REFERENCES

1 Boyle JD, Pearce ML, Guze LB: Purulent pericarditis: review of literature and report of 11 cases. Medicine ( Baltimore) 40: 119-144, 1961 2 Penny JL, Grace WJ, Kennedy RJ: Meningococcic pericarditis. A case report and review of the literature. Am J CardioI18:281-285, 1966 3 Wolf RE, Birbara CA: Meningococcal infections at an Anny training center. Am J Med 44:243-255, 1968 4 Koslow JL, Gaston WR: Meningococcal pericarditis with massive pericardial effusion and tamponade. Prog notes Dept Med us Anny Hosp, Fort Jackson, SC 1:1-3, 1970

Hyperacute Radiation Pneumonitis* Allan L. Goldman, M.D. o O and Robert Enquist, M.D.t

We present a patient who developed radiation pneumonitis only eight days after beginning therapy. The pneu-

moni& responded dramatically to prednisone on four occasions, which was a helpful point in the ditferential diagnosfi.

therapy commonly used to treat various R adiation thoracic neoplasms. Radiation may cause adverse is

6 Pierce HI, Cooper EB: Meningococcal pericarditis. Clinical features and therapy in five patients. Arch Intern Med 129:918-922, 1972

effects including acute radiation pneumonitis. Radiation pneumonitis characteristically appears one to 16 weeks after completion of radiotherapy.' A patient is presented who developed radiation pneumonitis only eight days after beginning therapy, the hyperacute onset causing great difficulty with diagnosis. Pneumonitis in his case was exquisitely corticosteroid responsive, and this proved to be a useful point in the differential diagnosis.

7 Herrick WW: Meningococcic pericarditis. Med Clin N Am 2:411-426, 1918

CASE REPoRT

5 Morse JR, Oretslcy MI, Hudson JA: Pericarditis as a complication of meningococcal meningitis. Ann Intern Med 74:212-217, 1971

8 Smith burn KC, Kempf GF, Zerfas LG, et al: Meningococcic meningitis: A clinical study of 144 epidemic cases. JAMA 95:776-780, 1930 9 Miller GC, Witham AC: Delayed febrile pleuropericarditis after sepsis. Ann Intern Med 79:194-197,1973 10 Lukash WM: Massive pericardial effusion due to meningococcic pericarditis. JAMA 185:598-600, 1963 11 Beal LR, Ustach TJ, Forker AD: Meningococcemia without meningitis presenting as a cardiac tamponade. Am J Med 51:659-662, 1971 12 Orgain ES, Poston MA: Pericarditis with effusion due to the meningococcus. Am Heart J 18:368-372, 1939 13 Roberts KB, Neff JM: Meningococcal pericarditis without meningitis in a child. Am J Dis Child 124:440-441, 197214 Wansbrough-Jones MH, Wong OP: Meningococcal pericarditis without meningitis. Br Med J 1:344-345, 1973 15 Herman RA, Rubin HA: Meningococcal pericarditis without meningitis presenting as a tamponade. N Eng) J Med 290:143-144,1974 16 Kauffman CA, Watanakunakorn C, Phair JP: Purulent pneumococcal pericarditis. A continuing problem in the antibiotic era. Am J Med 54:743-750, 1973 17 Paine TF, Garrard Jr CL, Walker PJ: Meningococcal pneumonia. Arch Intern Med 119:111-112, 1967 18 Saslaw S, Diserens RV: Purulent pericardial effusion complicating meningococcal meningitis. N Engl J Med 263:1074-1075,1960 19 Braude AI, Jones JL, Douglas H: The behavior of Escherichia coli endotoxin (somatic antigen) during infectious arthritis. J Immunol 90:297-311, 1963

CHEST, 67: 5, MAY, 1975

A 36-year-old man was admitted to Walter Reed General Hospital for evaluation of hemoptysis and an abnormal chest roentgenogram. He was a heavy smoker but denied anorexia, weight loss, chest pain, chills or fever. He underwent bronchoscopy and mediastinoscopy on June 15, 1973, which revealed nearly complete obstruction of the right mainstem bronchus and involvement of the right hilar lymph nodes by a large cell undifferentiated carcinoma. Figure 1 shows a pre-radiation therapy chest roentgenogram with the radiation ports marked. On June 19, 1973 the patient began a course of radiotherapy to consist of 5000 rads given as a daily dose of 200 rads in 25 treatments over a 37 day period. On June 26, after the 6th treatment, he developed dyspnea, a nonproductive cough, fever of 100°F (38.3°C), and malaise. He had been on no drugs. A complete blood count revealed a white cell count of 8,800 with 81 neutrophiles, 12 lymphocytes, and 7 monocytes. Sputum culture showed normal flora, and blood cultures showed no growth. A chest film at this time revealed opacification on the right side most marked in the area of irradiation (Fig 2). The patient was empirically begun on 40 mg of prednisone, and within 24 hours was asymptomatic. By June 29, 1974 the chest roentgenogram showed almost complete resolution of the inliltrate (Fig 3). Because of uncertainty of the diagnosis of radiation pneumonitis by the attending staff, the prednisone was abruptly discontinued. Within a day the patient had a clinical and roentgenologic relapse which rapidly responded to the reinstitution of prednisone. This sequence was repeated two more times, after which he has been maintained on 40 mg of prednisone until lost from followup in the middle of August. While maintained on the prednisone, he had no further acute episodes and neither clinical nor roentgenologic evidence of chronic radiation fibrosis. °From the Pulmonary Disease Section, Walter Reed General Hospital, Washington, D.C. o°Presently Chief, Pulmonary Disease Section, University of South Florida College of Medicine. tFellow in Pulmonary Disease. Reprint requests: Materiel Branch, walter Reed Army Medical Center, 2461 Linden Lane, Silver Spring, Maryland 20910

