sensed beat (sensing refractory period) . The variability of these periods may lead to the generation of complex electrocardiographic patterns requiring detailed knowledge of the design of the pulse generator for proper interpretation. The situation is further complicated by the sensitivity of the timing circuit to the voltage of the battery supply. With improvements in battery design and the common utilization of low-output pulse generators, the pacing systems now in use have a life span which is not absolutely predictable. When the failure of one cell causes a decrease in the voltage from the battery supply, most pulse generators respond by decreasing their pacing rate. All manufacturers provide for a testing rate, usually achieved by application of a magnet over the pulse generator, as a reliable indicator of battery depletion. In an R-wave-inhibited pulse generator, an increase in interval between pacing artifacts while spontaneously pacing is easily misinterpreted. 6 The presence of a ratehysteresis feature, the occurrence of partial recycling of the amplifler during the relative refractory period, electromagnetic interference, or sensed muscular potentials may cause a prolongation of the pacing interval which is not indicative of impending battery failure. Although the patient's ventricle should follow the pacing impulse, both patients reported here exhibited the inverse phenomenon. The common factor appears to be occurrence of exit block with a properly functioning R-wave inhibition circuit. In case 1, hyperkalemia and acidosis combined to give the exit block, probably on the basis of decreased myocardial excitability. 8 In case 2, fibrosis around the myocardial electrode gave exit block without disturbing the detected potentials enough to impair sensing. When failure to capture occurred, both patients reverted to idioventricular rhythm. In the presence of an intact sensing circuit, the idioventricular complex caused the timing circuit of the pulse generator to reset. A pacing artifact followed at an appropriate interval after the patient's complex. At an interval longer than the delivery refractory period but prior to the occurrence of the second pacing pulse, the timing circuit was again reset by an idioventricular complex, resulting in the appearance of a slow pacing rate. In order for the tag-along phenomenon to occur, therefore, the patient's spontaneous rhythm must have an interval equal to at least the escape interval plus the delivery refractory period, but not · more than the escape interval plus the basic pacing rate. The key to correct interpretation of such an electrocardiogram is the fact that the interval from each preceding complex to the succeeding pacemaker artifact is equal to the escape interval, indicating an intact and properly functioning sensing circuit. Treatment of the pacemaker arrhythmia should be directed toward correction of the cause of the exit block and not to replacement of the normally functioning pulse generator. When failure to capture occurs in a patient where the pacemaker has an intact sensing circuit, a tag-along phenomenon may occur which mimics the slow pacing rate of a pulse generator with severely depleted batteries.

CHEST, 70: 5, NOVEMBER, 1976

REFERENCES 1 Mymin D, Cuddy TE, Sinha SN, et al: Inhibition of demand pacemakers by skeletal muscle potentials. JAMA

223:527-529, 1973 2 Walter WH, Mitchell JA, Rustan PL, et al: Cardiac pulse generators and electromagnetic interference. JAMA 224: 1628-1631, 1973 3 Barold SS, Gaidula JJ, Lyon JL, et al: Irregular recycling

of demand pacemakers from borderline electromagnetic signals. Am Heart J 82:477-485, 1971 4 Barold SS: Clinical significance of pacemaker refractory periods. Am J Cardiol28:237-239, 1971 5 Barold SS, Gaidula JJ: Evaluation of normal and abnormal sensing functions of demand pacemakers. Am J Cardiol 28:201-210, 1971 6 Surawicz B, Chelbus H, Reeves JT, et al: Increase of ventricular excitability threshold by hyperpotassemia. JAMA 191:1049-1054, 1965

Acute Adult Respiratory Distress Syndrome Assodated with Gonococcal Septicemia* J. Daoid Markham, M.D.;•• Joseph R. Vilseck, Jr., M .D .;t and Walter J. O'Donohue, Jr., M.D., F.C.C.P.t

A case of gonococcal septicemia with monoarticular arthritis and adult respiratory distress syndrome is presented. Prompt treatment of the infection and early treatment for the adult respiratory distress syndrome prior to tbe fnD development of tbe syndrome appeared to ameHonte tbe conrse of illness to the extent that intnbation and mechanical ventilation were not required. 1be patient was succesafnDy treated in a community hospital with a relatively short conrse of tbenpy and fnD recovery. he adult respiratory distress syndrome has not been T reported previously in association with septicemia due to Neisseria gonorrhoeae. This case, presenting initially as acute arthritis of the knee, also demonstrates that early institution of intensive therapy for the adult respiratory distress syndrome is instrumental in modifying the course of the syndrome, to the extent that intubation was not required and treatment was successful in the intensive care unit of a community hospital.

