy and adverse reactions. 328 45

A dry cough, fever, generalized maculopapular rash, and myositis developed in a 67-year-old woman; she also had markedly abnormal liver function test results. Serologic tests proved that she had an infection of recent onset with Borrelia burgdorferi, the agent that causes Lyme disease. During a two-month course of illness, her condition remained refractory to treatment with antibiotics, salicylates, and steroids. Ultimately, fatal adult respiratory distress syndrome developed; this was believed to be secondary to Lyme disease.
JAMA 1988 May 13
PMID:Fatal adult respiratory distress syndrome in a patient with Lyme disease. 335 44

We describe a patient with ulcerative colitis and extracolonic manifestations in whom diffuse interstitial pulmonary disease developed that was responsive to glucocorticoid therapy one year after total proctocolectomy. The patient presented in December 1983 with a subacute course marked by cough and progressive exertional dyspnea, abnormal chest examination results, and a chest roentgenogram that revealed diffuse interstitial and alveolar infiltrates. A transbronchial biopsy specimen revealed a polymorphic interstitial infiltrate, mild interstitial fibrosis without apparent intraluminal fibrosis, and no vasculitis, granulomas, or significant eosinophilic infiltration. Within one week of the initiation of daily high-dose steroid therapy, the patient's symptoms dramatically improved; chest roentgenogram and forced vital capacity (60%) improved at a slower rate. All three measures deteriorated when alternate-day prednisone therapy was started but once again improved until the patient was totally asymptomatic, chest roentgenograms were normal, and forced vital capacity was 80% of the predicted value 2 1/2 years later.
JAMA 1988 Jul 01
PMID:Ulcerative colitis and steroid-responsive, diffuse interstitial lung disease. A trial of N = 1. 337 24

An explosive outbreak of a febrile respiratory illness occurred among members of a college fraternity. The preponderant signs and symptoms were muscle aches, cough, and low-grade fever. All illnesses occurred within 1.3 to 13 hours of attendance at a party where there was a dense airborne dust from straw that had been laid on the floor. Of the 67 fraternity members who attended the party and answered a questionnaire, 55 became ill (attack rate, 82%). Risk of illness was higher for those who spent more time at the party. Duration of illness ranged from 4.5 hours to seven days. Results of serological studies did not demonstrate an allergic or viral cause for these illnesses. The clinical and epidemiologic features of this outbreak were characteristic of organic dust toxic syndrome, an acute respiratory illness caused by inhalation of molds growing on hay, silage, or other agricultural products.
JAMA 1987 Sep 04
PMID:An outbreak of organic dust toxic syndrome in a college fraternity. 362 5

Fourteen of 23 female members of a church group experienced an acute self-limited illness characterized by chills, fever, chest pain, cough, and nausea, consistent with the diagnosis of Pontiac fever. All 14 affected women had used a whirlpool located in the women's locker room during a racquetball party. Legionella pneumophila serogroup 6 was isolated from the women's whirlpool. Nine of 14 cases showed a seroconversion to heat-fixed antigen prepared from the L pneumophila serogroup 6 isolate. Aerosol size studies show that the whirlpool aerator produced water droplets small enough to travel deep into the tracheobronchial tree but large enough to transport L pneumophila. This outbreak demonstrated that Pontiac fever may be associated with L pneumophila serogroup 6, that whirlpools can serve as a reservoir for these organisms, and that seroconversion can occur in the absence of illness.
JAMA 1985 Jan 25
PMID:An outbreak of Pontiac fever related to whirlpool use, Michigan 1982. 396 86

An unusual outbreak of measles occurred in 1982 in a pediatrician's office in Muskegon, Mich. Three children, who had arrived at the office 60 to 75 minutes after a child with measles had departed, developed measles. Using a model based on airborne transmission, it is estimated that the index patient was producing 144 units of infection (quanta) per minute while in the office. Characteristics such as coughing, increased warm air recirculation, and low relative humidity may have increased the likelihood of transmission. Adequate immunization of all patients and staff, respiratory isolation and prompt care of all suspected cases, and adequate fresh-air ventilation should decrease the risk of airborne transmission of measles in this setting. Airborne transmission may occur more often than previously suspected, a possibility that should be considered when evaluating current measles control strategies.
JAMA 1985 Mar 15
PMID:Airborne transmission of measles in a physician's office. 397 36

Pulmonary infiltrates developed in three middle-aged women while receiving naproxen sodium. Weakness, fatigue, cough, low-grade fever, and eosinophilia in blood and/or sputum were common to all. All symptoms and findings resolved within a few days after discontinuing naproxen therapy in two cases and with use of corticosteroids (prednisone) in one case. A hypersensitivity reaction due to naproxen seemed to be the likely cause.
JAMA 1984 Jan 06
PMID:Pulmonary infiltrates associated with naproxen. 669 Jul 68

Cough, dyspnea, and chest pain are symptoms common to many cardiopulmonary diseases. A comprehensive evaluation, including a history, physical examination, ECG, chest roentgenogram, and pulmonary function studies, will often yield a specific diagnosis. However, when these symptoms are intermittent, as they often are in patients with bronchial asthma, the diagnosis may not be apparent. If asthma is thought to be a diagnostic possibility, a bronchial inhalation challenge should be used to demonstrate bronchial hyperreactivity, the hallmark of asthma. The methacholine chloride inhalation challenge is a simple and useful laboratory test to diagnose bronchial hyperreactivity. We describe eight patients with a variety of clinical symptoms to demonstrate the usefulness of this test. Patients with unexplained respiratory symptoms should be considered for bronchial inhalation challenge before proceeding to more invasive diagnostic procedures.
JAMA 1981 Jul 17
PMID:Clinical applicability of a methacholine inhalational challenge. 701 82


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