blood bilirubin values were within normal limits. Thoracentesis produced an exudate predominantly composed of lymphocytes with a high ADA level (62 lUlL). Pleural 8uid, blood, and stool and sputum cultures showed no bacterial growth, and serologic determinations for Chlamydia, Coxiella, Legionella, and Mycoplasma were negative. Hepatic echography revealed hepatomegaly without other lesions. The patient was treated with erythromycin (4 gtd) and cefonicid (2 g/d), The clinical and radiologic evolution were favorable. Serologic blood determination 15 days after admission showed seroeonversion, by complement fixation test with a titer of 1:540 for

Chlamydia psittaci. Chlamydia psittaci, like Koch's bacillus, is an intracellular path-

ogen frequently found in the macrophages of tissues involved.' The collaboration of activated T lymphocytes is required for these macrophages to become bactericidal. Proliferation of these lymphocytes seems to increase ADA synthesis and secretion in the tissues," An increase in ADA activity in pleural effusions due to C psittaci could therefore be expected, as occurs in tuberculosis. To date, we have found no references regarding this association. Ramon Orriols, M.D., Xavier Munoz, M.D.,

Zvezda Drobnic, M.D.,

jaume Ferrer; M.D., and

Ferran MoreU, M.D., Seroei de Pneumologia, Hospital General Universitari Van d'Hebron, Barcelona, Spain

REFERENCES 1 Piras MA, Gakis C, Brudoni M, Andreoni G. Adenosine deaminase activity in pleural effusions: an aid to differential diagnosis. Br Med J 1978; 4:1751-52 2 Ocana I, Martfnez-Vazquez JM, Segura R, Fernandez de Sevilla T, Capdedvila lA. Adenosine deaminase in pleural fluids: test for diagnosis of tuberculous pleural effusion. Chest 1983; 84:51-3 3 Querol JM, Barbe F, Manresa F, Estaban L, Canate C. Low value of adenosine deaminase in tuberculous pleural effusions. Eur J Respir Dis 1990; 3:586-87 4 Schaffer W. Chlamydia psittaci (psittacosis). In: Mandell GL, Douglas RG Jr. Bennett JE. eds. Principles and practice of infectious diseases, 2nd ed. New York:John Wiley & Sons, 1985; 1061-63 5 Ribera E, Martinez-Vcizquez JM, Ocana I, Ruiz I, Segura R, Encaho G, et ale Interferon gamma y adenosina desaminasa en las pleuritis. Med Clin (Bare) 1990; 94:364-67

Bilateral Upper Extremity Blood Pressure Measurements Should Be Routine priorto Coronary Artery Surgery 1b the Editor: Recently, we described a situation in which the diagnosis of lea subclavian artery stenosis was made immediately prior to the induction of anesthesia in a patient scheduled for coronary artery bypass grafting with use of left internal mammary artery (IMA) and saphenous vein grafts. 1 This diagnosis was suspected because a difference of 50 mm Hg between blood pressures in the upper extremities was found immediately prior to the induction of anesthesia. The diagnosis was confirmed with postoperative Bmode Doppler ultrasonography. The IMA was not used in this case because of the potentially lethal complication of coronary subclavian steal following bypass grafting using the I MA.I On questioning the patient postoperatively, we discovered a 15-year history of being easily fatigued in his nondominant lea upper extremity, which was

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associated with difficulty in obtaining blood pressure measurements in the same arm. This case illustrates the failure to note a physical sign that was present over the course of 15 years of medical and cardiologic consultations, including an evaluation before cardiac catheterization and preoperative surgical and anesthetic evaluations. Ideally, the rate-limiting step should be the evaluation done prior to cardiac catheterization. If a gradient greater than 20 mm Hg is present between arms, then subclavian artery stenosis is likely to exist in over 90 percent of these patients'; a study of the aortic areh can be done immediately without additional morbidity to the patient. The IMA graft has become the coronary bypass graft of choice,' and its use is increasing. To date, coronary-subclavian steal following the use of the IMA has been reported in ten patients," Of concern, however, is the fact that other patients who suffered significant perioperative morbidity and mortality following coronary artery bypass grafting may have been casualties of undiagnosed subclavian artery stenosis. We, therefore, would like to emphasize the importance of bilateral blood pressure measurements in the prevention of this potentially lethal syndrome.

David Amar, M.D., LArry A. Attai, M.D., Sushil K. Gupta, M.D., and Anne}ones, B.S.N., R.\(L, Mootefiore Medical Center/Albert Einstein CoUege of Medicine, New York

REFERENCES 1 Amar D, Altai LA, Gupta SK, Jones AJ. Perioperative diagnosis of subclavian artery stenosis: a contraindication for internal mammary artery-coronary artery bypass graft. Anesthesiology 1990; 73:783-85 2 Brown AU, Wellington MS. Coronary steal by internal mammary graft with subclavian stenosis. J Thorac Cardiovasc Surg 1976; 73:690-93 3 Walker PM, Paley D, Harris KA, Thompson A, Johnston KW. What determines the symptoms associated with subclavian artery occlusive disease? J Vase Surg 1985; 2:154-57 4 Loop FD, Lytle B~ Cosgrove OM, Stewart ~ Goormastic M, Williams G~ et ale Influence of the internal-mammary-artery graft on ten-year survival and other cardiac events. N Engl J Med 1986; 314:1-6 5 Olsen CO, Dunton 8F, Maggs ~ Lahey SJ. Review of coronary subclavian steal following internal mammary artery-coronary artery bypass surgery Ann Thorac Surg 1988; 46:675-78

Pulmonary Hamartoma Syndrome 1b the Editor: It was with much interest that we read the report by Gabrail and Zara,l which appeared in the April 1990 issue of Chest. We are currently reviewing the cases of all patients with pulmonary hamartoma who underwent 6beroptic bronchoscopy at our hospital from January 1974 to September 1989. Of the 34 cases found, we were able to analyze 32; there were insufficient data in two cases. There were 26 male and six female patients, with a mean age of 57± 10 (SO) years. In 16 cases, hamartomas were located in the pulmonary parenchyma; in the remaining 16, the hamartomas were of endobronchial or tracheal origin. Associated pathology was evaluated in aU cases. Disorders ranged &om congenital abnormalities to tumors (Table 1). Although one or more pathologic findings were detected in most patients (24132), many of these conditions are common within the general population and are of high prevalence in the age groups of our patients. We believe that it is important to consider the hamartoma as asymptoCommunications to the Editor

Bilateral upper extremity blood pressure measurements should be routine prior to coronary artery surgery.

blood bilirubin values were within normal limits. Thoracentesis produced an exudate predominantly composed of lymphocytes with a high ADA level (62 lU...
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