HYPERACUTE RADIAnOM PMEDMOMms 613

3 . C hes t roentgenogra m sh ow in g almost comp lete resolution of th e infiltrate aft e r th ree days of pred n isone th erapy. F IG URE

1. Pr e -radiation th erapy chest roentgenogram with radiation ports marked.

FIGURE

DISCUSSION

As with any th erapeutic mod al ity, th er e ar e cer ta in inher ent risks in the use of radiat ion . Ra di ation to the lung may ind uce either ch ronic intersti tia l fibrosis, or an acute radiation p neu monitis. The chronic fibrotic stage ge ne rally begin s tw o to six mon ths a fter completion of th e ra d iot herapy. T he patien t prese n ts w ith a nonprodu ct ive cough and dyspnea, and serial chest roen tgen ogra ms reveal progressiv e volum e loss in th e irradiated ar ea ." In contrast to th e dela yed insidious onset of ch ron ic fib rosis is the m ore d ramatic onse t of acute radiation pn eumonitis . The patient presents wi th dyspnea and a

F U; UHE 2 . Ches t roentgenogram a fte r 6th treatm ent sh ow in g op acification on th e right sid e m ost marked in th e area of irrad iati on.

614 GOLDMAN, ENQUIST

nonproductive cough. F ev er may b e present, and thus simulate an ac ute infectious process . Location of th e in filtra te in th e irradiated field supports th e di agnosis . a T h e pn eumonitis characte ristica lly a ppears one to 16 weeks after completion of th e radiation th er apy. ' This ti me of ap peara n ce has b een useful in suggestin g th e dia gn osis. Rad ia tion pn eumo n itis may occur later if th e patient has been on corticoste roids tha t suppress its exp ression but it h as not b een repor ted earlier.' -" The occurrence of acu te radiation pn eumonitis is unp redictabl e, and its pathogen esis un clear. It h as b een found in a bout IO p er cent of a u topsies of po st radiation patients . ' H isto logi c features of acute ra diation pn eumonitis are nonsp ecific and include h yp erplasia of al ve ola r lining cells , alveola r septal thick en ing, h yaline me mb rane formation , des q uamation of atypical ce lls and vasculitis wi th foam cell plaques .":" These features are sim ila r to those induced b y man y antineoplastic drugs. The time and d ose fa ctors in volved are not w ell defin ed, an d som e feel it represents a h yp er sensit ivity react ion. :'-" The ve ry ea rly appearan ce in th e presen t case stren gthens th is beli ef. T he un expectedly early on set in th e present case ca used diagnostic difficulties . Other ca us es for th e pn eumonitis we re not apparent, and th e patien t h ad a dramatic response t o ora l prednison e . Skepticism as to th e d iag no sis resu lted in premature di scontinuation of the prednisone with a resultant flare in the radiation pn eumonitis. T his ha s b een obs erved in th e past." Reinstitution of prednisone a gain produced a dramatic response which was sus tain ed as lon g as the drug was maintained. T hi s dramatic response to prednison e on several occasions, to ge the r w ith the la ck of an y su bse q uen t progression of the infiltrat es, miti gates stron gly a gains t other p ossible di agn oses . W e wish to urge that acute rad iation pneumonitis b e conside red in any patient who has b een receivin g radia-

CHEST, 67; 5, MAY, 1975

tion should he develop an infiltrate in the irradiated area. Its occurrence is not limited to patients who have completed their course of radiation therapy. Correct diagnosis of this entity is essential because of its occasional severe morbidity, excellent response to corticosteroid therapy, and potential hazards of inappropriate antibiotic therapy. REFERENCE5