CASE REPoRT A 40-year-old woman came to her local physician on July 24, 1975, with a complaint of pain in her left knee and left arm. She was treated with aspirin, but because of worsening of the pain and swelling in her knee, she reported to the local hospital's emergency room two days later. At that time, her blood pressure was 142/90 mm Hg, her temperature was •From the Medical Service, Henrico Doctors' Hospital, and the Medical College of Virginia, Virginia Commonwealth University, Richmond. ••clinical Associate in Medicine, Medical College of Virginia. tChief, Respiratory Division, Henrico Doctors' Hospital. :!:Associate Professor of Medicine, Medical College of Virginia.

Reprint requests: Dr. Markham, 5700 Old JUchmond Avenue, Richmond, V lrglnia 23226

ACUTE ARDS ASSOCIATED WITH GONOCOCCAL SEPTICEMIA 687

FlcURE 1. Portable chest i-ray film ori admission (July 26, 1975) . There is right lower lobe infiltrate which appears to be minimal 37.4•C (99.4•F), her pulse was 135 beats per minute, and her respiration rate was 26/min. The white blood cell count ( WBC) was 18,600/cu mm, with 84 percent polymorphonuclear leukocytes. Her physician aspirated 40 ml oE cloudy yellow fluid from the left lcnee and referred the patient to an orthopedic surgeon at Henrico Doctors' Hospital. Medical consultation was obtained. The patient was transferred to the medical service and admitted to the intensive care unit. Significant past history included sporadically treated hypertension and a smoking history of at least one pack of ciga-

rettes daily. Physical examination on admission revealed a well-developed obese woman with a large frame who was in acute distress. She was uncooperative, wild, delirious, and diaphoretic, with marlced tachypnea. The patient's blood pressure was 116/64 mm Hg, her pulse was 102 beats per minute, and her respiration rate was 22 to 28 per minute. Her tongue was dry, and many teeth were missing. The lungs were clear to percussion and auscultation. Cardiac examination revealed marked tachycardia with regular rhythm. The heart sounds were of good quality, with no murmurs, rubs, or gallops audible. There was swelling and tenderness of the left lcnee, with ballotable fluid present. A profuse yellow-green purulent vaginal discharge was evident on pelvic examination. Findings from the remainder of the physical examination were within normal limits. The electrocardiogram suggested right cardiac strain. A portable chest x-ray film (Fig 1 ) showed a minimal perihilar infiltrate on the left and a suggestion of infiltrate above the left cardiophrenic sulcus. Arterial blood gas levels on admission and during the acute illness are shown in Table 1. The hemoglobin was 13.2 gm/100 ml, the hematocrit reading was 35.1 percent, and the WBC was 18,800/cu mm, with 89 percent polymorphonuclear leukocytes. Blood, cervical discharge, and joint fluid were cultured on admission. Unfortunately, blood cultures were obtained one hour after an intravenous dose of cephalothin, and the joint fluid was plated four hours after it had been obtained. The cervical discharge later grew N gonorrhoeae; other cultures were negative. The patient was sedated with diazepam, and treatment with digoxin was begun. Antibiotic therapy was continued with intravenous administration of ampicillin. On the following morning the chest x-ray film showed increasing infiltrates bilaterally, and arterial blood gas levels indicated persistent hypoxemia and respiratory alkalosis. The patient continued to be hyperkinetic with tachycardia but had no evidence of congestive heart failure or hypotension. Serum levels of radioactive triiodothyronine ( T s), thyroxine iodine ( T 4 ) , and free thyroxine were normal. Therapy with

Table 1-ArteriGI Blood Gu l'..etlela*

Hospitalization Time Day 1 12:45 All 9AM 1:30 Pll Day2 3 :15 All 8AM 3PII Day3 10:15 All

llPII

Day4 1:30 Pll 5 PM Day5 10 All Outpatient (51st day)

Oxygen Flow per Minute Room air Room air 4 L, nasal cannula

Pas, mmHg

Oxygen Saturation, percent

Paes, mmHg

pH

73 53 66

96 90 94

19 22 22

7.55 7.51 7.49

16 17 17

66

22

nco.-;

mEqfL

4 L, cannula 4 L, cannula 5 L, cannula

59 64

94 93 94

28 27 28

7.47 7.52 7.53

4 L, cannula 4 L, mask

85 101

97 98

34 42

7.51 7.53

27

Room air 4 L, mask

47 102

84 98

47

7.47 7.48

30

Room air Room air

77

62

92 96

40

7.46 7.47

28 22

40

31

20 23

34 29

*Values are correlated with clinical course in case record. PaCO., arterial carbon dioxide tension; HCO,-, bicarbonate.

888 MARKHAM, YILSECK, O'DONOHUE

CHEST, 70: 5, NOVEMBER, 1976

....

intermittent positive-pressure breathing was instituted, and nasal oxygen therapy was continued. A chest x-ray film showed increasing infiltrates in the left upper and right lower lobes. The patient developed a nonproductive cough; imd rales were present. At this point, therapy for the adult respiratory distress syndrome was begun, with intravenous administration of 1.0 gm of methylprednisolone and intramuscu1ar administration of 40 mg of furoSemide. On the second day of hospitalization (July 28, 1975), the arterial oxygen pressure ( Pa(h) continued to fall, but the patient had less tachypnea and no dyspnea. Examination of the lungs disclosed fine rales. The cardiac rate was 88 beats per minute, ~d grade 2 ejection murmurs were noted at the apex and left sternal border, with an accentuated pulmonic seeond sound. The platelet count and plasma level of fibrinogen were Dormal. Levels ·of split fibrin degradation products were slightly increased. Chest x-ray films showed the typical appearance of the adult respiratory distress syndrome (Fig 2). A total of 3.0 gm of methylprednisolone was administered intravenously in the first 30 hours. When the cervical culture was reported positive for N gOfiOf'f'hoeae, antibiotic therapy was changed to intravenous administration of 10 million units of penicillin G daily, with 1.0 gm of probenecid daily. On the fourth day of hospitalization, the patient's Pa02. while receiving 4 L of oxygen per minute via mask, was 102 mm Hg (Table 1) . The findings on the chest x-ray film had markedly improved (Fig 3), as had the patient's clinical status; Cardiac murmurs were essentially unchanged throughout her course and one month after discharge. The left knee returned to normal rapidly. The cervical discharge became culture-negative, and the patient was discharged Iully ambulatory 13 days following admission. DISCUSSION

The increasing prevalence of gonorrhea in the general population inevitably ·results in a greater incidence of complicated cases ~d unusual situations which involve

2. Chest x-ray film taken 36 hours after admission (July 28, 1975). Characteristic "whiteout" appearance of adult respiratory distress syndrome is apparent. FiGURE

CHEST, 70: 5, NOVEMBER, 1976

FiGURE 3. Posteroanterior standing film taken Aug. 1, 1975, showing recovery phase with marked improvement

consultants as well as primary care physicians. The case presented in this report is an excellent example of a common, usually simple infection with a bizarre course that demanded intensive and sophisticated care for a successful conclusion. ThiS patient, when first seen by us, was an acutely ill woman with arthritis,of the knee, marked general toxicity, delirium, and hyperventilation. Holmes and associates1 divided gonococcal arthritis into two stages, the bacteremic stage and the septic joint stage. The bacteremic stage is often asSociated with cutaneous manifestations,2•8 as well as polyarticular arthritis with transierit fever and chills in many cases (but not all). Rarely, endocarditis, myocarditis, and pericarditis may be encountered.1 The septic . arthritis which occurs later is usually monoarticular. The history in our patient followed this sequence but without cutaneous manifestations. ¥t addition, she presented in acute respiratory distress with normal auscultatory findings and minimal roentgenographic findings suggestive of early pneumonia. Despite her acutely ill state, pelvic examination was performed because of the septic arthritis. Without conclusive evidence of gonorrhea at that time, and with the possibility of pneumonia, it was decided to treat her with large doses of ampicillin. This was replaced by intravenous administration of penicillin G as soon as the cervical culture was reported positive for N gonorrhoeae. Following arterial blood gas analysis, intensive respiratory care was begun with acute adult respiratory distress syndrome in mind, although roentgenograms were not yet confirmatory. We believe that this early treatment modified the course of the adult respiratory distress syndrome in this patient to the extent that intubation apd cOntinuous mechanical ventilation were not required, despite the progression of roentgenographic

ACUTE ARDS ASSOCIATED WITH GONOCOCCAL SEPTICEMIA 889

changes to the usual "white-out.. appearance which is characteristic of the adult respiratory distress syndrome. It is probable that early recognition and treatment also shortened the duration of intensive respiratory care. A review of the literature indicates that this is the first reported case of the adult respiratory distress syndrome precipitated by gonococcal septicemia. The role of steroids in the treatment of the adult respiratory distress syndrome due to sepsis is controversial; however, control of sepsis is crucial. In a study at the Boston University Medical Center, Vito et al4 found that of 32 patients presenting with the adult respiratory distress syndrome without a history of trauma, of myocardial infarction, or of neurosurgical disease, 78 percent (25) were proven to have severe sepsis. The mortality in patients with sepsis and the adult respiratory distress syndrome was 68 percent. The clinical course and positive cervical culture confirm the diagnosis in this case. Blood cultures are frequently negative in gonococcal sepsis, 8 and negative cultures of synovial fluid are common, even when collected under ideal conditions, which did not prevail in our case.