1 Whitfield AGW, Bond WH, Kunkler PB: Radiation damage to thoracic tissues. Thorax 18:371-380, 1963 2 Smith JC: Radiation pneumonitis. Am Rev Resp Dis 87: 647-655,1963 3 Castellino RA, Glatstein E, Turbow MM, et a1: Latent radiation injury of lungs or heart activated by steroid withdrawal. Ann Intern Med 80:593-599,1974 4 Bennett DE, Million RR, Ackerman LV: Bilateral radiation pneumonitis, a complication of the radiotherapy of bronchogenic carcinoma (Report and analysis of seven cases with autopsy). Cancer 23: 1001-1018, 1969 5 Case Records of the Massachusetts General Hospital (Cass 11-1971). N EnglJ Med284:603-610, 1971 6 Boushy SF, Helgason AH, North LB: The effect of radiation on the lung and bronchial tree. Am J Roentgenol 108:284-292, 1970

III-Effects of Cardiac Resuscitation: Report of Two Unusual Cases" Steven G. Atcheson, M.D.,·· Gary V. Petersen, M.D.,t and Herbert L. Fred, M.D., F.C.C.P.t

Two mishaps associated with cJosed-cbest cardiac resuscitation are presented. One-pneumoperitoneumbecame evident during Ofe, created coosiderable diagnostic difficulty, and evoked treatment that possibly hastened the patient's death. The other-cardiac puncture-appeared at autopsy and its mechanism may be unique. recently witnessed two bizarre complications of W ecardiac resuscitation. The therapeutic and philo-

sophic implications of these accidents are important and form the basis of this communication. ·From the Departments of Internal Medicine, St. Joseph Hospital, Houston, Texas and McKay-Dee Hospital, Ogden, Utah. ··Resident in Medicine, The University of Texas Medical School at Houston. tStaff Cardiologist, McKay-Dee Hospital, Ogden, Utah. Clinical Instructor, Department of Internal Medicine, University of Utah College of Medicine, Salt Lake City. tDirector of Medical Education, St. Joseph Hospital, and Professor and Vice Chairman, Department of Internal Medicine, The University of Texas Medical School at Houston. Reprint requests: Dr. Fred, St. Joseph Hospital, Houston 77002

CHEST, 67: 5, MAY, 1975

CASE REPoRTS CASE

1

At entry into the hospital, this 82-year-old woman had physical and chest roentgenographic signs of congestive heart failure. Therapy with digitalis and diuretics resulted in substantial clinical improvement. One week after admission she suddenly manifested ventricular fibrillation. External cardiac massage, electric countershock, and ventilation via face mask restored sinus rhythm and normal blood pressure in ten minutes. Midway through the procedure, progressive abdominal distension occurred. Chest roentgenogram revealed free air beneath each hemidiaphragm, but none in the mediastinum, pericardium, pleura, or subcutaneous tissues. During the next several hours, abdominal distension persisted and her rectal temperature rose to 38.9 C. Gastric perforation seemed likely, and we reluctantly proceeded with celiotomy. Operation demonstrated massive, unexplained pneumoperitoneum. Her condition then steadily worsened, and she died four days later. Autopsy established no cause of her pneumoperitoneum. She did have bronchopneumonia in both lower lobes, severe coronary atherosclerosis, and recent subendocardial infarction. Notably absent was evidence for lacerated intestine, peritonitis, fractured ribs, or intrathoracic injury. 0

Comment: This case emphasizes that pneumoperitoneum consequent to closed-chest cardiac resuscitation need not reflect perforated gut. At least five patients have displayed postresuscitative pneumoperitoneum. In two, our patient and another, 1 the site and nature of air leak defied detection. Two others2 •3 had ruptured stomach, and the fifth 4 had ruptured esophagus just proximal to the stomach. A second point commands attention. Prompt surgical intervention in all of the aforementioned patients benefited just twO. 2,4 Hence, when pneumoperitoneum complicates resuscitation, a trial of judicious medical management may be wise. CASE

2

Several hours after sustaining an acute inferior myocardial infarction, a 78-year-old man suffered cardiac standstill. Resuscitative efforts failed. Postmortem examination disclosed extensive coronary atherosclerosis and a number of exceptional abnormalities. Several sharply pointed vertebral osteophytes measuring 2 x 2 x 1 cm and resembling railroad spikes lay directly behind and impinged upon the heart. Liquid and clotted blood filled the pericardium. A half-centimeter hole extended through the pericardium and posterior wall of the left ventricle. Muscle surrounding the hole looked normal; on cut sections, however, the fibers were fragmented and incompletely striated, findings suggesting early infarction. Although the mechanism of perforation remains uncertain, we believe that during chest-wall compression an osteophyte "backstabbed" the patient, piercing his heart.

Comment: This case brings into focus a fact and two questions. The fact is: Complications of successful closedchest cardiac resuscitation kill some patients.s" The questions are: 1) What kills the patient such as ours 8 ,9cardiac arrest or cardiac massage? and 2) Can one prevent catastrophes of resuscitation? Answers are conjectural at best.

ILL·EFFECTS OF CARDIAC RESUSCITATION 615

Hyperacute radiation pneumonitis.

We present a patient who developed radiation pneumonitis only eight days after beginning therapy. The pneumonitis responded dramatically to prednisone...
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