REFERENCES 1 Holmes KK, Counts GW, Beaty HN: Disseminated gonococcal infection. Ann Intern Med 74:979-993, 1971 2 Frichot BC lll, Everett MA: Gonorrhea: Arthritis, septicemia and cutaneous manifestations: A case report. Oklahoma State Med Assoc J 60:597-600, 1971 3 Gelpi AP: Gonococcal sepsis in college students. JAm Coli Health Assoc23:157-161, 1974 4 Vito L, Dennis RC, Weisel RD, et al: Sepsis presenting as acute respiratory insufficiency. Surg Gynecol Obstet 138: 896-900, 1974

CASE REPoRT A 26-year-old white man, a two-year resident of Arizona, presented in November 1973 with a six-month history of fatigue, tender cervical and axillary lymphadenopathy, fever; myalgia. right anterior pleuritic chest pain, and bilateral pulmonary hilar adenopathy. Slcin tests using a 1:100 dilution of coccidioidin and intermediate-strength purified protein derivative of tuberculin were negative. The slcin test with the 1: 100 dilution of coccidioidin became positive ooe month later, and a coccidioidin complement-fixation test had a titer of 1:16. By March 1974, cardiomegaly had developed, the complement-fixation titer increased to 1:32, and an el~ gram showed sinus tachycardia at 110 beats per minute and abnormal T -wave inversions. Low-grade fever, distant heart tones, and tender hepatomegaly were noted on physical examination. The white blood cell count was 7,900/cu mm, viral titers were not elevated, the creatinine clearance was 54 mVmin, the serum creatinine level was 1.5 mg/100 ml, and the blood urea nitrogen level was 19 mg/100 mi. The clinical impression at that time was active coccidioidomycosis with acute myocarditis. Treatment with amphotericin B was accompanied by increasing congestive heart failure, oliguria, and a serum creatinine level of 5.2 mg/100 mi. Treatment with digoxin and diuretics had little success. The patient was transferred to St. Joseph's Hospital and Medical Center on Mar 15 foe further evaluation. Physical examination revealed a tachypneic man in a very toxic condition, with blood pressure of 110/80 mm Hg and pulse rate of 110 beats per minute. Pulsus paradoms with a respiratory variation of 25 mm Hg was detected, the heart

Coccidioidal Pericarditis• Eugene L. Schwanz, M.D.; Edward B. Waldmann, M.D., F.C.C.P.; Robert M. P0J1116, M.D.; David Goldfarb, M.D., F.C.C.P.; Sam A. Kinard, M.D.; and Edward B. Diethrich, M.D., F.C.C.P.

(24) PCW

A 26-year-old man developed cocddioldomycosis wbkh resulted In myocarditis MIOdated with congestive heart failure. A perkardial etfuslon developed and progreaed

to coDStrictive pericarditis. A pericardiectomy

W1lll performed and revealed tbat tbe pericarditis W1lll due to Coccidioides immitis. The patient W1lll sublequendy treated with amphotericln B and showed marked im-

provement. is a pririlary fungal disease of the Coccidioidomycosis lungs which may disseminate to almost any organ in

the body. 1 • 2 The following case report deals with an unusual dissemination to the myocardium and pericardium and describes the management of this problem.

•From the Arizona Heart Institute and the Department of Medicine, St. Joseph's H~ital and Medical Center, Phoenix. Reprint requuts: Dt. WaldmDnn, St. ]OBefJh'a HO&pltal and Medical Center, Phoenix 85001

870 SCHWARTZ, ET AL

F'IcUBE 1. Cardiac catheterization data on pressure, measured in millimeters of mercury. IVC, Inferior vena cava; SVC, superior vena cava; a, a wave; v, v wave; m, mean; RA, right atrium; RV, right ventricle; PA, pulmooary artery; LA, left atrium; LV, left ventricle; and PCW,--pulmonary capillary wedge.

CHEST, 70: 5, NOVEMBER, 1976

Acute adult respiratory distress syndrome associated with gonococcal septicemia.

sensed beat (sensing refractory period) . The variability of these periods may lead to the generation of complex electrocardiographic patterns requiri...
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